Table 6 When to consider expanding the range of evidence syntheses undertaken to inform the development of a guideline or guidance

Principles:

• For most interventions for which guidance is developed, including clinical, health systems and public health interventions, guidance panels should consider how different stakeholders value different outcomes; the effectiveness, acceptability and feasibility of the intervention; implications for resource use; equity impacts; and implementation considerations

• A structured evidence-to-decision framework, such as the DECIDE framework [30, 31], should be used to guide these considerations, even if it is likely that evidence syntheses will not be needed for some of the considerations included in these frameworks (see below)

When to consider expanding the range of evidence syntheses informing guidance development:

• Expanding the range of evidence syntheses beyond evidence of effectiveness should be considered under the following circumstances:

 ◦ If the guidance is considering a new intervention, an intervention for which guidance has not previously been developed, or an intervention for which the implementation mechanism/s have changed

 ◦ If there are reasons to anticipate that feasibility, acceptability, resource use and/or equity are likely to be important considerations for the interventions included in this guidance. These considerations may be particularly important for interventions directed at health systems or other systems; interventions that focus on changing people’s views or behaviours; and interventions that have multiple components and long causal pathways or involve multiple actors or systems. Note that stakeholders should be involved in discussions on this issue

• If a decision has been made that the range of evidence syntheses needed to support the development of guidance should be expanded, consider the following:

 ◦ Do evidence syntheses already exist that could be used to address the considerations identified?

 ◦ Will existing evidence syntheses require additional work, for example, to assess how much confidence to place in the synthesis findings and/or to undertake specific subgroup analyses?

 ◦ If existing evidence syntheses are not available for some or all of the considerations to be explored by the guidance:

  ▪ Do the timeline and resources available for the guidance development allow for new syntheses to be undertaken?

  ▪ If so, which are the highest priority considerations for new syntheses and what should be the scope of these syntheses?

  ▪ What skills are likely to be required to undertake these syntheses? Are the skills to undertake these syntheses available within the lead organisation for the guidance or do they need to be commissioned externally?

  ▪ What financial and other resources are needed to conduct these syntheses within the timeframe for development of the guidance?

  ▪ Could the process of conducting multiple evidence syntheses be made more efficient by combining database searching and screening for several of the syntheses, such as those syntheses focusing on intervention effectiveness, acceptability, feasibility and resource use considerations?

• Once the evidence syntheses are underway or available, consider the following:

 ◦ What tools are needed to assess how much confidence to place in the synthesis findings (for instance, the GRADE approach)? Will these assessments be conducted by the review teams, by the guidance commissioners or by a third party?

  Who will be responsible for summarising the available evidence in order to populate an evidence-to-decision framework for each guidance question?