title: The GRADE evidence-to-decision framework: a report of its testing and application in 15 international guideline panels.
abstract: BACKGROUND
  Judgments underlying guideline recommendations are seldom recorded and presented in a systematic fashion. The GRADE Evidence-to-Decision Framework (EtD) offers a transparent way to record and report guideline developers' judgments. In this paper, we report the experiences with the EtD frameworks in 15 real guideline panels.
  
  
  METHODS
  Following the guideline panel meetings, we asked methodologists participating in the panel to provide feedback regarding the EtD framework. They were instructed to consider their own experience and the feedback collected from the rest of the panel. Two investigators independently summarized the responses and jointly interpreted the data using pre-specified domains as coding system. We asked methodologists to review the results and provide further input to improve the structure of the EtDs iteratively.
  
  
  RESULTS
  The EtD framework was well received, and the comments were generally positive. Methodologists felt that in a real guideline panel, the EtD framework helps structuring a complex process through relatively simple steps in an explicit and transparent way. However, some sections (e.g., "values and preferences" and "balance between benefits and harms") required further development and clarification that were considered in the current version of the EtD framework.
  
  
  CONCLUSIONS
  The use of an EtD framework in guideline development offers a structured and explicit way to record and report the judgments and discussion of guideline panels during the formulation of recommendations. In addition, it facilitates the formulation of recommendations, assessment of their strength, and identifying gaps in research.
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.|Department of Internal Medicine, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile.
authors.forename: Ignacio
authors.initials: I
authors.lastname: Neumann
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.|Evidence-Based Dentistry Unit, Faculty of Dentistry, University of Chile, Santiago, Chile.
authors.forename: Romina
authors.initials: R
authors.lastname: Brignardello-Petersen
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
authors.forename: Wojtek
authors.initials: W
authors.lastname: Wiercioch
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.|Evidence-Based Dentistry Unit, Faculty of Dentistry, University of Chile, Santiago, Chile.
authors.forename: Alonso
authors.initials: A
authors.lastname: Carrasco-Labra
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
authors.forename: Carlos
authors.initials: C
authors.lastname: Cuello
authors.affiliation: Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.
authors.forename: Elie
authors.initials: E
authors.lastname: Akl
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.|Department of Medicine/Nephrology and Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA.
authors.forename: Reem A
authors.initials: RA
authors.lastname: Mustafa
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
authors.forename: Waleed
authors.initials: W
authors.lastname: Al-Hazzani
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.|Basque Office for Health Technology Assessment-OSTEBA-Directorate for Health Research and Innovation, Ministry for Health Basque Government, Vitoria-Gasteiz, Spain.
authors.forename: Itziar
authors.initials: I
authors.lastname: Etxeandia-Ikobaltzeta
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia.
authors.forename: Maria Ximena
authors.initials: MX
authors.lastname: Rojas
authors.affiliation: Institute for Education and Research, Hospital Moinhos de Vento, Porto Alegre, Brazil.
authors.forename: Maicon
authors.initials: M
authors.lastname: Falavigna
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
authors.forename: Nancy
authors.initials: N
authors.lastname: Santesso
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.|Department of Clinical Epidemiology & Biostatistics, McMaster University Health Sciences Centre, Room 2C16, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
authors.forename: Jan
authors.initials: J
authors.lastname: Brozek
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
authors.forename: Alfonso
authors.initials: A
authors.lastname: Iorio
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.|Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau-CIBERESP), Barcelona, Spain.
authors.forename: Pablo
authors.initials: P
authors.lastname: Alonso-Coello
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada. schuneh@mcmaster.ca.|Department of Clinical Epidemiology & Biostatistics, McMaster University Health Sciences Centre, Room 2C16, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada. schuneh@mcmaster.ca.
authors.forename: Holger J
authors.initials: HJ
authors.lastname: Schünemann
mesh_terms: D019317:Evidence-Based Medicine / Q000379:methods*; D006284:Health Plan Implementation / Q000379:methods; D006801:Humans; D007600:Judgment; D017410:Practice Guidelines as Topic; D058028:Research Report
keywords: Clinical practice guidelines; Evidence to decisions framework; GRADE; GRADEpro; Recommendations