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. 2018 May 29;16(1):45.
doi: 10.1186/s12961-018-0320-2.

The GRADE Evidence to Decision (EtD) framework for health system and public health decisions

Jenny Moberg  1 , Andrew D Oxman  2 , Sarah Rosenbaum  2 , Holger J Schünemann  3 , Gordon Guyatt  4 , Signe Flottorp  2 , Claire Glenton  2 , Simon Lewin  2   5 , Angela Morelli  2 , Gabriel Rada  6 , Pablo Alonso-Coello  7 ; GRADE Working Group
Collaborators, Affiliations

The GRADE Evidence to Decision (EtD) framework for health system and public health decisions

Jenny Moberg et al. Health Res Policy Syst. .

Abstract

Objective: To describe a framework for people making and using evidence-informed health system and public health recommendations and decisions.

Background: We developed the GRADE Evidence to Decision (EtD) framework for health system and public health decisions as part of the DECIDE project, in which we simultaneously developed frameworks for these and other types of healthcare decisions, including clinical recommendations, coverage decisions and decisions about diagnostic tests.

Developing the framework: Building on GRADE EtD tables, we used an iterative approach, including brainstorming, consultation of the literature and with stakeholders, and an international survey of policy-makers. We applied the framework to diverse examples, conducted workshops and user testing with health system and public health guideline developers and policy-makers, and observed and tested its use in real-life guideline panels.

Findings: All the GRADE EtD frameworks share the same basic structure, including sections for formulating the question, making an assessment and drawing conclusions. Criteria listed in the assessment section of the health system and public health framework cover the important factors for making these types of decisions; in addition to the effects and economic impact of an option, the priority of the problem, the impact of the option on equity, and its acceptability and feasibility are important considerations that can inform both whether and how to implement an option. Because health system and public health interventions are often complex, detailed implementation considerations should be made when making a decision. The certainty of the evidence is often low or very low, but decision-makers must still act. Monitoring and evaluation are therefore often important considerations for these types of decisions. We illustrate the different components of the EtD framework for health system and public health decisions by presenting their application in a framework adapted from a real-life guideline.

Discussion: This framework provides a structured and transparent approach to support policy-making informed by the best available research evidence, while making the basis for decisions accessible to those whom they will affect. The health system and public health EtD framework can also be used to facilitate dissemination of recommendations and enable decision-makers to adopt, and adapt, recommendations or decisions.

Keywords: Decision-making; Evidence to decision; GRADE; Health systems; Methodology; Public health; Recommendations.

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Conflict of interest statement

Competing interests

All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/coi_disclosure.pdf and declare: support from the European Commission FP7 Programme (grant agreement 258,583), no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years, nor other relationships or activities that could appear to have influenced the submitted work. Authors are members of the GRADE Working Group and the DECIDE project. PAC is supported by a Miguel Servet investigator contract from the Instituto de Salud Carlos III (CP09/00137). JM affirms that the manuscript is an honest, accurate and transparent account of the study being reported, that no important aspects of the study have been omitted, and that any discrepancies from the study as planned have been explained.

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Figures

Fig. 1
Fig. 1
Evidence to Decision (EtD) conceptual map workflow
See this image and copyright information in PMC

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