Study Design and Setting
- •This paper provides consensus-based guidance for including health equity considerations in guideline development.
- •This paper adds an equity framework to the Grading Recommendations Assessment and Development Evidence (GRADE) guidance for rating the certainty of evidence in systematic reviews.
What this study adds to what was known?
- •Considering health equity in rating the certainty in synthesized evidence requires a priori elaboration of the disadvantaged populations and settings of interest, and methods to assess both relative and absolute effects for these populations.
- •GRADE judgements about directness require transparent reporting of how judgements were made.
What is the implication and what should change now?
2. Existing guidance
3. GRADE certainty in synthesized evidence and health equity
- a)Include health equity as an outcome
- b)Consider patient-important outcomes relevant to health equity
- c)Assess differences in the magnitude of effect in relative terms between disadvantaged and more advantaged individuals or populations
- d)Assess differences in baseline risk and hence the differing impacts on absolute effects for disadvantaged individuals or populations
- e)Assess indirectness of evidence to disadvantaged populations and/or settings.
3.1 Consider including health equity as an outcome for the SoF tables
3.1.1 Example 1
|Health equity as measured by socioeconomic disparities in caries||% of caries reduction||Inconsistent results on socioeconomic disparities (three studies)|
|dmft/DMFT||No data on socioeconomic disparities|
3.1.2 Example 2
3.2 Consider patient-important outcomes relevant to health equity
3.3 Assess differences in the magnitude of effect in relative terms between disadvantaged and more advantaged individuals or populations
3.3.1 Example: hypertension and ethnicity
- Leenen F.H.
- Nwachuku C.E.
- Black H.R.
- Cushman W.C.
- Davis B.R.
- Simpson L.M.
- et al.
3.4 Assess differences in baseline risk and the differing impacts on absolute effects for disadvantaged individuals or populations
3.4.1 Example 1: WHO guidelines on vitamin A supplementation in children 6–59 months
Guideline: vitamin A supplementation in infants and children 6-59 months of age.
3.4.2 Example 2: national guide to a preventive health assessment for Aboriginal and Torres Strait Islander people
3.5 Assess indirectness of evidence to disadvantaged populations
3.5.1 Example 1: Canadian migrant guidelines not rated down for indirectness
3.5.2 Example 2: CDC guidelines for brief alcohol counseling for people with HCV infection rated down for indirectness
4. Methodologic challenges
5. Research agenda
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Funding: V.A.W. at the Bruyère Research Institute is supported by her Ontario Early Researcher Award. P.T. at the University of Ottawa is supported by his Canada Research Chair in Health Equity. The Musculoskeletal Statistics Unit at the Parker Institute (RC) is supported by grants from the Oak Foundation (OCAY-13-309) . S.V.K. is funded by a NHS Research Scotland Senior Clinical Fellowship (SCAF/15/02), the Medical Research Council (MC_UU_12017/13 & MC_UU_12017/15) and the Scottish Government Chief Scientist Office (SPHSU13 & SPHSU15).
Conflict of interest: V.A.W. is a coconvener of the Campbell and Cochrane Equity Methods Group. R.L.M. holds an Australian NHMRC Early Career Fellowship #1054216. J.A.S. reports grants from Takeda and Savient, personal fees from Savient, Takeda, Regeneron, Merz, Bioiberica, Crealta and Allergan pharmaceuticals, WebMD, UBM LLC, and the American College of Rheumatology, grants from Horizon pharmaceuticals, outside the submitted work; and J.A.S. is a member of the executive of OMERACT, an organization that develops outcome measures in rheumatology and receives arms length funding from 36 companies; a member of the American College of Rheumatology's (ACR) Annual Meeting Planning Committee; Chair of the ACR Meet-the-Professor, Workshop and Study Group Subcommittee; and a member of the Veterans Affairs Rheumatology Field Advisory Committee. R.C. reports grants from the Oak Foundation. A.D. reports personal fees from Lectures on GRADE and clinical practice guideline development from different medical specialty organizations, outside the submitted work. H.S. reports that he is Co-Chair of the GRADE Working Group but does not report any direct financial conflicts of interest. P.T. reports other from Amgen, Astra Zeneca, Bristol-Myers Squibb, Celgene, EliLilly, Genentech/Roche, Genzyme/Sanofi, Horizon Pharma Inc, Merck, Novartis, Pfizer, PPD, Quintiles, Regeneron, Savient, Takeda Pharmaceutical, UCB Group, Vertex, Forest, Bioiberica, other from Astra Zeneca, personal fees from Bristol-Myers Squibb, Chelsea, UCB, other from Pfizer Canada, Hoffman La-Roche, Eli Lilly and Company, other from Elsevier, Little Brown, Wolters Kluwer Ltd, John Wiley & Sons Ltd, other from Abbott, Roche, Schering Plow/Merck, UCB, BMS, outside the submitted work; and I am an advisory committee member of the Canadian Reformulary Group Inc., a company that reviews the evidence for health insurance companies employer drug plans. All other authors have nothing to disclose.
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