1. Volume 146, Issue 3, Pages 727-734 (September 2014)
Adaptation of Trustworthy Guidelines Developed Using the GRADE Methodology 
Annette Kristiansen, MD, Linn Brandt, MD, Thomas Agoritsas, MD, Elie A. Akl, MD, PhD, MPH, Eivind Berge, MD, PhD, Johan Bondi, MD, PhD, Anders E. Dahm, MD, PhD, Lars-Petter Granan, MD, PhD, Sigrun Halvorsen, MD, PhD, Pål-Andre Holme, MD, PhD, Anne Flem Jacobsen, MD, PhD, Eva-Marie Jacobsen, MD, PhD, Ignacio Neumann, MD, Per Morten Sandset, MD, PhD, Torunn Sætre, MD, PhD, Arnljot Tveit, MD, PhD, Trond Vartdal, MD, PhD, Gordon Guyatt, MD, FCCP, Per Olav Vandvik, MD, PhD 
CHEST 
Volume 146, Issue 3, Pages (September 2014)
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Copyright © 2014 The American College of Chest Physicians Terms and Conditions

2. Figure 1
– Timeline of the Norwegian adaptation of AT9. AT9 = Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines; GRADE = Grading of Recommendations Assessment, Development and Evaluation.
CHEST  , DOI: ( /chest )
Copyright © 2014 The American College of Chest Physicians Terms and Conditions

3. Figure 2
– Structured application of the taxonomy. The panel member first decides whether to keep or exclude the recommendation. If the recommendation is retained, the need for modification is assessed. If the recommendation is modified, the panel member recognizes and explicitly states which, if any, of the five factors about the underlying evidence he or she disagrees with, including the clinical question (PICO-question) documentation, assessment of the evidence, applied baseline risk, and relative risk. The panel member then considers the deliberations made when moving from evidence to recommendation (disagreement with the balancing of the benefits and harms of the interventions and, thus, the assumed typical patient preferences and values; the overall grading of the quality of the evidence or national or local resource issues either societal or patient related). After discussions within the panel, the final mode of modification is stated before writing the modified recommendation. PICO = patient, intervention, comparator, outcome; rec = recommendation.
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Copyright © 2014 The American College of Chest Physicians Terms and Conditions

4. Figure 3
– Overview of modifications according to the taxonomy.1 19 due to lacking applicability; two due to low prevalence; and nine deemed redundant as isolated recommendations, but often the information was included in the general introduction or under practical information.2 Most new recommendations were developed due to new and updated documentation (see the second article in this series11 for more details).3 An evidence profile is a table providing an overview of the PICO question, including only patient-important outcomes, the relative and absolute estimates of effect, and a rating of the quality of evidence according to five factors (risk of bias, heterogeneity, imprecision, indirectness, and publication bias). The 35 new or modified evidence profiles provided new absolute effect estimates due to altered baseline risks or relative effects. These new absolute estimates resulted in six recommendations changing direction and four changing in strength and in the addition of seven new recommendations.4 Often, one or more interventions or comparators were excluded due to feasibility issues (eg, medications not being readily available or infrequently used in Norway and equal options being suggested instead).5 Five recommendations were modified due to new baseline documentation from a Norwegian or Scandinavian population. Twenty-six recommendations were modified partly due to updated documentation published after November For the chapters on major orthopedic surgery and pregnancy, the relative effect of low-molecular-weight heparin vs placebo as thromboprophylaxis was derived from a meta-analysis by Collins et al cited in the AT9 chapter on the prevention of VTE in nonorthopedic surgical patients.25,6 Baseline risk refers to the risk in untreated patients.7 Disagreement with how the balance between the benefits and harms of an intervention is valued resulting from disagreement with the panel's assumption of typical patient preferences and values.8 Disagreement with the assessment of the overall quality of the evidence across individual outcomes.9 Disagreement with the assessment of resource use, cost-effectiveness, and so forth.10 Eight recommendations were modified from strong to weak, whereas the remaining 11 were modified from weak to strong.11 A PICO element is excluded, added, or modified, for example, exclusion of intermittent pneumatic compression device as one of several thromboprophylactic options, adding apixaban to dabigatran as a treatment option in patients with atrial fibrillation, and modifying where AT9 states vitamin K antagonists to warfarin in the adapted guideline because this is the only available vitamin K antagonist in Norway. See Figure 1 and 2 legends for expansion of abbreviations.
CHEST  , DOI: ( /chest )
Copyright © 2014 The American College of Chest Physicians Terms and Conditions