Operationalizing the GRADE-Equity criterion to inform guideline recommendations: Application to a Medical Cannabis guideline
2University of Ottawa, Canada
3University of Calgary, Canada
4McMaster University, Canada
5Western University, Canada
Background: Equity is at the forefront of clinical and public health practice and policy. The incorporation of equity in guideline recommendation requires additional considerations for development methodology. The GRADE working group proposed the consideration of equity in several stages of the guideline development process, such as applying an equity lens in the conduct of the evidence syntheses. However, there is no pragmatic guidance on how to collect evidence from systematic reviews to inform equity considerations in guideline recommendations.
Objectives: We operationalized the GRADE-Equity criterion for collecting and appraising evidence from primary studies of systematic reviews to inform guideline recommendations. We demonstrated the application of this plan in a clinical practice guideline on prescribing medical cannabis for patients with chronic pain.
Methods: We developed the operationalization plan through three steps. First, we reviewed guidance related to guideline development, including the GRADE-Equity series, GRADE evidence to decision (EtD) frameworks. Second, we drafted the operationalization plan using the four signalling questions for the “impact on health equity” criterion of the GRADE EtD and refined the draft based on analyses of reported equity considerations in primary studies. Third, we presented the plan to the steering committee of the medical cannabis guideline and developed an evaluation framework to pilot our approach using primary studies identified from systematic reviews of benefits and harms, values, and preferences.
Results: We propose the following seven-step operationalization plan: 1) identify populations experiencing inequities, 2) examine available data for specific populations, 3) evaluate population baseline risk for primary outcomes, 4) assess representation of these populations in primary studies, 5) appraise analyses, 6) identify barriers to implementation of effective interventions for these populations, and 7) suggest supportive strategies to facilitate implementation of effective interventions. The evaluation of each study ranged from 10 to 30 minutes, depending on the amount of detail provided in the studies. We present examples describing its application to the cannabis guideline.
Conclusions: We present a pragmatic approach to inform equity considerations of systematic reviews informing guideline recommendations. The application of this approach in different topics is needed to test its reliability and feasibility.
Patient, public and/or healthcare consumer involvement: no.