Users of clinical practice guidelines and other recommendations need to know how much confidence they can place in the recommendations Systematic and explicit methods of making judgments can reduce errors and improve communication We have developed a system for grading the quality of evidence and the strength of recommendations that can be applied across a wide range of interventions and contexts In this article we present a summary of our approach from the perspective of a guideline user Judgments about the strength of a recommendation require consideration of the balance between benefits and harms, the quality of the evidence, translation of the evidence into specific circumstances, and the certainty of the baseline risk It is also important to consider costs (resource utilisation) before making a recommendation Inconsistencies among systems for grading the quality of evidence and the strength of recommendations reduce their potential to facilitate critical appraisal and improve communication of these judgments Our system for guiding these complex judgments balances the need for simplicity with the need for full and transparent consideration of all important issues

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Grading quality of evidence and strength of recommendations.

ContextModifiable behavioral risk factors are leading causes of mortality in
the United States. Quantifying these will provide insight into the effects
of recent trends and the implications of missed prevention opportunities.ObjectivesTo identify and quantify the leading causes of mortality in the United
States.DesignComprehensive MEDLINE search of English-language articles that identified
epidemiological, clinical, and laboratory studies linking risk behaviors and
mortality. The search was initially restricted to articles published during
or after 1990, but we later included relevant articles published in 1980 to
December 31, 2002. Prevalence and relative risk were identified during the
literature search. We used 2000 mortality data reported to the Centers for
Disease Control and Prevention to identify the causes and number of deaths.
The estimates of cause of death were computed by multiplying estimates of
the cause-attributable fraction of preventable deaths with the total mortality
data.Main Outcome MeasuresActual causes of death.ResultsThe leading causes of death in 2000 were tobacco (435 000 deaths;
18.1% of total US deaths), poor diet and physical inactivity (400 000
deaths; 16.6%), and alcohol consumption (85 000 deaths; 3.5%). Other
actual causes of death were microbial agents (75 000), toxic agents (55 000),
motor vehicle crashes (43 000), incidents involving firearms (29 000),
sexual behaviors (20 000), and illicit use of drugs (17 000).ConclusionsThese analyses show that smoking remains the leading cause of mortality.
However, poor diet and physical inactivity may soon overtake tobacco as the
leading cause of death. These findings, along with escalating health care
costs and aging population, argue persuasively that the need to establish
a more preventive orientation in the US health care and public health systems
has become more urgent.

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Actual causes of death in the United States, 2000.

To maintain their own health and the health of their families and communities, consumers rely heavily on the health information that is available to them. This information is at the core of the partnerships that patients and their families forge with today?s complex modern health systems. This information may be provided in a variety of forms ? ranging from a discussion between a patient and a health care provider to a health promotion advertisement, a consent form, or one of many other forms of health communication common in our society. Yet millions of Americans cannot understand or act upon this information. To address this problem, the field of health literacy brings together research and practice from diverse fields including education, health services, and social and cultural sciences, and the many organizations whose actions can improve or impede health literacy. Health Literacy: Prescription to End Confusion examines the body of knowledge that applies to the field of health literacy, and recommends actions to promote a health literate society. By examining the extent of limited health literacy and the ways to improve it, we can improve the health of individuals and populations.

Health literacy : a prescription to end confusion

Such diverse thinkers as Lao-Tze, Confucius, and U.S. Defense Secretary Donald Rumsfeld have all pointed out that we need to be able to tell the difference between real and assumed knowledge. The systematic review is a scientific tool that can help with this difficult task. It can help, for example, with appraising, summarising, and communicating the results and implications of otherwise unmanageable quantities of data. This is important because quite often there are so many studies, and their results are often so conflicting, that no policymaker or practitioner could possibly carry out this task themselves.Systematic review methods have been widely used in health care, and are becoming increasingly common in the social sciences (fostered, for example, by the work of the Campbell Collaboration). 

This book outlines the rationale and methods of systematic reviews, giving worked examples from social science and other fields. It requires no previous knowledge, but takes the reader through the process stage by stage. It draws on examples from such diverse fields as psychology, criminology, education, transport, social welfare, public health, and housing and urban policy, among others.The book includes detailed sections on assessing the quality of both quantitative, and qualitative research; searching for evidence in the social sciences;meta-analytic and other methods of evidence synthesis; publication bias; heterogeneity; and approaches to dissemination.

Systematic Reviews in the Social Sciences: A Practical Guide

Infectious Diseases Society of America.

The Centers for Disease Control and Prevention's Environmental Public Health Tracking (EPHT) Program has funded multiple partners to develop a nationwide surveillance system that focuses on the environment and its impact on human health. To show that investing in a nationwide EPHT Network is a sound practice, the program must demonstrate that monetized improvements to the public's health due to tracking outweigh the costs. In the process of developing capacity for the EPHT Network, programs have had a positive impact on the public health. Results from successful programs can be used to estimate financial measures of the EPHT performance, such as net present value, return on investment, and payback period. The estimation of such measures for the EPHT requires an understanding of the economic elements for analysis in the context of surveillance systems. A quantitative assessment must take into account elements that are difficult to measure and value. By performing a return on investment, a financial measure of program performance, the expected costs and potential benefits of individual projects need to be assessed and compared with the current cost burden of the health condition.

Vilma G Carande-Kulis

Papers

Measuring success: the case for calculating the return on investment of environmental public health tracking.