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EBM analysis
Different knowledge, different styles of reasoning: a challenge for guideline development
  1. Sietse Wieringa1,2,
  2. Dunja Dreesens3,4,
  3. Frode Forland5,
  4. Carel Hulshof6,
  5. Sue Lukersmith7,
  6. Fergus Macbeth8,
  7. Beth Shaw9,
  8. Arlène van Vliet10,
  9. Teun Zuiderent-Jerak11
  10. on behalf of the AID Knowledge Working Group of the Guidelines International Network
    1. 1 Department of Health Sciences, University of Oslo, Oslo, Norway
    2. 2 Department of Continuing Education, University of Oxford, Oxford, UK
    3. 3 School CAPHRI, department of General Practice, Maastricht University, Maastricht, The Netherlands
    4. 4 Knowledge Institute of Medical Specialists, Utrecht, The Netherlands
    5. 5 Division for Infectious Diseases and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway
    6. 6 Coronel Institute of Occupational Health, Amsterdam Medical Center, Amsterdam, The Netherlands
    7. 7 Research School of Population Health, Australian National University, Australia
    8. 8 Centre for Trials Research, Cardiff University, Cardiff, UK
    9. 9 National Institute for Health and Care Excellence, London, UK
    10. 10 Leiden University Medical Center/Dutch Working Party on Infection Prevention, Leiden, The Netherlands
    11. 11 Department of Thematic Studies - Technology and social change, Linköping University, Linkoping, Sweden
    1. Correspondence to Dr Sietse Wieringa, Department of Continuing Education, University of Oxford, Oxford OX1 2JA, UK; sietse.wieringa{at}kellogg.ox.ac.uk

    https://doi.org/10.1136/bmjebm-2017-110844

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      Introduction: the challenge of knowledge inclusion in guidelines

      Evidence-based guidelines whether national, regional or developed by specialty groups, must search for, and explicitly consider, evidence from sources other than conventional clinical trials and their quantitative data. This need for appraising and including knowledge from a wide variety of sources in guideline development is well recognised.1–3

      Although evidence on statistical association—usually from randomised controlled trials (RCTs)—is commonly thought to be the dominant type of knowledge appraised and included, guideline developers frequently use a range of other types of knowledge including the views and experiences of those using and providing health services, understanding of how interventions work (eg, from logic models or realist evaluations), and other information, such as aetiology and the context of care (online supplementary text box 1).

      Supplementary file 1

      [SP1.pdf]

      These different types of knowledge are used and needed in many situations, for example, when evidence from RCTs is not available, impossible to obtain, contradictory or inappropriate. They can also be used in conjunction with knowledge from RCTs to provide context, to assess relevance and to understand bias. Furthermore, explicit (written or spoken) knowledge and the more intricate forms of knowledge like experiential and contextual knowledge can help guideline makers to take an approach consistent with the intentions of early evidence-based medicine (EBM) proponents: namely, that best evidence is not restricted to evidence from RCTs and meta-analyses alone.4

      However, how to properly appraise (judge) and include (integrate) different kinds of knowledge remains unclear. Agreed methods are not yet available or are in the early stages of development and the need for and use of different kinds of knowledge is not always explicitly acknowledged, which affects the use of guidelines in practice.5 6 International and cultural differences in guideline production practices may further impede developments in appraising and including a broader range of types of knowledge (online supplementary …

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