Using Explicit Thresholds were valuable for judging Benefits and Harms in partially contextualized GRADE Guidelines.

OBJECTIVES: Guideline panels must assess the magnitude of health benefits and harms to develop sensible recommendations. However, they rarely use explicit thresholds. In this paper we report on the piloting and the use thresholds for benefits and harms. STUDY DESIGN AND SETTING: We piloted the use of thresholds in a Chilean COVID-19 living guideline. For each of the critical outcomes, we asked panelists to suggest values of the thresholds for large, moderate, small, or trivial or no effect. We collected this information through a survey and an on-line discussion. RESULTS: Twelve panelists decided on thresholds for three critical outcomes (mortality, need for mechanical ventilation and serious adverse events). For all outcomes, an absolute risk reduction was considered larger with more than 50 events, moderate with less than 50 events, small with less than 25 events, and trivial with less than 10 events. Having these a priori thresholds in place significantly impacted on the development of recommendations. CONCLUSION: Explicit thresholds were a valuable addition to the judgment of the certainty in the evidence, to decide the direction and strength of the recommendation and to evaluate the need for update. We believe this is a line of research worth perusing.

Questions and health outcomes prioritization for the development of a COVID-19 dental clinical practice guideline: A case study.

RATIONALE, AIMS AND OBJECTIVES: In the context of a pandemic, the rapid development of clinical practice guidelines (CPGs) is critical. The guideline development process includes prioritization of the guideline topic, questions and health outcomes. This case study describes the application of a new methodology to prioritize questions and rate the importance of health outcomes for a COVID-19 dental guideline. METHODS: Panel members rated the topic and the questions' overall importance, using a 9-point scale (1 = least important; 9 = most important). In addition, they rated six criteria if multiple questions received the same overall importance rating: common in practice, uncertainty in practice, variation in practice, new evidence available, cost consequences, not previously addressed. Panellists also rated the importance of each outcome, defined with health outcome descriptors, using a 9-point scale and the utility of health outcomes on a visual analogue scale. The correlation between each criterion and overall question importance was tested by Spearman correlation coefficient. RESULTS: Of seven topics, four were rated as high priority and three were rated as important, but not of high priority. Thirty-six percent of the questions (18/50) were rated as high priority to address in the guideline and 64% (32/50) were rated as an important question but not of high priority. Of the 11 outcomes, 72.7% were rated as critical for decision making. The mean utility rating was 0.57 (SD 0.32), with a minimum mean rating of 0.16 and a maximum of 0.76 (SD 0.23). CONCLUSION: This case study demonstrated that this approach provides a rigorous and transparent methodology to conduct the prioritizations of guideline topics, questions and health outcomes.

Effectiveness of Telerehabilitation in Physical Therapy: A Rapid Overview.

OBJECTIVE: The purpose of this article was to summarize the available evidence from systematic reviews on telerehabilitation in physical therapy. METHODS: We searched Medline/PubMed, EMBASE, and Cochrane Library databases. In addition, the records in PROSPERO and Epistemonikos and PEDro were consulted. Systematic reviews of different conditions, populations, and contexts-where the intervention to be evaluated is telerehabilitation by physical therapy-were included. The outcomes were clinical effectiveness depending on specific condition, functionality, quality of life, satisfaction, adherence, and safety. Data extraction and risk of bias assessment were carried out by a reviewer with non-independent verification by a second reviewer. The findings are reported qualitatively in the tables and figures. RESULTS: Fifty-three systematic reviews were included, of which 17 were assessed as having low risk of bias. Fifteen reviews were on cardiorespiratory rehabilitation, 14 on musculoskeletal conditions, and 13 on neurorehabilitation. The other 11 reviews addressed other types of conditions and rehabilitation. Thirteen reviews evaluated with low risk of bias showed results in favor of telerehabilitation versus in-person rehabilitation or no rehabilitation, while 17 reported no differences between the groups. Thirty-five reviews with unclear or high risk of bias showed mixed results. CONCLUSIONS: Despite the contradictory results, telerehabilitation in physical therapy could be comparable with in-person rehabilitation or better than no rehabilitation for conditions such as osteoarthritis, low-back pain, hip and knee replacement, and multiple sclerosis and also in the context of cardiac and pulmonary rehabilitation. It is imperative to conduct better quality clinical trials and systematic reviews. IMPACT: Providing the best available evidence on the effectiveness of telerehabilitation to professionals, mainly physical therapists, will impact the decision-making process and therefore yield better clinical outcomes for patients, both in these times of the COVID-19 pandemic and in the future. The identification of research gaps will also contribute to the generation of relevant and novel research questions.