Interpreting the guideline recommendations
In developing the recommendations in this guideline, evidence was assessed alongside multidisciplinary health professional expertise and consumer perspectives. There are four key elements of each recommendation:
- certainty of evidence (for evidence-based recommendations)
- grade (strength) of recommendation (for evidenced-based recommendations).
Recommendation type is either evidence-based (EBR) or clinical consensus recommendation (CCR). In addition, clinical practice points (CPP) were included for implementation issues such as safety, side effects and risks (Table 1). For CCRs and CCPs certainty/strength and grade ratings are not applicable (NA).
Table 1. Recommendation types
|EBR||Evidence-based recommendation: a structured/systematic evidence review was performed to answer a prioritised question to inform the recommendation.|
|CCR||Clinical consensus recommendation: recommendation was developed in either of the following ways:|
Evidence to answer a prioritised question was sought, but there was insufficient evidence to inform an EBR. Therefore, a narrative review was prepared by an expert subgroup of the guideline development group (GDG) (see Table 5 and Methods for more information about the narrative review approach).
For questions of lower priority, or where high-quality evidence is known to be limited or non-existent, evidence was not sought and an expert subgroup within the GDG prepared a narrative review.
|CPP||Clinical practice point: guidance based on expert opinion and clinical experience, provided on important issues arising from discussion of evidence-based or clinical consensus recommendations, outside the scope of the evidence-finding process.|
Recommendation wording reflects the guideline development group’s (GDG’s) overall interpretation of the evidence and other considerations. The word ‘should’ indicate the GDG’s judgment that the benefits of the recommended action exceed the harms. ‘Could’ indicates that the quality of evidence was limited, or the available studies did not clearly demonstrate the advantage of one approach over another, or the balance of benefits to harm was unclear. ‘Should not’ indicates either a lack of appropriate evidence or that the harms were judged to outweigh the benefits.
Certainty of evidence
Certainty of evidence (very low to high) for EBRs reflects the quality and relevance of the evidence, based on information about the number and design of studies addressing the outcome, judgments about the quality of the studies and/or synthesised evidence, across risk of bias, inconsistency, indirectness, imprecision, and any other quality considerations; key statistical data; and classification of importance of outcomes (see Table 2).
Table 2. Certainty of the evidence leading to the recommendation for Evidence-Based Recommendations
|We are very confident that the true effect lies close to that of the estimate of the effect.|
|We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.|
|Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.|
|We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.|
GradeThe grade (strength) of EBRs (strong recommendation or conditional recommendation; Table 3) was determined by the GDG based on comprehensive consideration of all elements of the evidence to decision framework (National Health and Medical Research Council, 2009), including desirable and undesirable effects, balance of effects, resource requirements, equity, acceptability, and feasibility (see Methods).
Table 3. Strength (grade) of recommendations for Evidence-Based Recommendations
|****||Strong recommendation for the option|
|***||Conditional recommendation for the option|
|**||Conditional recommendation for either the option or the comparator|
|*||Conditional recommendation against the option|
This guideline integrates a summary of the clinical need for guidance on each topic, the clinical question, the evidence summary (systematic and/or narrative), the recommendation or practice points and a justification developed by the GDG. The full evidence reviews, narrative reviews and GRADE frameworks supporting each recommendation, when relevant, can be found in the supplementary Technical Report, along with voting to reflect degree of consensus (voting results available upon request).The following recommendations should be read in conjunction with the Principles and Assumptions section, which provides information about requirements for clinicians implementing these recommendations.