Module 4 - Making Recommendations

Module 4: Making recommendations

So far in the modules, we’ve learned how to gather evidence.  Next, we use clinical expertise and the values of people with lived experience to make practical recommendations.  This makes sure that our recommendations are likely to be acceptable to people living with conditions and put into practice.

What steps are involved to get from the evidence to recommendation?

We call this stage ‘considered judgement.’ During this process, guideline development groups give a summary of all the evidence covered by each evidence table. This summary should cover the following:

• the amount and quality of the evidence, and whether it is consistent
• whether the findings of the studies carried out on a sample of people can be
• applied to the wider population
• whether the evidence can be applied directly to the people the guideline is for
• whether the treatments are effective and if there are any side effects or harms
• the resources needed to take on new treatments
• how acceptable the treatments are to people with lived experience
• how practical it would be for the NHS in Scotland to put the recommendation into practice.

Guideline development groups record the main points of their considered judgement. Once the groups have considered the issues, they summarise their view of the evidence and make the recommendation.

 

Levels of evidence

The ‘level of evidence’ tells you how likely it is that the conclusions of a research paper are true. It corresponds to the design of the study and how well it was done. Systematic reviews of randomised controlled trials (RCTs) and well-designed randomised controlled trials are the highest level, followed by observational studies such as cohort and case-control studies. Case studies and personal opinion are the lowest level.

 

Levels of evidence
1++	High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+	Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1-	Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++	High-quality systematic reviews of case-control or cohort studies High quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+	Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-	Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3	Non-analytic studies, eg case reports, case series
4	Expert opinion

 

Two Evidence and Information Scientists who appraise the quality of the study decide on the level of evidence depending on how well the study has been carried out.

 

Making recommendations

Our grading system places a lot of importance on the quality of the evidence that supports each recommendation. It emphasises that a recommendation should be based on the evidence as a whole and should not rely on a single study.

You will be involved in assessing whether the draft recommendations:

• are sensitively worded
• consider the treatments and outcomes that are important from the lived experience perspective
• take account of preferences of people with lived experience of conditions
• consider the needs of relevant groups of people (for example ethnic minorities).

 

Grading recommendations

The outcome of the decision making process is to make recommendations that are strong or weak based on the evidence.  It will also take account of benefits and harms.  We refer to weak recommendations as ‘conditional.’

A strong recommendation is made where:

• the evidence is of high quality
• we are quite certain that the treatment will improve outcomes for people
• there are few downsides of the treatment
• treatment or therapy is highly accepted among people living with conditions.

A conditional recommendation is made where:

• there are weaknesses in the evidence
• there is some doubt that the treatment will produce the expected improvement in outcome for people
• we need to balance the benefits and harms of the therapy
• varying levels of acceptance among

Members of the guideline development group can also lower a recommendation from strong to conditional if:

• they do not think the findings of the study can be applied to the wider population
• the evidence cannot be directly applied to the people the guideline is aimed at, or
• they think the evidence is weaker than the study methods would suggest.

When the evidence is poor quality and the treatment has no downsides, a strong recommendation may also be made.

 

Good practice points

Guideline groups may want to emphasise a practical point which lacks evidence, like when a treatment is widely accepted but not been studied formally. 

Points like this are shown as ‘good practice points’ and are marked with a tick. They should appear alongside an associated recommendation and cannot be standalone recommendations.

 

Consensus statements

When there's no good evidence, but the group feels strongly about a recommendation, they can make it, but it should be considered weak and based on low-quality evidence. They need supporting opinions from outside the group. If none exist, they should develop a consensus-based recommendation, clearly labelled as such in the guideline.

 

Do the quiz

To complete this module, take a few minutes to do the end-of-module quiz.  It’s a quick way to make sure you’ve learned everything you need.