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Table 2 Similarities and differences between the Evidence to Decision (EtD) framework for health system and public health decisions and other types of decisions

From: The GRADE Evidence to Decision (EtD) framework for health system and public health decisions

Similarities
 Structure of the EtD framework All EtD frameworks include three sections: the question, an assessment and conclusions
 Question All EtD frameworks include question details, which include the setting and perspective that is taken, subgroups that are important to consider, and background information. They all also include a summary of declarations of interest for each panel member and how they were managed
 Assessment All EtD frameworks include criteria and, for each criterion, a judgment, research evidence to inform the judgment, additional considerations and detailed judgments. All of the EtD frameworks include criteria for the priority of the problem, how substantial the benefits and harms are, the certainty of the evidence, how much people value the main outcomes, the balance between the desirable and undesirable effects, cost-effectiveness, acceptability and feasibility
 Conclusions All of the EtD frameworks include a summary of judgments, decision options (types of recommendations or decisions), the decision, a justification for the decision, subgroup considerations (or, for coverage decisions, ‘restrictions’), implementation considerations, and monitoring and evaluation considerations
 Multiple options For each type of decision there are templates to accommodate decisions when there are more than two options (Box 1)
Differences
 Nature of the decision Health system and public health decisions (and coverage decisions) are made by policy-makers or managers on behalf of a population, whereas clinical decisions are typically made by individuals (health professionals or patients)
 Question details Other EtD frameworks, for the most part, use ‘PICO’– patients, intervention, comparison and outcomes. Health system and public health decisions typically begin with a problem and consider options for addressing the problem, so ‘POCO’ is used – problem, option, comparison and outcomes
 Priority of the problem The number of people affected is important to consider when making a judgment about the priority of a health system and public health problem, whereas it is not directly relevant for other types of decisions. The number of people affected by a problem can influence a clinical recommendation (from a population perspective) or coverage decision because of the impact on resource requirements (the more people affected, the greater the cost). However, this is addressed directly by another criterion: How large are the resource requirements (costs)? A problem is not more or less important to the people with the problem because of the number of people affected and most people would not consider a severe problem to be more or less important to treat depending on the number of people affected
 Benefits and harms Policy-makers and managers often must make health system and public health decisions when the certainty of the evidence is low or very low, and they also need to consider indirect as well as direct effects; this is not unique for health system and public health decisions, but is more characteristic and important than for other types of decisions
 Resources Because resources are limited, policy-makers and managers making health system and public health decisions must consider the resource implications of implementing alternative options; this also is not unique for health system and public health decisions, but is more characteristic and important than for other types of decisions
 Equity Consideration of impacts on equity is more important for health system and public health options than for clinical recommendations, although it also is sometimes important for clinical recommendations.
 Acceptability Consideration of acceptability is more important for health system and public health options than for clinical recommendations, and acceptability typically needs to be considered for multiple stakeholders, more so than for clinical recommendations and coverage decisions
 Feasibility Consideration of feasibility is more important for health system and public health options than for clinical recommendations
 Decisions EtD frameworks for clinical decisions are designed to be used by panels to make recommendations, although they can be used as the basis for decision-support tools for individual patients and clinicians. EtD frameworks for health system and public health decisions (and for coverage decisions) can be used directly for decisions or for recommendations (Box 1)
 Monitoring and evaluation Because there is often important uncertainty about the effects of health system and public health interventions, monitoring and evaluation considerations are a key element of these EtD frameworks