Clinical guidelines using the GRADE system (Grading of Recommendations Assessment, Development and Evaluation)

The Ministry of Health of Chile, aiming to improve the quality of clinical practice guidelines, gradually incorporated the GRADE system (Grading of Recommendations, Assessment, Development and Evaluation) to develop evidence based recommendations. This system summarizes and evaluates the certainty of the available evidence. It moves from evidence to decision in a systematic and transparent manner, based on four main dimensions: balance between benefits and harms, certainty of evidence, patient's values and preferences and use of resources. The GRADE system produces strong and conditional recommendations. Strong recommendations provide confidence that the favorable consequences of an intervention clearly outweigh the adverse consequences, or vice versa. These recommendations apply to a broad range of patients and circumstances. Conditional recommendations, however, indicate that there is a close balance between favorable and unfavorable consequences of the intervention, there is uncertainty in the magnitude of benefits or adverse effects, there is uncertainty or variability in values and preferences of individuals or costs are not justified. These recommendations apply to many patients, but not all of them: ideally they should be discussed with each person. To achieve a better implementation of the recommendations made with GRADE methodology, health professionals should know the meaning of strong and conditional recommendations and they should be able to critically assess of them

Clinical guidelines using the GRADE system (Grading of recommendations assessment, development and evaluation) Cómo interpretar guías de práctica clínica elaboradas con metodología GRADE

© 2017, Sociedad Medica de Santiago. All rights reserved. The Ministry of Health of Chile, aiming to improve the quality of clinical practice guidelines, gradually incorporated the GRADE system (Grading of Recommendations, Assessment, Development and Evaluation) to develop evidence based recommendations. This system summarizes and evaluates the certainty of the available evidence. It moves from evidence to decision in a systematic and transparent manner, based on four main dimensions: balance between benefits and harms, certainty of evidence, patient’s values and preferences and use of resources. The GRADE system produces strong and conditional recommendations. Strong recommendations provide confidence that the favorable consequences of an intervention clearly outweigh the adverse consequences, or vice versa. These recommendations apply to a broad range of patients and circumstances. Conditional recommendations, however, indicate that there is a close balance between favorable and unf

Clinical practice guidelines: Qualitative study of their implementation in the Chilean health system Guías de práctica clínica: Estudio cualitativo sobre su implementación en el sistema de salud de Chile

Objective. Characterize the implementation process, barriers, and facilitators of evidence-based recommendations in the context of developing clinical practice guidelines (CPGs) generated by the Ministry of Health of Chile, in order to make proposals to optimize the process. Methods. Qualitative "action-oriented research" study. Nineteen semi-structured interviews were conducted and nine discussion groups were organized at various levels of the Chilean public health system. The analysis was conducted using Atlas.ti® software and manually, in a content analysis framework, by categorizing and coding information according to pre-specified dimensions and with the inclusion of emerging categories where relevant. Results. The main challenge mentioned with regard to implementing recommendations is the lack of an explicit and structured process. Actors in the health system recognize difficulties specific to the context in which the recommendations are followed. In this unprecedented insti

Guías de práctica clínica: estudio cualitativo sobre su implementación en el sistema de salud de Chile

Objective. Characterize the implementation process, barriers, and facilitators of evidence-based recommendations in the context of developing clinical practice guidelines (CPGs) generated by the Ministry of Health of Chile, in order to make proposals to optimize the process. Methods. Qualitative “action-oriented research” study. Nineteen semi-structured interviews were conducted and nine discussion groups were organized at various levels of the Chilean public health system. The analysis was conducted using Atlas.ti® software and manually, in a content analysis framework, by categorizing and coding information according to pre-specified dimensions and with the inclusion of emerging categories where relevant. Results. The main challenge mentioned with regard to implementing recommendations is the lack of an explicit and structured process. Actors in the health system recognized difficulties specific to the context in which the recommendations are followed. In this unprecedented institutional review, participants suggested a series of strategies that could be implemented to address these challenges, presented in a management flowchart optimized for CPG development and implementation. This process has raised awareness of the importance of implementing CPGs in Chile. Conclusion. After characterizing the implementation process, barriers, and facilitators, a plan to implement recommendations was developed in order to orient and monitor the process. Including key informants inside and outside of the Ministry of Health in the review process would facilitate the implementation of strategies and the introduction of improvements to the CPG development process. Studies of this kind should be conducted with physicians and patients in order to complement the collected information.Objetivo. Caracterizar el proceso de implementación, barreras y facilitadores de recomendaciones basadas en evidencia en el contexto del desarrollo de guías prácticas clínicas (CPG) generadas por el Ministerio de Salud de Chile, a fin de brindar propuestas para la optimización del proceso. Métodos. Estudio cualitativo del tipo “investigación-acción”. Se realizaron 19 entrevistas semiestructuradas y se armaron nueve grupos de discusión a distintos niveles del sistema público de salud chileno. El análisis se realizó mediante el software Atlas.ti® y en forma manual, desde un marco de análisis de contenido, mediante la categorización y codificación de la información según dimensiones preespecificadas y con la inclusión de categorías emergentes cuando fue pertinente. Resultados. El principal desafío de implementación de recomendaciones mencionado es la falta de un proceso explícito y estructurado. Los actores del sistema de salud reconocen dificultades dependientes del contexto al momento de usar las recomendaciones. En esta experiencia inédita de revisión institucional, los participantes sugirieron una serie de estrategias a poner en práctica para superar dichos desafíos, representadas en un flujograma de gestión optimizada para el desarrollo e implementación de CPG. El mismo proceso ha permitido tomar conciencia de la importancia de la implementación de CPG en Chile. Conclusión. Tras caracterizar el proceso de implementación, barreras y facilitadores se articuló un plan de implementación de recomendaciones que permitiría orientar y monitorizar dicho proceso. Hacer partícipes del proceso de revisión a informantes claves dentro y fuera del Ministerio de Salud facilitaría la implementación de estrategias y la introducción de mejoras al proceso de desarrollo de CPG. Estudios de este tipo deberían ser realizados en médicos y pacientes para complementar la información recogida