Prioritising topics, formulating questions, and selecting outcomes for a World Health Organization nutrition guideline
Michael McCaul, Division of Epidemiology and Biostatistics
2Centre for Evidence-based Health Care, Division of Biostatistics and Epidemiology, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
Developing trustworthy guidelines requires considerable investment of resources and time. This makes priority-setting of topics and questions a key aspect of guideline development. Explicit and thorough prioritization engaging a range of appropriate stakeholders enhances the relevance, potential utility, and uptake of priority recommendations by end users.
Objectives: To identify priority topics, formulate questions, and select outcomes for a World Health Organization nutrition guideline.
Methods: The guideline steering group and external guideline methodologists partnered to coordinate the prioritisation. We aligned the approach with WHO methods, and good practice for priority-setting, including an explicit and comprehensive process involving stakeholder engagement, information management, consideration of values and context, and opportunities to review decisions. Draft guideline questions were informed by four commissioned scoping reviews, areas of uncertainty needing guidance identified by member countries or implementing organisations, and past WHO meetings, with inputs from the guideline development group (GDG) at an initial scoping meeting. Working groups refined draft questions into proposed PICO formats, which the GDG prioritised according to clear criteria (online survey). Informed by survey results, the most important questions were agreed upon by the GDG at a consensus meeting, after which the GDG scored outcomes online according to importance. All contributors declared interests.
Results: The 16 prioritised guideline questions comprised intervention effectiveness (treatment and prevention), prognostic, and diagnostic questions. Our approach took us iteratively through pre-prioritisation and prioritisation stages, as well as post-prioritisation, in which broad questions required further splitting into several focused sub-PICOs to unpack complexity (e.g., effect modification and baseline risk differences) and enable identification of relevant evidence by systematic reviews for the questions and evidence-to-decision criteria for recommendations. A systematic process enabled the consideration of social determinants of health, equity, human rights, and gender throughout the process, guided by PROGRESS-Plus stratifiers. Documenting the approach aided transparency, and inclusivity facilitated stakeholder buy-in. Conclusion: This priority-setting process was complex, time-intensive, and recursive but clearly valuable and necessary to direct efforts and resources to the most important needs for guidance, representing a step towards improving delivery of evidence-informed care and key outcomes. Patient, public, and/or healthcare consumer involvement: Stakeholders included guideline implementers and researchers.