In July 2022, Jose F. Meneses-Echavez et al. from the Norwegian Institute of Public Health published an article in the Journal of Clinical Epidemiology entitled "Evidence to decision frameworks enabled structured and explicit development of healthcare recommendations". The aim of this study was to identify and describe the processes suggested for the formulation of healthcare recommendations in healthcare guidelines available in guidance documents. 

The process of moving from evidence to recommendations represents a cornerstone of guideline development. This process implies a systematic and transparent integration of the evidence supporting the criteria influencing the recommendation. A number of frameworks have been proposed for addressing this process, such as the GRADE-EtD (Grading of Recommendations Assessment, Development, and Evaluation evidence to decision) framework. The GRADE-EtD framework aims to help panel members use evidence in a structured and transparent way to inform healthcare decisions (Fig. 1), which has been widely used by international organizations including the World Health Organization.

This study conducted a systematic and comprehensive search of the Guidelines International Network library, MEDLINE, Google Scholar, and The Cochrane Methodology Register, resulting in the inclusion of 68 guidance documents for analysis. The results showed that most organizations reported a system for grading the strength of recommendations (88%), half of them being the GRADE approach. Two out of three guidance documents (66%) proposed the use of a framework to guide the EtD process. The GRADE-EtD framework was the most often reported framework (19 organizations, 42%), whereas 20 organizations (44%) proposed their own multicriteria frameworks. Using any EtD framework was related to a more comprehensive set of recommendation-related criteria compared to no framework, especially for criteria like values, equity, and acceptability.

Implications for practice and research: 1) Guidance documents for guideline development require improvements in the reporting of the EtD process; 2) Guideline development organizations should follow a more systematic and explicit methodology for formulating recommendations; 3) A more complete and detailed reporting of the EtD process should be included in guideline development guidance documents; 4) Organizations may use our findings to either prepare their own guidance documents or to reassess their existing ones by identifying gaps in EtD criteria or to follow suggestions for improvement.

Fig. 1. GRADE-EtD frameworks workflow.