In this article, we describe how to include considerations about resource utilization when making recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.
Study design and settings:
We focus on challenges with rating the confidence in effect estimates (quality of evidence) and incorporating resource use into evidence profiles and Summary of Findings (SoF) tables.
GRADE recommends that important differences in resource use between alternative management strategies should be included along with other important outcomes in the evidence profile and SoF table. Key steps in considering resources in making recommendations with GRADE are the identification of items of resource use that may differ between alternative management strategies and that are potentially important to decision makers, finding evidence for the differences in resource use, making judgments regarding confidence in effect estimates using the same criteria used for health outcomes, and valuing the resource use in terms of costs for the specific setting for which recommendations are being made.
With our framework, decision makers will have access to concise summaries of recommendations, including ratings of the quality of economic evidence, and better understand the implications for clinical decision making.
"Studies were assessed using the methods recommended by the Campbell and Cochrane Economic Methods Group . These include the methods outlined in the Cochrane handbook and more recent developments 
, including methods to incorporate an economic perspective into the GRADE evidence system . Current guidance from the CCEMG on quality assessment of cost-analyses is to use relevant components from one of two checklists: Jefferson et al. (1995) and Drummond et al. (2005) 
[Show abstract][Hide abstract] ABSTRACT: Purpose of the StudyTo systematically review cost, cost-minimization and cost-effectiveness studies for assisted living technologies (ALTs) that specifically enable older people to ‘age in place’ and highlight what further research is needed to inform decisions regarding aging in place.DesignPeople aged 65+ and their live-in carers (where applicable), using an ALT to age in place at home opposed to a community-dwelling arrangement.MethodsStudies were identified using a predefined search strategy on two key economic and cost evaluation databases NHS EED, HEED. Studies were assessed using methods recommended by the Campbell and Cochrane Economic Methods Group and presented in a narrative synthesis style.ResultsEight eligible studies were identified from North America spread over a diverse geographical range. The majority of studies reported the ALT intervention group as having lower resource use costs than the control group; though the low methodological quality and heterogeneity of the individual costs and outcomes reported across studies must be considered.ImplicationsThe studies suggest that in some cases ALTs may reduce costs, though little data were identified and what there were was of poor quality. Methods to capture quality of life gains were not used, therefore potential effects on health and wellbeing may be missed. Further research is required using newer developments such as the capabilities approach. High quality studies assessing the cost-effectiveness of ALTs for ageing in place are required before robust conclusion on their use can be drawn.
PLoS ONE 07/2014; 9(7):e102705. DOI:10.1371/journal.pone.0102705 · 3.23 Impact Factor
"The GRADE working group recommended the approach used to evaluate the quality of the evidence (Balshem et al., 2011; Guyatt et al., 2011a, b, c, d, e, f, g, h, 2013a, b, c; Andrews et al., 2013a, b; Brunetti et al., 2013). The GRADE system separates the process of grading scientific evidence to inform recommendations from the process of making recommendations. "
[Show abstract][Hide abstract] ABSTRACT: Piglets reared in swine production in the USA undergo painful procedures that include castration, tail docking, teeth clipping, and identification with ear notching or tagging. These procedures are usually performed without pain mitigation. The objective of this project was to develop recommendations for pain mitigation in 1-to 28-day-old piglets undergoing these procedures. The National Pork Board funded project to develop recommendations for pain mitigation in piglets. Recommendation development followed a defined multi-step process that included an evidence summary and estimates of the efficacies of interventions. The results of a systematic review of the interventions were reported in a companion paper. This manuscript describes the recommendation development process and the final recommendations. Recommendations were developed for three interventions (CO 2 /O 2 general anesthesia, non-steroidal anti-inflammatory drugs (NSAIDs), and lidocaine) for use during castration. The ability to make strong recom-mendations was limited by low-quality evidence and strong certainty about variation in stake-holder values and preferences. The panel strongly recommended against the use of a CO 2 /O 2 general anesthesia mixture, weakly recommended for the use of NSAIDs and weakly recommended against the use of lidocaine for pain mitigation during castration of 1-to 28-day-old piglets.
Animal Health Research Reviews 06/2014; 15(1). DOI:10.1017/S1466252314000073
"Most recently, methods guidelines have been published on the use of the GRADE system to rate quality of evidence for resource use and costs, which will facilitate the incorporation of economic evidence into Summary of Findings tables. These tables are increasingly used in Cochrane to summarise principal findings and quality of evidence for important outcomes . "
[Show abstract][Hide abstract] ABSTRACT: Methods for systematic reviews of the effects of health interventions have focused mainly on addressing the question of 'What works?' or 'Is this intervention effective in achieving one or more specific outcomes?' Addressing the question 'Is it worth it given the resources available?' has received less attention. This latter question can be addressed by applying an economic lens to the systematic review process.This paper reflects on the value and desire for the consideration by end users for coverage of an economic perspective in a Cochrane review and outlines two potential approaches and future directions.
Two frameworks to guide review authors who are seeking to include an economic perspective are outlined. The first involves conducting a full systematic review of economic evaluations that is integrated into a review of intervention effects. The second involves developing a brief economic commentary. The two approaches share a set of common stages but allow the tailoring of the economic component of the Cochrane review to the skills and resources available to the review team.
The number of studies using the methods outlined in the paper is limited, and further examples are needed both to explore the value of these approaches and to further develop them. The rate of progress will hinge on the organisational leadership, capacity and resources available to the CCEMG, author teams and other Cochrane entities. Particular methodological challenges to overcome relate to understanding the key economic trade-offs and casual relationships for a given decision problem and informing the development of evaluations designed to support local decision-makers.
Methods for incorporating economic perspectives and evidence into Cochrane intervention reviews are established. Their role is not to provide a precise estimate of 'cost-effectiveness' but rather to help end-users of Cochrane reviews to determine the implications of the economic components of reviews for their own specific decisions.
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