Research methods unit VIII Power Point


Comparison of Alternative Evidence Summary and Presentation Formats in Clinical Guideline Development: A Mixed-Method Study Newton Opiyo1,2*, Sasha Shepperd3, Nyokabi Musila1, Elizabeth Allen4, Rachel Nyamai5,

Atle Fretheim2,6, Mike English1,7

1 Health Services Research Group, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya, 2 Institute of Health and Society, University of Oslo, Oslo, Norway,

3 Department of Public Health, University of Oxford, Oxford, United Kingdom, 4 Department of Medical Statistics, London School of Hygiene and Tropical Medicine,

London, United Kingdom, 5 Division of Paediatrics, Ministry of Medical Services, Nairobi, Kenya, 6 Global Health Unit, Norwegian Knowledge Centre for Health Services,

Oslo, Norway, 7 Department of Paediatrics, University of Oxford, Oxford, United Kingdom


Background: Best formats for summarising and presenting evidence for use in clinical guideline development remain less well defined. We aimed to assess the effectiveness of different evidence summary formats to address this gap.

Methods: Healthcare professionals attending a one-week Kenyan, national guideline development workshop were randomly allocated to receive evidence packaged in three different formats: systematic reviews (SRs) alone, systematic reviews with summary-of-findings tables, and ‘graded-entry’ formats (a ‘front-end’ summary and a contextually framed narrative report plus the SR). The influence of format on the proportion of correct responses to key clinical questions, the primary outcome, was assessed using a written test. The secondary outcome was a composite endpoint, measured on a 5- point scale, of the clarity of presentation and ease of locating the quality of evidence for critical neonatal outcomes. Interviews conducted within two months following completion of trial data collection explored panel members’ views on the evidence summary formats and experiences with appraisal and use of research information.

Results: 65 (93%) of 70 participants completed questions on the prespecified outcome measures. There were no differences between groups in the odds of correct responses to key clinical questions. ‘Graded-entry’ formats were associated with a higher mean composite score for clarity and accessibility of information about the quality of evidence for critical neonatal outcomes compared to systematic reviews alone (adjusted mean difference 0.52, 95% CI 0.06 to 0.99). There was no difference in the mean composite score between SR with SoF tables and SR alone. Findings from interviews with 16 panelists indicated that short narrative evidence reports were preferred for the improved clarity of information presentation and ease of use.

Conclusions: Our findings suggest that ‘graded-entry’ evidence summary formats may improve clarity and accessibility of research evidence in clinical guideline development.

Trial Registration: ISRCTN05154264

Citation: Opiyo N, Shepperd S, Musila N, Allen E, Nyamai R, et al. (2013) Comparison of Alternative Evidence Summary and Presentation Formats in Clinical Guideline Development: A Mixed-Method Study. PLoS ONE 8(1): e55067. doi:10.1371/journal.pone.0055067

Editor: Hamid Reza Baradaran, Tehran University of Medical Sciences, Islamic Republic of Iran

Received September 30, 2012; Accepted December 18, 2012; Published January 25, 2013

Copyright: � 2013 Opiyo et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: NO and NM were supported by funds from a Wellcome Trust Strategic Award (#084538). ME is supported by a Wellcome Trust Senior Fellowship (#076827). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. All authors carried out this research independently of the funding body.

Competing Interests: The authors have declared that no competing interests exist.

* E-mail: [email protected]


Policy decisions about which interventions to implement,

modify or withdraw from health care, should be informed by

the best available evidence. While systematic reviews are a key

source of evidence [1,2], technical language and the time it takes

to read and identify the key findings in a review, may deter

healthcare decision makers from applying this evidence [3]. Thus,

alternative ways of summarising and presenting evidence have

been developed to improve accessibility and use [Box S1]. Such

summaries need to be up to date and well aligned to the needs of

policymakers and clinicians. Most examples and most evaluations

of their effectiveness in supporting healthcare decision come from

high-income countries (HICs) [4,5]. Experience with existing

research synthesis (systematic review derived) products [Box S1],

and the required adaptations to formats for their effective use in

low-income countries, remain under researched. In this paper we

report the findings of a mixed-method evaluation of the usefulness

of these products, compared with more traditional formats, for a

large, multidisciplinary guideline development panel in Kenya.

PLOS ONE | 1 January 2013 | Volume 8 | Issue 1 | e55067


Ethics Statement Ethical approval for the conduct of this study was granted by the

Kenya Medical Research Institute scientific committee and

National Ethics Review Committee in Kenya (SSC Protocol

No 1770). Individual written informed consent for participation

and audio recording of discussions was obtained prior to the face-

to-face interviews. Confidentiality of participant information was

ensured by assigning anonymous codes to individual audio

interviews and transcripts.

Study Design This was a mixed-method study incorporating a randomised

controlled trial (RCT) to assess the effectiveness of three different

evidence summary formats with semi-structured follow-up inter-

views to explore panel members’ views of these formats,

experience with appraisal, use of and engagement with the

research evidence.

Study Setting The Kenya Medical Research Institute - Wellcome Trust

Research Programme together with Kenya’s Ministry of Medical

Services collaborated to host a one-week national guideline

development workshop (‘Child Health Evidence Week’) [6], held

in Nairobi, Kenya, between 21st and 25th June, 2010.

Participants Trial participants consisted of a multidisciplinary panel of

healthcare professionals with varied roles in neonatal and

paediatric policy and care in Kenya (table 1). All 77 participants

nominated by their departmental heads to participate in the one-

week national guideline development workshop were eligible for

recruitment. The Ministry of Medical Services sent invitation

letters to those nominated, describing their expected roles (e.g. pre-

reading of provided research evidence) and the research compo-

nent of the workshop. We contacted those nominated by phone to

confirm their agreement to participate and to further explain

workshop procedures. We made follow-up telephone calls to non-

responsive participants. Participants who declined participation at

this stage were excluded from the sampling list; this reduced our

sample size to 70 participants. For the interviews, we purposively

selected a sub-sample of stakeholders (n = 16) who attended the

guideline development workshop to: (1) achieve representation

from groups involved at different levels of the health system; and

(2) maximise the variety of views and experiences examined.

Interventions We assembled evidence in three formats: systematic reviews

(SR) alone (pack ‘A’), systematic reviews with summary-of-findings

tables (SR with SoF tables; pack ‘B’) and ‘graded-entry’ formats

(pack ‘C’). Evidence pack ‘A’ represented the common standard

practice of using systematic reviews and lengthy technical reports

to inform healthcare policy and guideline development. Evidence

pack ‘B’ represented the recently enriched format for preparing

full Cochrane reviews [5].

Evidence pack C was designed to allow stepwise access (i.e.

‘graded-entry’) to the evidence. It started with a ‘front-end’ short

interpretation of the main findings and conclusions, drawn from

evidence synthesis (webappendix S1). These front-end concise

summaries were followed by a locally prepared, short, contextually

framed, narrative report (hereafter called a narrative report) [7] in

which the results of the systematic review (and other evidence

where relevant) were described and locally relevant factors that

could influence the implementation of evidence-based guideline

recommendations (e.g. resource capacity) were highlighted. The

front-end summary and the narrative report were combined with

the full systematic review (e.g. as published by the Cochrane

Collaboration) to make a three-component set branded pack ‘C’.

The ‘front-ends’ in pack ‘C’ were adapted from existing review-

derived formats designed to allow rapid scanning for key messages

[Box S1]. Further development of these formats was guided by

theoretical frameworks on information transfer for non-research

audiences [8–10]. Briefly, these frameworks propose that to

improve knowledge transfer dissemination materials need to be

easy to use, accessible, credible (trustworthy) and desirable. The

content needs to be current, relevant, methodologically competent

and comprehensive. Finally, the ‘messages’ need to be tailored to

the specific needs and context of the users.

The GRADE (Grading of Recommendations Assessment,

Development, and Evaluation) system [11] was used to appraise

and summarise evidence in summary-of-findings tables. These

tables were included in the front-end summaries and narrative

reports. The summaries were delivered to participants as pre-

reading materials one month before the workshop.

Randomisation/Outcome Measures Evidence summaries in pack A, B and C formats were prepared

for three ‘tracer-interventions’ relevant to neonatal care where

new guidelines were being considered and for which systematic

reviews had been recently published: (1) feeding regimens in sick

newborns [12]; (2) hand hygiene for infection prevention [13]; and

Table 1. Profile of guideline panel members.

Characteristic Frequency %


Male 34 49

Female 36 51

Age (years)

21–30 8 11

31–40 35 50

41–50 14 20

51–60 10 14

Above 60 3 4


Paediatrician 32 46

Medical Officer 11 16

Nursing Officer 7 10

Research (research supervision) role 5 7

Trainer of healthcare workers 5 7

National or provincial role for MoM/MoPHS 4 6

Clinical Officer 3 4

Pharmacist 2 3

Academic administration 1 1

Number of years as a healthcare professional

3–7 23 33

8–12 14 20

13–21 16 23

22–40 17 24


Evidence Summary Formats in Guideline Development

PLOS ONE | 2 January 2013 | Volume 8 | Issue 1 | e55067

(3) kangaroo care for low birth weight babies [14]. For example,

for feeding regimens we packaged evidence in the format of a

systematic review (pack ‘A’), a systematic review with summary-of-

findings tables (pack ‘B’) and a ‘graded-entry’ format (pack ‘C’); a

similar approach was used to assemble differing evidence for hand

hygiene and kangaroo care. We then provided all individual

participants with evidence on all three tracer topics but used

randomisation, within 5 professional strata, to ensure that all

participants received one tracer-topic with packaging approach A,

one with packaging approach B and one with packaging approach

C. This enabled us, when examining which package is most

effective at conveying research information, to address the

possibility that the relationship is confounded by the nature of

the topic and, in subsequent interviews, explore participants’ views

on all the 3 evidence packaging formats. Further details on the

randomisation process is summarised in webappendix S2 and

Figure 1.

The primary outcome was the proportion of correct responses

to key clinical questions relevant to the specific tracer topics. This

tested the understanding of the effects of tracer-interventions on

critical neonatal outcomes (mortality, morbidity). The secondary

outcome measure was a composite score representing participants’

self-reports of the clarity and accessibility of the evidence;

participants rated their responses on a 3 or 5-point scale. These

domains have successfully been tested and used in previous trials


Data Collection Participants completed questionnaires on the first day (June

21st, 2010) of the guideline development workshop before the

panel discussions about guidance recommendations. The ques-

tionnaires were adapted from existing studies [5,15,16], and

required responses from participants on: (1) personal characteris-

tics (e.g. age, sex); (2) experience with interpreting research

evidence and evidence based medicine skills; (3) recognition and

understanding of key messages; (4) ease of access to and perceived

value of provided evidence summaries; and (5) preferred summary

formats. The questionnaires were pilot-tested on two occasions on

a multi-disciplinary group of 18 local researchers and clinicians

and further refined based on feedback received. Participants were

allowed up to 45 minutes to complete the questionnaire during

which they had access to their personalized ‘evidence packs’.

Individual face-to-face interviews were conducted (between July

and August 2010) by NO following completion of the question-

naire but before analysis. Interview questions were derived from a

review of literature on best practices in clinical guideline

development [17–19], pilot-tested (with three child health experts),

and modified. The interviews lasted approximately 30 to 45

minutes and focused on collecting information about participants’

experiences with appraisal, the use of research evidence and views

on evidence summary formats.

Analysis The sample size calculation was based on the pre-specified

primary outcome assuming a two-way comparison of the three-

component pack (C) versus the minimum standard pack (A) and a

1:1 allocation ratio. The trial was designed to have 90% power at

an alpha (significance level) of 0.05 to detect a 40% absolute

difference in the proportion of correct responses with 35

observations on each evidence pack (calculated using a conven-

tional two-sided Chi-squared test). Assuming a non-response rate

Figure 1. Trial profile. doi:10.1371/journal.pone.0055067.g001

Evidence Summary Formats in Guideline Development

PLOS ONE | 3 January 2013 | Volume 8 | Issue 1 | e55067

of 10% we targeted at least 40 participants for randomisation. All

analyses treated the respondent as a unit of clustering.

The crude odds (likelihood) of correct responses for pack C

compared to the odds for pack A (assumed baseline pack) were

estimated using logistic regression. The models were also adjusted

for the effect of strata and the tracer intervention. Pack by strata

interaction terms were included to assess whether the effect of the

different evidence packs differed by strata. The secondary outcome

measure was the clarity and accessibility score. The mean clarity

and accessibility scores of pack C compared to the mean scores of

pack A were estimated using linear regression and the lack of

normality of the scores (webappendix S3) was accounted for using

bootstrapping methods [20]. Similar processes were used to

compare mean scores of pack B to A. To confirm the results of

linear regression analysis, an alternative approach to the analysis

was undertaken: the odds of a one point increase in the ‘clarity and

accessibility’ scores of pack B and C compared to the odds of pack

A were estimated using ordinal logistic regression models. Further

tests of interactions between pack and strata were performed using

likelihood ratio tests. Where evidence of interaction was found,

stratum-specific ORs and 95% CIs were calculated. All analyses

were done with STATA (version 11.0). Further details on data

handling and analysis is summarised in webappendix S4.

Audio interviews were transcribed verbatim by NO. Emerging

themes and concepts were extracted by at least two co-

investigators (NO, SS, NM, AF) working independently [21].

These were compared and discussed; NO summarised the

recurrent concepts into a set of initial descriptive themes with

narrative summaries explaining each theme. These were discussed

by investigators iteratively, with reference to the original interview

transcripts, until a final set of themes was agreed upon.

Although quantitative and qualitative components of this study

were pre-specified in the proposal integration occurred after

separate analysis of each component at the point of interpretation

of the results.


The trial profile is summarised in Figure 1. Seventy (91%) out of

77 participants invited attended the workshop. The most common

reason for non-attendance was related to timing of the meeting.

Table 1 shows the baseline characteristics of participants. A total

of 16 participants were interviewed: three paediatricians from

district hospitals, two senior paediatric trainees, one nurse

manager, four trainers of healthcare workers (nursing and

paediatric academics), one World Health Organization (WHO)

officer, one research director and four government policymakers.

Quantitative Findings Sixty-five (93%) of 70 participants completed questions on

primary outcome measures. A descriptive summary of the

proportion of correct and incorrect responses for each evidence

pack is shown in table 2. There were no significant differences

between packs in the odds of correct responses (adjusted ORs: pack

B versus A 0.59, 95% CI 0.32 to 1.07; pack C versus A 0.66, 95% CI

0.36 to 1.21; table 3). There was some evidence of differences in the

odds of correct responses across different groups of healthcare

professionals (p = 0.057). Results of sub-group analyses (although

not statistically significant) suggested that both pack B (systematic

reviews with SoF tables) and pack C (the three component, graded

entry pack) improved understanding for policymakers (pack B: OR

1.5, 95% CI 0.15 to 15.15; pack C: OR 1.5, 95% CI 0.64 to 3.54)

and trainee paediatricians (pack B: OR 1.3, 95% CI 0.37 to 4.66;

pack C: OR 1.78, 95% CI 0.43 to 7.33).

‘Graded-entry’ formats (pack C), compared to systematic review

formats (pack A), were associated with a significantly higher mean

‘value and accessibility’ score (adjusted mean difference 0.52, 95%

CI: 0.06 to 0.99; table 3). Similarly, pack C, compared to pack A,

was associated with a 1.5 higher odds of judgments about the

quality of evidence for critical neonatal outcomes being clear and

accessible (adjusted OR: 1.52, 95% CI 1.06 to 2.20; table 3).

There was no evidence that pack B (systematic reviews with SoF

tables) improved this composite score compared to pack A

(adjusted mean difference: 20.11, 95% CI 20.71 to 0.48; table 3). More than half of the respondents (60%) found systematic

reviews to be more difficult to read compared to narrative reports,

but some (17%) responded that systematic reviews were easy to

read. About half of the participants (51%) found systematic reviews

to be easier to read compared to summary-of-findings tables

(26%). A higher proportion of participants preferred evidence

summarised in narrative report formats to the full version of the

systematic reviews (53% versus 25%). See table 4 for a complete

overview of these findings.

Participants’ self-rated experiences with research literature and

familiarity with evidence based medicine terminology are

presented in table 5. Of note are that about 29% of respondents

had not read a systematic review in the last year. Most of the

participants (53[82%]) responded that they spent less than 12

hours reading provided evidence summaries before the workshop

and 6 (9%) reported not reading materials at all.

Qualitative Findings Views on the different formats for presenting systematic

review evidence (see Box 1 for illustrative quotes). The

majority of participants interviewed found research information

summarised in the form of narrative reports to be clearer, easy to

read, easy to understand and containing ‘just the right amount of

information’. Conversely, participants expressed considerable

variability in views for systematic reviews and GRADE summa-

ry-of-findings tables: while some found the comprehensive and

structured nature of information presentation in systematic reviews

to be useful, a number expressed difficulties with extracting

pertinent information. Some participants found GRADE summa-

ry tables to be good for ‘rapid consultation’; however, a number of

participants found them difficult to understand as stand-alone

summaries. For example, one participant expressed difficulties

with distinguishing between the GRADE categories of quality of

evidence. Of note, many participants reported lack of time and the

volume of evidence as factors contributing to more complete

engagement with the evidence.

Experiences with appraisal and use of research evidence

(See Box 2 for illustrative quotes). The majority of partic-

ipants responded that they were not conversant with assessing the

Table 2. Proportion of incorrect and correct responses (N = 65 participants).

Responses Pack A Pack B Pack C Total

Incorrect 39 (30.0) 51 (39.2) 49 (38.0) 139 (35.7)

Correct 91 (70.0) 79 (60.8) 80 (62.0) 250 (62.3)

Total 130 130 129 389

Figures in brackets are percentages; pack A = systematic review; pack B = systematic review with summary-of-findings table; pack C = ‘graded-entry’ format (a ‘front-end’ summary of key information linked to a short contextually framed narrative report and full systematic review). doi:10.1371/journal.pone.0055067.t002

Evidence Summary Formats in Guideline Development

PLOS ONE | 4 January 2013 | Volume 8 | Issue 1 | e55067

quality of scientific literature or evidence-based medicine termi-

nology, such as PICO (Patient, Intervention, Comparison,

Outcome). A number suggested that a short course on evidence-

based medicine would be beneficial to support evidence-based

guideline development.


Interpretation of Results The current study assessed the effectiveness and panelists’ views

and experiences with different evidence summary formats. The

quantitative evaluation showed that ‘graded-entry’ evidence sum-

Table 3. Primary and secondary outcomes (N = 65 participants).

Odds ratios for correct responses

Pack Unadjusted OR (95% CI) p-value Adjusted OR (95% CI) {


Pack A 1 (Referent) – 1 –

Pack B 0.66 (0.37–1.20) 0.366 0.59 (0.32–1.07) 0.220

Pack C 0.70 (0.39–1.27) 0.66 (0.36–1.21)

Mean differences in ‘value and accessibility’ scores

Mean difference (95% CI) p-value Mean difference (95% CI){ p-value

Pack A 1 – 1 –

Pack B 20.14 (20.77 to 0.49) 0.046 20.11 (20.71 to 0.48) 0.025

Pack C 0.49 (0.01 to 0.98) 0.52 (0.06 to 0.99)

Odds ratios for ‘value and accessibility’ scores

Unadjusted OR (95% CI) p-value Adjusted OR (95% CI){ p-value

Pack A 1 – 1 –

Pack B 0.97 (0.64–1.47) 0.038 0.91 (0.57–1.46) 0.022

Pack C 1.48 (1.06–2.08) 1.52 (1.06–2.20)

OR = odds ratio; CI = confidence interval; { Adjusted for type of strata and tracer-intervention; pack A = systematic review; pack B = systematic review with summary-of-findings table; pack C = ‘graded-entry’ format (a ‘front-end’ summary of key information linked to a short contextually framed narrative report and full systematic review); p-values - values for tests of significance of joint association between the summary formats and outcomes. doi:10.1371/journal.pone.0055067.t003

Table 4. Ease of use and summary format preferences.


Percentage (95% confidence interval)

Easy to read Neutral Difficult

How easy to read did you find evidence summarised in systematic review formats compared to narrative report formats

10/58 17% (8%–27%)

13/58 22% (12%–0.33%)

35/58 60% (48%–73%)

How easy to read did you find evidence summarised in systematic review formats compared to summary-of-findings table formats

16/61 26% (15%–37%)

14/61 23% (13%–33%)

31/61 51% (38%–63%)

Strongly prefer systematic review

Neutral Strongly prefer narrative report

Comparing systematic review versus narrative report formats 16/64 25% (14%–36%)

14/64 22% (12%–32%)

34/64 53% (41%–65%)

Strongly prefer systematic review

Neutral Strongly prefer SoF table

Comparing systematic review versus summary-of-findings (SoF) table 20/63 32% (20%–43%)

18/63 29% (17%–40%)

25/63 40% (27%–52%)

Strongly prefer narrative report

Neutral Strongly prefer SoF table

Comparing narrative report versus summary-of-findings (SoF) table 24/64 38% (25%–50%)

25/64 39% (27%–51%)

15/64 23% (13%–34%)

{ Denominators exclude missing data. doi:10.1371/journal.pone.0055067.t004

Evidence Summary Formats in Guideline Development

PLOS ONE | 5 January 2013 | Volume 8 | Issue 1 | e55067

mary formats which included narrative reviews highlighting local

factors relevant for implementation, compared to full systematic

reviews, were associated with higher composite scores for clarity and

accessibility of information on critical outcomes. However, the

proportion of correct answers to questions testing the ability to

identify, access and reproduce key messages from the evidence

summaries was not improved. This failure may reflect a true lack of

effect of format on this outcome. Alternatively, it may be due to

inadequate power to detect a smaller but useful effect or inadequate

participant preparation in those with limited prior exposure to

research evidence (Box 1 and table 5). Although not statistically

significant, results of stratified analyses provide some support for the

latter possibility as performance of policymakers and trainee

paediatricians, arguably more familiar with interpreting evidence,

was somewhat better. This interpretation of the trial findings, seen

together with the qualitative data showing difficulties engaging with

evidence among some panelists (Box 2), suggests that improving

basic skills in evidence-based medicine may be important as we seek

to engage wider participation in guideline development. Strategies

to enhance panelists’ skills in evidence retrieval and interpretation

may include: (1) involvement of panel members in the preparatory

stages of guideline development (e.g. in the conduct of systematic

reviews) [22,23]; and (2) education of panel members on guideline

development methods (e.g. on the GRADE system).

Despite an absence of effect on our main outcome, ‘graded-entry’

summary formats and their components were reported to: improve

clarity of information presentation, improve accessibility to key

information, be more reader-friendly (both narrative reports and

summary-of-findings tables) and were preferred by participants over

systematic reviews. These formats are also likely to be more suited to

the different backgrounds, interests and levels of expertise in

multidisciplinary guideline panels. For example, those with limited

training and skills in research synthesis (such as point of care

clinicians) and busy policymakers may only need to scan the ‘front-

end’ summaries for key results. On the other hand, those with

expertise in research synthesis may prefer the detail available in

narrative reports and systematic reviews to assess the reliability of

the results before considering their applicability. These findings are

further supported by the qualitative findings (Box 1). A preference

for narrative reports may be due to: (1) their abbreviated and plain

language nature; (2) incorporation of judgments on the quality of

evidence for guideline relevant outcomes; and (3) inclusion of

contextual information (e.g. local antimicrobial resistance patterns).

A comparison of our findings with related studies is summarised in

Box 3. However, it is clear that such ‘graded-entry’ formats are not

Table 5. Participants’ self-rated experience with research literature and familiarity with evidence-based medicine terminologies{.

Characteristic Frequency (%)

Frequency of reading journal articles in the last one year (n = 65)

Less than once per year 16 (24.6%)

1 to 4 times per year 15 (23.1%)

5 to 10 times per year 13 (20.0%)

More than 10 times per year 21 (32.3%)

Frequency of reading systematic review in the last 1 year (n = 65)

Never before now 19 (29.2%)

Less than once per year 14 (21.5%)

1 to 4 times per year 21 (32.3%)

More than 5 times per year 11 (16.9%)

Time spent reading provided evidence summaries (n = 65)

,12 hours 53 (81.6%)

.12 hours 6 (9.2%)

Did not read 6 (9.2%)

Confidence in interpreting the term ‘randomisation’ (n = 65)*

Very confident 20 (30.8%)

Confident 33 (50.8%)

Not so confident 12 (18.5%)

Description of a systematic review (n = 63)

Correct 39 (61.9%)

Incorrect 24 (38.1%)

Interpretation of risk ratio (n = 64)

Correct 32 (50.0%)

Incorrect 32 (50.0%)

Calculation of risk ratio of mortality comparing two treatments (n = 65)

Correct 16 (24.6%)

Incorrect 49 (75.4%)

{Denominator exclude missing data. *Similar results were obtained for responses to questions ‘confidence in interpreting the term blinding’ and ‘confidence in interpreting the term selection bias’. doi:10.1371/journal.pone.0055067.t005

Evidence Summary Formats in Guideline Development

PLOS ONE | 6 January 2013 | Volume 8 | Issue 1 | e55067

by themselves an answer to the problem of improving the use of

evidence in multidisciplinary guideline panels comprising important

policy and provider groups - something that needs to be taken into

account when structuring future approaches.

Implications for Development of Health Systems Guidance in Low- and Middle-Income Countries (LMICs) We believe the results of our evaluation provide valuable inputs

into methods for summarising and communicating evidence to

those charged with formulating recommendations in LMICs. First,

there is a need for wider sensitization to the principles of and tools

for evidence-informed decision making. We also found our

narrative reports, that adapted the GRADE system to synthesize

and present evidence on treatment effects and on-the ground

(contextual) factors and values that might influence intervention

effectiveness, to be liked by busy decision makers. Such narrative

reports could be made even more policy-relevant by inclusion of

information on wider health systems perspectives such as: potential

structural changes needed for effective implementation, equity,

feasibility of scaling up and monitoring and evaluation issues.

However, current findings could also inform future guideline

development work in high-income countries.

Strengths and Limitations Combining a quantitative RCT design with qualitative inter-

views and using both in our interpretation of data improved our

understanding of, and confidence in the study results. Our decision

to study multiple tracer-topics rather than focus on a single

guideline development topic may be considered a weakness or a

strength. Perhaps if participants had only to read the literature

provided for one topic, ‘graded-entry’ formats may have proved

superior even on the primary outcome. However, in a low-income

country setting like ours, it seems unlikely that countries will have

the resources in the near future to engage specific panels for

meetings for each guideline topic. Thus, we deliberately wished to

examine a potentially efficient approach in which the panel

considered multiple topics. Finally, although our randomization

strategy (stratified by job-type/seniority) may have reduced

possible variation in format quality and expertise (within the

population enrolled) on the main findings, we cannot rule out the

possible influence of these factors on the intended outcomes.

Future Research Although our findings suggest possible benefits of ‘graded-entry’

formats, evidence about the best formats for improving actual

understanding and use of research findings in decision making

processes (a key aim in knowledge translation) appears to be

lacking. Thus, further studies are needed to learn more about the

relative effectiveness of the various evidence summary formats that

are available and how these may be combined with alternative


Conclusions ‘Graded-entry’ formats were found to improve clarity and

accessibility of research evidence, although this was not reflected in

the number of correct responses to key clinical questions.

Providing a ‘front-end’ summary of key information linked to

Box 1. Panelists’ views on the research summary and presentation formats

[006]: ‘The mini-review [narrative report] I think was like one of the most useful things I came across, because I found that they had just the right amount of information…and also the Cochrane reviews I found were very good’ [010]: ‘…this particular one [table-of-key findings] was not very easy for me to understand…sometimes making a clear cut difference between especially the quality grades was not very easy…alone on itself I found it difficult…I needed to go back to the summaries, read a bit and come and compare…one needed to have some prior knowledge especially on how to interpret it…’ [012]: ‘The systematic reviews give more information on what was done in the research but you will need a lot of time to go through it. So if I were to be asked which one I preferred, I would pick the mini-review [narrative report] because it was very brief and easy to understand. It’s easy to understand and you don’t go and go until you get tired along the way’ [014]: ‘The Cochrane is good because it’s comprehensive and a very good summary of the work that’s available as well as what has been done. Its main disadvantage is that it takes more time to read through and digest. The mini-reviews [narrative reports] were the most useful because they were a condensed version, so they are easy to use even when you have limited time they will prove useful. The table-of-key findings is good for a rapid consultation but doesn’t give you a feel of how those conclusions were arrived at’ [016]: ‘The problem with the reviews is that most of them had limited data…But I was feeling that a lot more other data probably from observation studies could be available and would have been of more value. But at the end of the day you base most of your decisions on randomised controlled trials, but you should know a little more of what was done in the other studies’ Pre-workshop materials [006]: ‘…like the people I was sitting with, most of them had not gone through all of the material, a few had gone through about half and a few had not looked at it at all’ [008]: ‘No, the reading of the materials appeared not to have been exhausting except you backed it up by making presentations…’ [010]: ‘Generally I think very few of the participants went through the materials before coming to the workshop. Personally I would say I didn’t spend adequate time that would have enabled me to understand the material better, for better participation during the workshop…’ [012]: ‘…and the volume of the document was another challenge. With the limited time people had and the volume of the document, people had very little time to go through them’

Box 2. Panelists’ experiences with appraisal and use of research evidence

[004]: ‘No, I can’t say I was comfortable, even when the PICO [Patient, Intervention, Comparison, Outcome] format was introduced I personally had problems understanding it…but now I understand it very properly and even the GRADE system, for me it really sunk well after the evidence week’ [011]: ‘Not at all, even being able to synthesize a research paper…it’s still a process that I would like to learn. For many of the participants I think a short course in that area would be useful and it would help a bit also in the voting’ [013]: ‘Most of us take it [research information] as it’s given to us; we don’t sieve it and see whether it’s of high or low quality…the general practitioners don’t really know the difference of [between] these studies’ [015]: ‘…I didn’t know there is low quality, moderate [quality] or even when I find in the books that it is low quality, I did not know actually what they based it on’

Evidence Summary Formats in Guideline Development

PLOS ONE | 7 January 2013 | Volume 8 | Issue 1 | e55067

locally relevant factors that support implementation, and the full

systematic review, may help those developing guidelines access

and contextualise research evidence.

Supporting Information

Box S1 Research synthesis products. (DOC)

Webappendix S1 Front-end evidence summary. (PDF)

Webappendix S2 Randomisation. (DOCX)

Webappendix S3 Distribution of value and accessibility scores. (DOCX)

Webappendix S4 Data handling and analysis.



We are grateful to Judy Nganga for her help with the organisation of the

workshop. We thank all participants for their time and contributions

during the guideline development workshop. This work is published with

the permission of the Director of KEMRI.

Author Contributions

Conceived and designed the experiments: NO SS EA AF RN ME.

Performed the experiments: NO SS NM AF ME. Analyzed the data: EA

NO ME. Contributed reagents/materials/analysis tools: NO SS NM EA

AF RN ME. Wrote the paper: NO SS NM EA AF RN ME.


1. Mulrow C (1994) Rationale for systematic reviews BMJ 309 (6954).

2. Tugwell P, Robinson V, Grimshaw J, Santesso N (2006) Systematic reviews and

knowledge translation. Bull World Health Organ 84: 643–651.

3. Lavis J, Davies H, Oxman A, Denis J, Golden-Biddle K, et al. (2005) Towards

systematic reviews that inform health care management and policy-making.

J Health Serv Res Policy 10 (Suppl 1):35–48.

4. GRADE working group. Available:

Accessed 2012 Sep 29.

5. Rosenbaum SE, Glenton C, Oxman A (2010) Summary-of-findings tables in

Cochrane reviews improved understanding and rapid retrieval of key

information. J Clin Epidemiol 63: 620–626.

6. Opiyo N, Shepperd S, Musila N, English M, Fretheim A (2012) The ‘‘Child

Health Evidence Week’’ and GRADE grid may aid transparency in the

deliberative process of guideline development. J Clin Epidemiol 65: 962–969.

7. Improving delivery of hospital care in Africa (iDOC Africa). Available: http://

2010.html. Accessed 2012 Dec 7.

8. Communication notes. Reader-friendly writing - 1:3:25. Canadian Health

Services Research Foundation. Available:

PDF/CommunicationNotes/cn-1325_e.pdf. Accessed 2012 Sep 29.

9. Morville P (2004) User experience design Ann Arbor: Semantic Studios LLC.


php. Accessed 2012 Dec 8.

Box 3. Research in context

To compare current results with related studies we searched The Cochrane Library and PubMed (both from database inceptions up to March 2012) for articles examining ways of presenting evidence for use in healthcare decision-making (full search strategy available from the authors on request). The search identified six related studies: three systematic reviews [3,24,25], two randomised controlled trials [5,26] and one qualitative study [15]. Only one [26] of the studies was conducted in a guideline development context. The system- atic reviews noted that presentation of results of systematic reviews [3,24] and health technology assessments [25] using ‘graded-entry’ formats (e.g. one page take home messages, a three-page executive summary and a 25-page report, 1:3:25 format) rendered them more useful to healthcare managers and policymakers. Research syntheses using ‘graded-entry’ formats were however reported to be rare (identified in only 7% of 45 websites searched) [3]. In the first randomised controlled trial [5] participants attending an evidence-based practice workshop (N = 72; Norway) and a Cochrane Collaboration entities meeting (N = 33; UK) were allocated to receive a Cochrane review with or without a summary-of-findings table. Inclusion of a summary-of-findings table was found to significantly im- prove understanding and rapid retrieval of key findings. In the second randomised controlled trial [26], paediatricians and trainee paediatricians in private and public practice in Mexico (N = 216) were allocated to receive the same clinical recommendation presented using four different grading systems: NICE (National Institute for Health and Clinical Excellence), SIGN (Scottish Intercollegiate Guidelines Net- work), GRADE and Oxford CEBM (Centre for Evidence-Based Medicine). The primary outcome was mean change (before

compared to after reading the guideline) in simulated clinician decision to use a therapy. The findings showed that clinician’s decision to use a therapy was influenced most by the GRADE system. However, no significant differences were found between systems in the clarity of presentation of care recommendation (defined as ‘ease of reading and undestanding’). The qualitative interview (N = 13) study [15] explored health policymakers’ and managers’ experiences with short sum- maries of systematic reviews in five low- and middle-income countries, LMICs (Argentina, China, Colombia, South Africa, Uganda). The findings showed that participants preferred ‘graded-entry’ formats, particularly the section on the ‘relevance of the summaries for LMICs, which compensated for the lack of locally-relevant detail in the original review’. Overall, observed differences in results across systematic reviews and primary studies examining impacts of evidence presentation formats, including our own, could be explained by differences in: study designs (randomised controlled trials versus user surveys), presentation formats (due to variations in layouts, contents, visual aids), types of participants (multidisciplinary versus unidisciplinary; variations in evi- dence based behaviors and skills); study contexts (evidence based medicine training versus policymaking environments); definitions of outcome measures (e.g. in Garcı́a et al [26], unlike in other studies, clarity of presentation of recommen- dation was defined as ‘ease of reading and understanding’); and durations of exposure to the evidence summaries. These differences underscore the need for a unified system for evaluating impacts of evidence summary and presentation formats to enhance comparability and interpretation of results of accumulating work in this field.

Evidence Summary Formats in Guideline Development

PLOS ONE | 8 January 2013 | Volume 8 | Issue 1 | e55067

10. Dobbins M, Rosenbaum P, Plews N, Law M, Fysh A (2007) Information

transfer: what do decision makers want and need from researchers? Implement

Sci 2: 20.

11. Guyatt G, Oxman A, Vist G, Kunz R, Falck-Ytter Y, et al. (2008) Rating quality

of evidence and strength of recommendations GRADE: an emerging consensus

on rating quality of evidence and strength of recommendations. BMJ 336: 924–


12. Edmond K, Bahl R (2006) Optimal feeding of low-birth-weight infants.

Technical review. World Health Organisation.

13. World Health Organisation (WHO) (2009) WHO guidelines on hand hygiene in

health care. Geneva: World Health Organisation.

14. Conde-Agudelo A, Belizán J (2003) Kangaroo mother care to reduce morbidity

and mortality in low birthweight infants. Cochrane Database Syst Rev, Issue

2 Art No: CD002771 DOI: 101002/14651858CD002771.

15. Rosenbaum S, Glenton C, Wiysonge C, Abalos E, Mignini L, et al. (2011)

Evidence summaries tailored to health policy-makers in low- and middle-income

countries. Bull World Health Organ 89: 54–61.

16. Rosenbaum S, Glenton C, Cracknell J (2008) User experiences of evidence-

based online resources for health professionals: user testing of The Cochrane

Library. BMC Med Inform Decis Mak 8: 34.

17. National Institute for Health and Clinical Excellence (NICE) (2009) The

guidelines manual. London: National Institute for Health and Clinical


18. World Health Organisation (WHO) (2008) WHO handbook for guideline

development. 19. Murphy M, Black N, Lamping D, McKee C, Sanderson C, et al. (1998)

Consensus development methods, and their use in clinical guideline develop-

ment. Health Technol Assess 2: 1–88. 20. Henderson A (2005) The bootstrap: a technique for data-driven statistics. Using

computer-intensive analyses to explore experimental data. Clin Chim Acta 359: 1–26.

21. Pope C, Ziebland S, Mays N (2000) Qualitative research in health care.

Analysing qualitative data. BMJ 320: 114–116. 22. Duke T, Campbell H, Ayieko P, Opiyo N, English M, et al. (2006) Accessing and

understanding the evidence. Bull World Health Organ 84: 922. 23. English M, Opiyo N (2011) Getting to grips with GRADE-perspective from a

low-income setting. J Clin Epidemiol 64: 708–710. 24. Chambers D, Wilson P, Thomson C, Hanbury A, Farley K, et al. (2011)

Maximizing the impact of systematic reviews in health care decision making: a

systematic scoping review of knowledge-translation resources. Milbank Q 89: 131–156.

25. Lavis J, Wilson M, Grimshaw J, Haynes R, Ouimet M, et al. (2010) Supporting the use of health technology assessments in policy making about health systems.

Int J Technol Assess Health Care 26: 405–414.

26. Garcı́a C, Alvarado K, Gaxiola G (2011) Grading recommendations in clinical practice guidelines: randomised experimental evaluation of four different

systems. Arch Dis Child 96: 723–728.

Evidence Summary Formats in Guideline Development

PLOS ONE | 9 January 2013 | Volume 8 | Issue 1 | e55067

Copyright of PLoS ONE is the property of Public Library of Science and its content may not be copied or

emailed to multiple sites or posted to a listserv without the copyright holder's express written permission.

However, users may print, download, or email articles for individual use.