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Illustrating the GRADE Methodology: The Cather Associated-UTI Case Study. Craig A Umscheid, MD, MSCE, FACP Assistant Professor of Medicine and Epidemiology Director, Center for Evidence-based Practice University of Pennsylvania. TEACH Level II Workshop 5 NYAM August 9 th , 2013.

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Illustrating the grade methodology the cather associated uti case study

Illustrating the GRADE Methodology: The Cather Associated-UTI Case Study

Craig A Umscheid, MD, MSCE, FACP

Assistant Professor of Medicine and Epidemiology

Director, Center for Evidence-based Practice

University of Pennsylvania

TEACH Level II Workshop 5

NYAM

August 9th, 2013


Cdc guideline on preventing cauti
CDC Guideline on Preventing CAUTI

Full guideline at http://www.cdc.gov/hicpac/index.html


Grade working group

GRADE Working Group

Grades of Recommendation Assessment, Development and Evaluation


The grade working group
The GRADE Working Group

Since 2000

Researchers/guideline developers with interest in methodology

Goal to develop one worldwide system of rating quality of evidence and strength of recommendations

Clear separation of 2 elements:

Quality of evidence: very low, low, moderate, or high quality

Strength of recommendation: weak or strong

www.GradeWorking-Group.org


Grade uptake
GRADE Uptake

World Health Organization

National Institute Clinical Excellence (NICE)

British Medical Journal

Infectious Disease Society of America

Centers for Disease Control and Prevention (HICPAC and ACIP)

American College of Chest Physicians

UpToDate

American College of Physicians

Cochrane Collaboration

Agency for Healthcare Research and Quality (AHRQ)

Over 20 other major organizations


Example key question in guideline
Example key question in guideline:

Do Texas catheters impact UTI outcomes

differently than Foley catheters?

VS.



Determinants of quality
Determinants of quality catheters?

RCTs start high

Observational studies start low

5 factors lower the quality of evidence

3 factors can increase the quality of evidence



Overall quality grades
Overall Quality Grades catheters?

High

further research is very unlikely to change confidence in the estimate of effect

Moderate

further research is likely to impact confidence in the estimate and may change the estimate

Low

further research is very likely to impact confidence in the estimate and is likely to change the estimate

Very low

any estimate is very uncertain



Grading the evidence for each outcome1
Grading the Evidence for Each Outcome catheters?

* = CRITICAL OUTCOMES


Grading the evidence for each outcome2
Grading the Evidence for Each Outcome catheters?

* = CRITICAL OUTCOMES


Narrative evidence summary
Narrative Evidence Summary catheters?

Q2A1. Condom versus indwelling urethral

There was moderate quality evidence to support the use of condom catheters over indwelling urethral catheters in male patients. This was based on decreased risk of symptomatic UTI as well as increased patient satisfaction with condom catheters.


Formulating recommendations
Formulating Recommendations catheters?

  • Three key inputs:

    • Values and preferences used to determine the “critical” outcomes

    • Overall GRADE of the evidence for the “critical” outcomes

    • Net benefits, net harms, or trade-offs that result from weighing the "critical" outcomes


Grading the evidence for each outcome3
Grading the Evidence for Each Outcome catheters?

* = CRITICAL OUTCOMES



Recommendation
Recommendation catheters?

Example:

Condom catheter drainage should be used in cooperative male patients without urinary retention or bladder outlet obstruction. (Category IA)


Questions
Questions? catheters?


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