As evidence-based guidelines, the German S3 guidelines follow a structured approach. The first step in the guideline process is to nominate the people who will contribute to the guidelines. This includes the guideline project team who coordinate the guidelines, the team of experts who review the literature and last but not least the extended committee who formulate and pass the proposed recommendations. The next step is to review the literature. As the hits based on the different literature databases are not very sensitive and specific, the relevant articles need to be pre-screened and selected for the review process. In the review process itself the papers are evaluated for inclusion/exclusion criteria, quality of the methods and presentation of the results. Finally, a grade of evidence is given to each paper. As several definitions for the "grade of evidence" exist, the grade of evidence itself needs to be defined. Usually, it is based on the recommendations from the Oxford Centre of Evidence Based Medicine.
Using the Oxford classification as a basis, the German Guidelines Team developed an adapted version, ranging from systematic reviews with meta-analyses (the highest level) to expert opinions (the lowest level). As the grade of evidence is based on a single paper, a "level of evidence" was assigned to sum up the evidence of all reviewed papers for one intervention. Here again, the highest grade would be for an intervention that is based on systematic reviews or the consistent results of good clinical trials.
The final "therapeutic recommendations"are formulated considering the evaluated evidence-based literature on efficacy, as well as other aspects such as safety, practicability and costs. These therapeutic recommendations should be real consensus statements and great efforts have to be taken to make sure that the majority of the guideline group agrees on the formulation.
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