There is a document outlining guidelines for standardizing the wording used in evidence conclusions and recommendations in evidence-based reviews developed by the Centre for Evidence-Based Practice of Belgian Red Cross-Flanders. The document provides criteria for evidence conclusions, including specifying the number and type of studies, intervention, comparison, outcome, level of evidence, and direction of effect. It establishes standard wording for different categories of evidence conclusions based on statistical significance, level of evidence, and precision of results. The implications for drafting recommendations based on the evidence conclusions are also discussed.

1. Standard wording for
formulating evidence
conclusions and implications for
recommendations
Emmy De Buck
Manager Centre for Evidence-Based Practice
Belgian Red Cross-Flanders
Rode Kruis

2. Disclosure of interests
I certify that, to the best of my knowledge, no aspect of my
current personal or professional situation might reasonably be
expected to affect significantly my views on the subject on
which I am presenting, other than the following:
Financial relationships:
Employment at the Centre for Evidence-Based Practice of
Belgian Red Cross-Flanders

3.  Centre for Evidence-Based Practice (CEBaP) of Belgian Red
Cross-Flanders:
provides evidence-based support to all programmes and
activities of Belgian Red Cross-Flanders, by developing:
− Practice guidelines
− Systematic reviews
 Staff: 4 methodologists, PhD’s
Introduction

4. Rationale
 In our centre several methodologists (reviewers) work
in parallel to develop evidence reviews in a timely way
 The evidence conclusions go from the methodologists
to other collaborators (colleagues of operational
services, experts)
 Þ Important to standardize the evidence synthesis and
to provide standard wording of the evidence
conclusions/statements

5. Wording of evidence conclusions (1)
 Information from guideline developers:
− NICE1: “A short evidence statement should be presented
alongside the evidence profile, summarising the key
features of the evidence on clinical and cost effectiveness”
− SIGN2: no narrative evidence conclusions
− Finnish Medical Society Duodecim3: wording varies
depending on the level of evidence
1 http://publications.nice.org.uk/the-guidelines- manual-pmg6/reviewing-the-evidence
2 http://www.sign.ac.uk/methodology/index.html
3http://2011.colloquium.cochrane.org/sites/2011.colloquium.cochrane.org/files/uploads/users/
u721/Wording%20of%20evidence%20and%20recommendations%20in%20EBM%20Guidelines.doc

6. Wording of evidence conclusions (2)
 Information from systematic review developers:
− Wide variation among authors in the Cochrane Library in
reporting results and conclusions1
− The Cochrane Handbook, Chapter 9, Section 9.12:
• “A narrative assessment of the evidence can be challenging...”
• “If a descriptive paragraph is provided for the results from each
study, this should be done consistently, including the same
elements of information for each study.”
• “Organizing the studies into groupings or clusters is encouraged
(e.g. by intervention type, population groups, setting etc).”
 Conclusion: almost no guidance about wording of
evidence conclusions
1 Van Tulder et al. 2003. SPINE 28(12): 290–1299
2 http://handbook.cochrane.org/chapter_9/9_1_introduction.htm

7. Criteria for evidence conclusions (1)
 Target population for reading the evidence conclusions:
− colleagues who write draft recommendations
− experts who validate the draft recommendations
 Evidence conclusions should contain:
− number and type of studies
− intervention, comparison
− outcome
− level of evidence
− direction of effect

8. Criteria for evidence conclusions (2)
 Wording of evidence conclusions should reflect:
− if results were statistically significant or not
− the quality of the evidence
− the difference between “evidence of no effect” and “no
evidence of effect” 1
 Evidence conclusions should be organized according to
the intervention, outcome,…
 Categories of evidence conclusions:
− Evidence and limited evidence
− No evidence
− Conflicting evidence
1 Altman and Bland 1995. BMJ 311: 485

9. START
Is the intervention considered as
common sense?
Is there any evidence available?
Y
Is the evidence conflicting?
N
Is the body of evidence of low or very
low quality?
N
Is there any imprecision?
“No evidence”
N
Y
Y
“Conflicting
evidence”
“Limited evidence”
Y “Limited evidence”
N
“Evidence”
Y
N
Is it an
important practical point
Flowchart
of which the expert panel reaches
a consensus and nobody
is likely to question
it?
Y
N
Is the balance made by the expert
panel positive?
No Good Practice Point
Y Recommendation
N No Recommendation
Is the balance made by the expert
panel positive?
Y
N
Is the balance made by the expert
panel positive?
Y
N
Good Practice Point
Literature review Consensusmeeting with experts
Recommendation
No Recommendation
Recommendation
No Recommendation

10. Standard wording
Category of evidence Wording of evidence conclusion
No evidence No relevant studies were identified using the
above search strategy and criteria.
Conflicting evidence There is conflicting evidence from # experimental
studies and/or # observational studies…
(Limited) evidence Wording depends on:
-statistical significance
-level of evidence (LOE)
-imprecision
See extended table

11. P-value
LOE Imprecisio
n
Wording
Standard wording
< 0.05 A/B No There is evidence from # experimental studies and/or #
observational studies in favour of [intervention] (<Author>
<year>, <Author> <year>, etc.).
It was shown that <intervention> resulted in a statistically
significant increase/decrease of <outcome>, compared to
<comparison> (<Author> <year>).
Evidence is of high/moderate quality.
Yes There is limited evidence ... It was shown that ...
Evidence is of moderate quality and results cannot be
considered precise due to limited sample size, lack of data
and/or large variability of results.
C/D No There is limited evidence ... It was shown that ...
Evidence is of low/very low quality.
Yes There is limited evidence ... It was shown that ...
Evidence is of low/very low quality and results cannot be
considered precise due to ...

12. P-value
LOE Imprecisio
n
Wording
> 0.05 A/B No There is evidence from # experimental studies and/or #
observational studies, neither in favour of the intervention
nor the control (<Author> <year>, <Author> <year>, etc.).
It was shown that <intervention> did not result in a
statistically significant difference of <outcome>,
compared to <comparison> (<Author> <year>).
Evidence is of high/moderate quality.
Yes There is limited evidence ...
A statistically significant increase/decrease of <outcome>,
using <intervention> compared to <comparison>, could not
be demonstrated (<Author> <year>).
Evidence is of moderate quality and results of this
study/these studies are imprecise due to limited sample
size, lack of data and/or large variability of results.
C/D No There is limited evidence ... It was shown that
<intervention> did not result ...
Evidence is of low/very low quality.
Yes There is limited evidence ... A statistically significant
increase/decrease ... could not be demonstrated ...
Evidence is of low/very low quality and results of this
study/these studies are imprecise due to ...

13. Implications for recommendations
 Only in case of p<0.05, LOE A/B and no imprecision, a
draft recommendation for or against the intervention
should be included in the guideline
 In the other cases: a draft recommendation may be
included in the guideline
 The final recommendation will be based on the
judgement of the multidisciplinary expert panel, taking
into account:
− the scientific evidence
− preferences of the target group
− expertise and practical experience

14. Example
 PICO: Is rice water (I) effective compared to standard
Oral Rehydration Solution (ORS) (C) to improve
diarrhoea (O) in adults or children with diarrhoea (P)?
 Included studies: 2 RCTs: Metha 1986, Fakhir 1990
High [A] Downgrading due to
Limitations of study
design
-1 Lack of blinding/blinding
unclear; lack of
allocation concealment
in 1 study
Imprecision -1 Limited sample size
Inconsistency 0
Indirectness 0
Publication bias 0
QUALITY (GRADE) Low [C]

15. Example
Outcome Comparison Effect Size #studies
# parti-cipants
Ref
Stool frequency
between 1 and 3
per day
Rice water
versus glucose
ORS
Day 1: Not statistically significant:
4/100 vs 0/100; RR: 9.00, 95% CI [0.49, 165.00] (p=0.14)
Day 2: Statistically significant:
16/100 vs 6/100; RR: 2.67, 95% CI [1.09, 6.54] (p=0.03)
Day 3: Statistically significant:
46/100 vs 27/100; RR: 1.70, 95% CI [1.16, 2.51] (p=0.007)
Day 4: Statistically significant:
68/100 vs 42/100; RR: 1.62, 95% CI [1.24, 2.11]
(p=0.0004)
1, 100 vs
100
Metha,
1986
Small stool volume Day 1: Not statistically significant:
2/100 vs 0/100; RR: 5.00, 95% CI [0.24, 102.85] (p=0.30)
Day 2: Not statistically significant:
40/100 vs 30/100; RR: 1.33, 95% CI [0.91, 1.96] (p=0.14)
Day 3: Not statistically significant:
56/100 vs 42/100; RR: 1.33, 95% CI [1.00, 1.78] (p=0.05)
Day 4: Statistically significant:
76/100 vs 44/100; RR: 1.73, 95% CI [1.35, 2.21]
(p<0.0001)
Duration of purging
in the hospital
(hours)
Statistically significant:
60.2±2.6 vs 78.6±4.6
MD: -18.40, 95%CI ; [-20.60;-16.20] (p=0.00001)
1, 20 vs
23
Fakhir,
1990

16. P-value
LOE Imprecisio
n
Wording
Example
< 0.05 A/B No There is evidence from # experimental studies and/or #
observational studies in favour of [intervention] (<Author>
<year>, <Author> <year>, etc.).
It was shown that <intervention> resulted in a statistically
significant increase/decrease of <outcome>, compared to
<comparison> (<Author> <year>).
Evidence is of high/moderate quality.
Yes There is limited evidence ... It was shown that ...
Evidence is of moderate quality and results cannot be
considered precise due to limited sample size, lack of data
and/or large variability of results.
C/D No There is limited evidence ... It was shown that ...
Evidence is of low/very low quality.
Yes There is limited evidence ... It was shown that ...
Evidence is of low/very low quality and results cannot be
considered precise due to ...

17. Example
 PICO: Is rice water (I) effective compared to standard Oral
Rehydration Solution (ORS) (C) to improve diarrhoea (O) in
adults or children with diarrhoea (P)?
 Evidence conclusion:
There is limited evidence from 2 experimental studies in
favour of rice water (Metha 1986, Fakhir 1990).
It was shown that rice water resulted in a statistically
significant decrease of duration of purging, stool frequency
on day 2 to 4 and stool volume on day 4 compared to using
standard ORS.
Evidence is of low quality and results cannot be considered
precise due to a limited sample size.

18. Take home message
 The use of standard wording in our evidence
conclusions resulted in:
− standardized training of new staff members
− guidelines with uniform evidence statements
− a better interpretation of the available evidence
− more transparency in our methodology
 Recommendation for guideline developers:
− use standard wording of evidence conclusions, in
order to improve consistency within one guideline
and between guidelines

19. Acknowledgements
 Thanks to my colleagues Tessa, Nele and Hans for
the fruitful discussions concerning this subject.

20. Centre for Evidence-Based Practice
 Thank you for your attention !
 Questions ?
 Contact:
 Cebap@rodekruis.be
 Emmy.Debuck@rodekruis.be