title: Senior GRADE methodologists encounter challenges as part of WHO guideline development panels: an inductive content analysis.
abstract: BACKGROUND
  The World Health Organization (WHO) classifies a substantial proportion of their recommendations as strong despite low or very low confidence (certainty) in estimates of effect. Such discordant recommendations are often inconsistent with Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance.
  
  
  OBJECTIVE
  To gain the perspective of senior WHO methodology chairs regarding panels' use of GRADE, particularly regarding discordant recommendations.
  
  
  METHODS
  Senior active GRADE methodologists who had served on at least two WHO panels and were an author on at least one peer-reviewed published article on GRADE methodology.
  
  
  METHODS
  Five eligible methodologists participated in detailed semistructured interviews. Respondents answered questions regarding how they were viewed by other panelists and WHO leadership, and how they handled situations when panelists made discordant recommendations they felt were inappropriate. They also provided information on how the process can be improved. Interviews were recorded and transcribed, and inductive content analysis was used to derive codes, categories, and emergent themes.
  
  
  RESULTS
  Three themes emerged from the interviews of five methodologists: (1) The perceived role of methodologists in the process, (2) Contributors to discordant recommendations, and (3) Strategies for improvement. Salient findings included (1) a perceived tension between methodologists and WHO panels as a result of panel members' resistance to adhering to GRADE guidance; (2) both financial and nonfinancial conflicts of interest among panel members as an explanation for discordant recommendations; and (3) the need for greater clarity of, and support for, the role of methodologists as co-chairs of panels.
  
  
  CONCLUSIONS
  These findings suggest that the role of the GRADE methodologist as a co-chair needs to be clarified by the WHO leadership. They further suggest the need for additional training for panelists, quality monitoring, and feedback to ensure optimal use of GRADE in guideline development at WHO.
authors.affiliation: Health Research Methods (HRM), Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8N 3Z5, Canada. Electronic address: elias98_99@yahoo.com.
authors.forename: Paul E
authors.initials: PE
authors.lastname: Alexander
authors.affiliation: Health Research Methods (HRM), Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.
authors.forename: Shelly-Anne
authors.initials: SA
authors.lastname: Li
authors.affiliation: Knowledge and Evaluation Research Unit, Mayo Graduate School, Mayo Clinic, Plummer 3-35, 200 First Street SW, Rochester, MN 55905, USA; Knowledge and Evaluation Research Unit, Mayo Clinic, Plummer 3-35, 200 First Street SW, Rochester, MN 55905, USA.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Gionfriddo
authors.affiliation: Division of Nutritional Sciences, Cornell University, 120 Savage Hall, Ithaca, NY 14853, USA.
authors.forename: Rebecca J
authors.initials: RJ
authors.lastname: Stoltzfus
authors.affiliation: Health Research Methods (HRM), Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8N 3Z5, Canada; Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
authors.forename: Ignacio
authors.initials: I
authors.lastname: Neumann
authors.affiliation: Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Plummer 3-35, 200 First Street SW, Rochester, MN 55905, USA.
authors.forename: Juan P
authors.initials: JP
authors.lastname: Brito
authors.affiliation: H. Lee Moffitt Cancer Center, University of South Florida, FL, USA.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Djulbegovic
authors.affiliation: Knowledge and Evaluation Research Unit, Division of Endocrinology and Diabetes, Mayo Clinic, Plummer 4-402, 200 First Street SW, Rochester, MN 55905, USA; Knowledge and Evaluation Research Unit, Division of Health Care Policy and Research, Mayo Clinic, Plummer 4-402, 200 First Street SW, Rochester, MN 55905, USA.
authors.forename: Victor M
authors.initials: VM
authors.lastname: Montori
authors.affiliation: Department of Clinical Epidemiology & Biostatistics, McMaster University Health Sciences Centre, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
authors.forename: Holger J
authors.initials: HJ
authors.lastname: Schünemann
authors.affiliation: Department of Clinical Epidemiology & Biostatistics, McMaster University Health Sciences Centre, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
authors.forename: Gordon H
authors.initials: GH
authors.lastname: Guyatt
mesh_terms: D035843:Biomedical Research; D019317:Evidence-Based Medicine; D019983:Guideline Adherence; D006801:Humans; D007407:Interviews as Topic; D017410:Practice Guidelines as Topic / Q000592:standards*; D011643:Publishing; D012107:Research Design; D014944:World Health Organization
keywords: Discordant recommendations; Financial conflicts of interest; GRADE; Guidelines; Low confidence; Methodologist; Nonfinancial conflicts of interest; Panel; Strong recommendation; WHO