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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p><p>School of Health and Related Research (ScHARR), University of Sheffield. Clinical Guidelines for the Classification and Care of Women at Risk of Familial Breast Cancer in Primary, Secondary and Tertiary Care [Internet]. Sheffield (UK): University of Sheffield; 2004 May. (NICE Clinical Guidelines, No. 14.)</p></div><div class="bk_msg_box bk_bttm_mrgn clearfix bk_noprnt"><div class="iconblock clearfix"><a class="img_link icnblk_img" title="Table of Contents Page" href="/books/n/nicecg164guid/"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-nicecg164guid-lrg.png" alt="Cover" height="100px" width="80px" /></a><div class="icnblk_cntnt"><ul class="messages"><li class="info icon"><span class="icon"><a href="/books/n/nicecg164guid/">A new version of this title is available</a></span></li></ul></div></div></div><div class="messagearea bk_noprnt" style="margin-bottom:1.3846em "><ul class="messages"><li class="warn icon"><span class="icon">This publication is provided for historical reference only and the information may be out of date.</span></li></ul></div><div class="bk_prnt"><p style="color:red;"><strong>This publication is provided for historical reference only and the information may be out of date.</strong></p></div><div class="iconblock clearfix whole_rhythm no_top_margin bk_noprnt"><a class="img_link icnblk_img" title="Table of Contents Page" href="/books/n/nicecg14/"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-nicecg14-lrg.png" alt="Cover of Clinical Guidelines for the Classification and Care of Women at Risk of Familial Breast Cancer in Primary, Secondary and Tertiary Care" height="100px" width="80px" /></a><div class="icnblk_cntnt eight_col"><h2>Clinical Guidelines for the Classification and Care of Women at Risk of Familial Breast Cancer in Primary, Secondary and Tertiary Care [Internet].</h2><a data-jig="ncbitoggler" href="#__NBK65467_dtls__">Show details</a><div style="display:none" class="ui-widget" id="__NBK65467_dtls__"><div>NICE Clinical Guidelines, No. 14.</div><div>School of Health and Related Research (ScHARR), University of Sheffield.</div><div>Sheffield (UK): <a href="https://www.sheffield.ac.uk/scharr" ref="pagearea=page-banner&targetsite=external&targetcat=link&targettype=publisher">University of Sheffield</a>; 2004 May.</div></div><div class="half_rhythm"><ul class="inline_list"><li style="margin-right:1em"><a class="bk_cntns" href="/books/n/nicecg14/">Contents</a></li></ul></div></div><div class="icnblk_cntnt two_col"><div class="pagination bk_noprnt"><a class="active page_link prev" href="/books/n/nicecg14/ch1/" title="Previous page in this title">< Prev</a><a class="active page_link next" href="/books/n/nicecg14/ch3/" title="Next page in this title">Next ></a></div></div></div></div></div>
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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/CreativeWork"><div class="meta-content fm-sec"><h1 id="_NBK65467_"><span class="label"> 2</span><span class="title" itemprop="name">Guideline development</span></h1></div><div class="jig-ncbiinpagenav body-content whole_rhythm" data-jigconfig="allHeadingLevels: ['h2'],smoothScroll: false" itemprop="text"><div id="ch2.s1"><h2 id="_ch2_s1_">2.1. The guideline</h2><p>The guideline is aimed at all health care professionals providing care to women who present with concerns about the <a class="def" href="/books/n/nicecg14/glossary.gl1/def-item/glossary.gl1-d27/">risk</a> of developing breast cancer because of a <a class="def" href="/books/n/nicecg14/glossary.gl1/def-item/glossary.gl1-d7/">family history</a>.</p><p>The guideline aims to provide recommendations to help health care professionals in primary, secondary and tertiary care.</p><p>Guideline development methods are NICE development process, which are described in three NICE Guideline Development Process Manuals, available on the NICE website (<a href="http://www.nice.org.uk" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">www.nice.org.uk</a>).</p><p>Key features of the guideline are that:</p><ul><li class="half_rhythm"><div>it is evidence based, where evidence is available</div></li><li class="half_rhythm"><div>in areas where evidence is lacking this is made clear, and the consensus methods used are clearly described</div></li><li class="half_rhythm"><div>recommendations are explicitly linked to evidence where it is available</div></li><li class="half_rhythm"><div>the recommendations, methods and conclusions in the guideline are explicit and transparent.</div></li></ul><p>The full scope of the guideline is presented in <a href="/books/n/nicecg14/appendixes.app22/">Appendix 22</a>.</p></div><div id="ch2.s2"><h2 id="_ch2_s2_">2.2. Using guidelines</h2><p>Guidelines are only one type of information that health care professionals may use when making decisions about patient care. It is assumed that this guideline, like all guidelines, will be used by health care professionals who will also bring to bear their clinical knowledge and judgement in making decisions about caring for individual patients. It may not always be appropriate to apply either specific recommendations or the general messages in this document to each individual or in every circumstance. The availability of resources may also influence decisions about patient care, including the adoption of recommendations.</p></div><div id="ch2.s3"><h2 id="_ch2_s3_">2.3. Responsibility and support for the guideline</h2><p>The guideline was commissioned by NICE. The development of the guideline was undertaken by ScHARR, University of Sheffield, a provider partner in the National Collaborating Centre for Primary Care (NCC-PC). The guideline development group (GDG) was convened by the NCC-PC. The guideline development group consisted of relevant health care professionals, patient representatives and guideline developers, including a systematic reviewer. The membership of guideline development group is shown in <a href="/books/n/nicecg14/appendixes.app21/">Appendix 21</a>.</p></div><div id="ch2.s4"><h2 id="_ch2_s4_">2.4. Scope of the guideline</h2><p>The scope of this guideline was care, and classification, of women at <a class="def" href="/books/n/nicecg14/glossary.gl1/def-item/glossary.gl1-d27/">risk</a> of breast cancer because of <a class="def" href="/books/n/nicecg14/glossary.gl1/def-item/glossary.gl1-d7/">family history</a>. The guideline covers women aged 18 years and older. It does not cover women who have breast cancer. It does <b>not</b> cover the care and management of men who may be at risk because of family history. The guideline addresses care in primary, secondary and tertiary care in respect of these women. However, the guideline does not cover in detail some aspects of some interventions that may be relevant, for example it does not address methods of screening in detail as that is outwith the scope. The full scope can be seen in <a href="/books/n/nicecg14/appendixes.app22/">Appendix 22</a>.</p></div><div id="ch2.s5"><h2 id="_ch2_s5_">2.5. Key clinical questions</h2><p>The guideline development group identified the potential pathways that women with a <a class="def" href="/books/n/nicecg14/glossary.gl1/def-item/glossary.gl1-d7/">family history</a> of breast cancer might take in accessing and moving though health care services. From these pathways they identified potential interventions that might be available and also the decision points where these interventions might have to be considered by women and those involved in their care.</p><p>This evidence pathway is presented in <a href="/books/n/nicecg14/appendixes.app24/">Appendix 24</a>, along with the literature search strategies.</p></div><div id="ch2.s6"><h2 id="_ch2_s6_">2.6. Evidence identification</h2><p>The development of the clinical guideline took an explicit, systematic approach to evidence identification, consideration and presentation. However it is perhaps worth noting that it is a clinical guideline and is resourced as such rather than a set of exhaustive systematic reviews. The guideline does not set out to undertake comprehensive systematic reviews for each topic area that it covers as this cannot be achieved with the resources available. In this guideline about 30 would have been required. The NICE guideline development process allows the use of existing meta-analyses and systematic reviews where they exist as a basis for evidence statements and recommendations.</p><p>The searching provided most of the papers contained in the guideline. This was in spite of the searching for articles that specifically addressed populations with a <a class="def" href="/books/n/nicecg14/glossary.gl1/def-item/glossary.gl1-d7/">family history</a> not being straightforward. Many papers addressed breast cancer in populations both with and without family histories and the indexing of papers in databases did not always pick this up, leading to some articles perhaps being missed. We used the expertise available on the group to identify papers that may have been missed as is common practice in NICE and other guideline development and other evidence assimilation processes.</p><p>In addition to the guideline scope the GDG identified key clinical questions to be addressed by the guideline these provided a starting framework for considerations of relevance. Late papers have been accommodated in the document and these have been discussed with the GDG to consider what if any impact they have on the recommendations, evidence statements and discussions in the relevant sections.</p><div id="ch2.s7"><h3>2.6.1. Search strategies</h3><p>The search strategies attempted to locate the best available evidence for the interventions identified. It was recognised very early that in many instances this would not be meta-analyses, systematic reviews or RCTs. The searches therefore were wide ranging in the types of study that were searched for.</p><p>Searches for studies that included women with a <a class="def" href="/books/n/nicecg14/glossary.gl1/def-item/glossary.gl1-d7/">family history</a> of breast cancer, including BRCA1 and BRCA2 carriers were undertaken. However, in many instances studies relevant for family history were not found and therefore studies of general populations of women were also used.</p><p>Searches were limited to English language citations.</p><p>The databases searched and example search strategies can be found in <a href="/books/n/nicecg14/appendixes.app24/">Appendix 24</a>.</p><p>For each intervention the evidence of effectiveness, evidence of harm and cost effectiveness information was sought.</p></div><div id="ch2.s8"><h3>2.6.2. Sifting and reviewing the evidence</h3><p>Studies retrieved were assessed for their quality and relevance in answering the key clinical questions identified by the clinical working group and the pathways of care exercise.</p><p>For studies where our concern is that of what intervention seems to be most effective, then in our assessment of those studies our key concern was the quality of the study in terms of the various aspects of study validity. Firstly, if a study can credibly demonstrate the causal relationship between treatment and outcome then it can be said to have internal validity. Secondly, if the findings can be generalised from the specific study sample to a wider population, then it is said to be generalisable or to have external validity. Thirdly, if the study actually measures what it says it measures then it is said to have construct validity.</p><p>Study quality was assessed using modified SIGN checklists.</p></div><div id="ch2.s9"><h3>2.6.3. Synthesising the evidence</h3><p>Extraction tables and narrative descriptions of studies were used to provide the basis for conclusions about the findings of the body of evidence.</p><p>Many meta-analyses and systematic reviews included papers that involved populations of women with a <a class="def" href="/books/n/nicecg14/glossary.gl1/def-item/glossary.gl1-d7/">family history</a> and women without a family history, and in many instances did not differentiate in any given conclusions etc. In the guideline if there are papers that were concerned primarily with women with a family history, we have often given a précis of these studies in addition to the meta-analyses/systematic reviews as this population is the one the guideline is primarily concerned with and may have information that is pertinent to this group but lost in the overall findings.</p></div><div id="ch2.s10"><h3>2.6.4. Areas without evidence</h3><p>The guideline development group used informal consensus methods to derive evidence statements and recommendations in areas where research literature was not available, drawing upon their clinical knowledge and experience. Theses are graded accordingly (D level recommendations).</p><p>Although research evidence may be lacking there is a clinical need for this guideline and it is therefore acceptable to present consensus based recommendations for care.</p></div></div><div id="ch2.s11"><h2 id="_ch2_s11_">2.7. Evidence grading</h2><p>Once individual papers had been assessed for methodological quality and relevance in terms of our key clinical questions, they were graded according to the levels of evidence currently used by NICE.</p><div id="ch2.tu1" class="table"><h3><span class="title">Classification of Evidence</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK65467/table/ch2.tu1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__ch2.tu1_lrgtbl__"><table class="no_top_margin"><thead><tr><th id="hd_h_ch2.tu1_1_1_1_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">Evidence level</th><th id="hd_h_ch2.tu1_1_1_1_2" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;">Description</th></tr></thead><tbody><tr><td headers="hd_h_ch2.tu1_1_1_1_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;"><b>Ia:</b></td><td headers="hd_h_ch2.tu1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">evidence from meta-analysis of randomised controlled trials</td></tr><tr><td headers="hd_h_ch2.tu1_1_1_1_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;"><b>Ib:</b></td><td headers="hd_h_ch2.tu1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">evidence from at least one randomised controlled trial</td></tr><tr><td headers="hd_h_ch2.tu1_1_1_1_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;"><b>IIa:</b></td><td headers="hd_h_ch2.tu1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">evidence from at least one controlled study without randomisation</td></tr><tr><td headers="hd_h_ch2.tu1_1_1_1_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;"><b>IIb:</b></td><td headers="hd_h_ch2.tu1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">evidence from at least one other type of quasi-experimental study</td></tr><tr><td headers="hd_h_ch2.tu1_1_1_1_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;"><b>III:</b></td><td headers="hd_h_ch2.tu1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies</td></tr><tr><td headers="hd_h_ch2.tu1_1_1_1_1" rowspan="1" colspan="1" style="text-align:center;vertical-align:top;"><b>IV:</b></td><td headers="hd_h_ch2.tu1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">evidence from expert committee reports or opinions and/or clinical experience of respected authorities</td></tr></tbody></table></div></div><p>This classification is most appropriate for questions of causal relationships, and is usually used to assign studies, dealing with causal relationships, to levels of evidence.</p><p>In many areas within this guideline other types of evidence have been used. In many areas the best available evidence comes quite far down the hierarchy. In some instances the most appropriate type of study has been used (e.g. cohort), so despite attracting a ‘low’ level of evidence in this hierarchy, it is nonetheless the best and methodologically appropriate evidence. Thus the best evidence might not appear to be very strong but this should be seen in terms of a shortcoming of the grading approach rather than a reflection of the evidence available in many instances.</p><p>The literature was synthesised, using a qualitative narrative approach, to produce an evidence report. This also included health economics information. This evidence report, with summary evidence statements, was presented to the guideline development group.</p></div><div id="ch2.s12"><h2 id="_ch2_s12_">2.8. Derivation and grading of recommendations</h2><p>The derivation of recommendations usually involves assessment of evidence, processes of interpretation and consensus to arrive at recommendations. The mix of evidence, interpretation and consensus will vary between topic areas. The grading of recommendations takes account of this and therefore variation may occur between different groups presented with the same evidence. Whilst evidence statements can be formulated without reference to the context in which clinicians practise, this is not always the case with recommendations.</p><p>Recommendations were graded A to D, using the current NICE approach.</p><div id="ch2.tu2" class="table"><h3><span class="title">Grading of Recommendations</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK65467/table/ch2.tu2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__ch2.tu2_lrgtbl__"><table class="no_top_margin"><tbody><tr><td rowspan="1" colspan="1" style="text-align:center;vertical-align:top;"><b>A</b></td><td rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">directly based on category I evidence</td></tr><tr><td rowspan="1" colspan="1" style="text-align:center;vertical-align:top;"><b>B</b></td><td rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">directly based on category II evidence, or extrapolated recommendation from category I evidence</td></tr><tr><td rowspan="1" colspan="1" style="text-align:center;vertical-align:top;"><b>C</b></td><td rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">directly based on category III evidence, or extrapolated recommendation from category I or II evidence</td></tr><tr><td rowspan="1" colspan="1" style="text-align:center;vertical-align:top;"><b>D</b></td><td rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">directly based on category IV evidence, or extrapolated recommendation from category I, II or III evidence</td></tr></tbody></table></div></div><p>The NICE guideline development process requires that recommendations are graded on the basis of the evidence that underpins them. The recommendation grading process does not take clinical importance into account. In some instances a lower than expected recommendation grading may be presented, but this will be as a result of extrapolation of higher level evidence, and may for example reflect different populations or settings presented in the evidence and that found in clinical practice in England and Wales.</p><p>A low graded recommendation e.g. a D level recommendation does not therefore mean that it is not an important recommendation it only reflects the level of evidence, using the hierarchy described previously, that underpins the recommendation and is not a reflection of its clinical or policy relevance or importance.</p></div><div id="ch2.s13"><h2 id="_ch2_s13_">2.9. Cost effectiveness review and analysis</h2><p>NICE guidelines do not currently require a cost impact to be undertaken, which would model the likely cost of implementing all or some of the recommendations. It is recognised that the issue of resource implications of guideline implementation is a major concern. A pilot study to look at methods of undertaking cost impacts of guidelines is currently being commissioned.</p><div id="ch2.s14"><h3>2.9.1. Review</h3><div id="ch2.s15"><h4>Identification of papers</h4><p>This strategy aimed to identify all relevant studies of cost-effectiveness across the entire scope of the guideline. A literature search was undertaken alongside the clinical literature review. Details of the databases searched and the filters used to identify relevant economic studies are given in <a href="/books/n/nicecg14/appendixes.app24/">Appendix 24</a>. Titles and abstracts were then examined by hand in order to identify cost-effectiveness, cost-utility or cost-benefit studies (CEA, CUA, CBA). Members of the guideline development group provided additional references that had not been identified by the searches.</p><p>Studies that did not appear to be CEA, CUA or CBA were not reviewed. This excluded a number of studies that examined only costs. Only primary studies were included except in the area of mammographic surveillance since in this area there were no studies relevant directly to women with a familial history but a large number of studies relating to the cost-effectiveness of surveillance in other women. Consistent with the clinical review, the IARC screening report (<a href="/books/n/nicecg14/references.rl1/#references.r132" data-bk-pop-rid="/books/n/nicecg14/references.rl1/def-item/references.r132/" data-bk-pop-others="" class="bk_pop">IARC 2002a</a>) was used.</p></div><div id="ch2.s16"><h4>Reviewing the evidence</h4><p>Eligible papers were assessed using the Drummond checklist (Drummond et al. 1996) for economic evaluations as a basis for review. A narrative was produced for each paper that reflected these methodological issues and any additional information that was considered relevant to the guideline.</p></div></div><div id="ch2.s17"><h3>2.9.2. Estimation of cost effectiveness</h3><p>The scope of the guideline is broad, including the assessment of <a class="def" href="/books/n/nicecg14/glossary.gl1/def-item/glossary.gl1-d27/">risk</a>, genetic testing, management strategies including risk reducing surgery, chemo- <a class="def" href="/books/n/nicecg14/glossary.gl1/def-item/glossary.gl1-d21/">prophylaxis</a>, and surveillance. Inevitably there are substantial gaps in the economic evidence base. At an early stage the guideline development group identified those areas that they felt were most likely to require additional, primary economic analysis. A decision analytic model was developed as a result of these discussions in order to assess the cost-effectiveness of genetic testing of women at varying degrees of breast cancer risk due to familial history. This model is discussed in more detail in <a href="/books/n/nicecg14/appendixes.app20/">Appendix 20</a>.</p></div></div><div id="ch2.s18"><h2 id="_ch2_s18_">2.10. Consensus in recommendations</h2><p>There may be areas where the group was unable to reach consensus on an area, no matter whether evidence is available or not. Where this has happened it is stated that a consensual recommendation could not be reached, the opposing views are presented and the final decision is left to the user of the guidelines.</p><p>Consensus was reached in all recommendations.</p></div><div id="ch2.s19"><h2 id="_ch2_s19_">2.11. Guideline review</h2><p>The process of reviewing the evidence is expected to begin 4 years after the date of issue of this guideline. Reviewing may begin earlier than 4 years if significant evidence that affects the guideline recommendations is identified sooner. The updated guideline will be available within 2 years of the start of the review process.</p></div><div id="bk_toc_contnr"></div></div></div>
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<div class="post-content"><div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © 2004, School of Health and Related Research (ScHARR), University of Sheffield.</div><div class="small"><span class="label">Bookshelf ID: NBK65467</span></div><div style="margin-top:2em" class="bk_noprnt"><a class="bk_cntns" href="/books/n/nicecg14/">Contents</a><div class="pagination bk_noprnt"><a class="active page_link prev" href="/books/n/nicecg14/ch1/" title="Previous page in this title">< Prev</a><a class="active page_link next" href="/books/n/nicecg14/ch3/" title="Next page in this title">Next ></a></div></div></div></div>
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<div xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>Views</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="PDF_download" id="Shutter"></a></div><div class="portlet_content"><ul xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="simple-list"><li><a href="/books/NBK65467/?report=reader">PubReader</a></li><li><a href="/books/NBK65467/?report=printable">Print View</a></li><li><a data-jig="ncbidialog" href="#_ncbi_dlg_citbx_NBK65467" data-jigconfig="width:400,modal:true">Cite this Page</a><div id="_ncbi_dlg_citbx_NBK65467" style="display:none" title="Cite this Page"><div class="bk_tt">School of Health and Related Research (ScHARR), University of Sheffield. Clinical Guidelines for the Classification and Care of Women at Risk of Familial Breast Cancer in Primary, Secondary and Tertiary Care [Internet]. Sheffield (UK): University of Sheffield; 2004 May. (NICE Clinical Guidelines, No. 14.) 2, Guideline development.<span class="bk_cite_avail"></span></div></div></li><li><a href="/books/n/nicecg14/pdf/">PDF version of this title</a> (7.0M)</li><li><a href="#" class="toggle-glossary-link" title="Enable/disable links to the glossary">Disable Glossary Links</a></li></ul></div></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>In this Page</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="page-toc" id="Shutter"></a></div><div class="portlet_content"><ul xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="simple-list"><li><a href="#ch2.s1" ref="log$=inpage&link_id=inpage">The guideline</a></li><li><a href="#ch2.s2" ref="log$=inpage&link_id=inpage">Using guidelines</a></li><li><a href="#ch2.s3" ref="log$=inpage&link_id=inpage">Responsibility and support for the guideline</a></li><li><a href="#ch2.s4" ref="log$=inpage&link_id=inpage">Scope of the guideline</a></li><li><a href="#ch2.s5" ref="log$=inpage&link_id=inpage">Key clinical questions</a></li><li><a href="#ch2.s6" ref="log$=inpage&link_id=inpage">Evidence identification</a></li><li><a href="#ch2.s11" ref="log$=inpage&link_id=inpage">Evidence grading</a></li><li><a href="#ch2.s12" ref="log$=inpage&link_id=inpage">Derivation and grading of recommendations</a></li><li><a href="#ch2.s13" ref="log$=inpage&link_id=inpage">Cost effectiveness review and analysis</a></li><li><a href="#ch2.s18" ref="log$=inpage&link_id=inpage">Consensus in recommendations</a></li><li><a href="#ch2.s19" ref="log$=inpage&link_id=inpage">Guideline review</a></li></ul></div></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>Other titles in this collection</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="source-links" id="Shutter"></a></div><div class="portlet_content"><ul xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="simple-list"><li><a href="/books/n/nicecollect/">National Institute for Health and Clinical Excellence: Guidance
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