GRADE equity guidelines 1: considering health equity in GRADE guideline development: introduction and rationale

Vivian Welch ,Janet Jull,Jennifer Petkovic,Matthias Briel,Roger Stanev,Kevin Pottie,Peter Tugwell,Rachael Morton,Monica Hultcrantz,Javier Eslava-Schmalbach,Jasvinder A Singh,Inday Dans,Hans De Beer,Srinivasa Vittal Katikireddi,Thomy Tonia,Joseph Watine,Gordon Guyatt,Elie A Akl,Tony Dans,Sigurd Vitols,Holger J Schünemann,Mohammed Ansari ,Mario Tristán ,Annhild Mosdøl ,Joerg J Meerpohl ,Ravi Sharaf

doi:10.1016/j.jclinepi.2017.01.014

Abstract

ObjectivesThis article introduces the rationale and methods for explicitly considering health equity in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology for development of clinical, public health, and health system guidelines. Study Design and SettingWe searched for guideline methodology articles, conceptual articles about health equity, and examples of guidelines that considered health equity explicitly. We held three meetings with GRADE Working Group members and invited comments from the GRADE Working Group listserve. ResultsWe developed three articles on incorporating equity considerations into the overall approach to guideline development, rating certainty, and assembling the evidence base and evidence to decision and/or recommendation. ConclusionClinical and public health guidelines have a role to play in promoting health equity by explicitly considering equity in the process of guideline development.

Highlights

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework can facilitate guideline panels’ consideration of health equity issues
We propose that considering evidence for health equity can inform individual clinical discussions, and the current GRADE frameworks for considering values/preferences, trade-offs of benefits and harms, resource use, and feasibility can be used to consider possible differences
We searched for articles addressing health equity in any of the aforementioned guideline types in PubMed and the National Guidelines Clearinghouse (Appendix for search strategies) and reviewed online handbooks of organizations known to consider health equity (i.e., World Health Organization (WHO), National Institute for Health and Care Excellence (NICE), National Health and Medical Research Council [NHMRC], New Zealand, Agency for Healthcare Research and Quality, Canadian Task Force, Community Guide)

Summary

Introduction

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework can facilitate guideline panels’ consideration of health equity issues. This article is a preamble and rationale for three subsequent articles in this series in JCE on considering health equity explicitly in GRADE guidelines throughout the process (Akl et al.), rating certainty of evidence (Welch et al.), and in the evidence to decision framework (Pottie et al.) (Table 1). Health inequity has been defined as differences in health that are avoidable and considered unfair or unjust [1]. Health inequities persist both between and within countries for many health conditions, including noncommunicable diseases, communicable diseases, and injuries. Gradients in morbidity are sometimes enormously unfair (e.g., the incidence of tuberculosis [TB] in northern Canadian indigenous peoples is 60 times higher than the rest of Canada, with a rate of 304 per 100,000 compared with only 4.6 per 100,0000 in the rest of Canada) [3]

Objectives

Methods

Conclusion