Anja Fog Heen

• Stokland, Ann-Elin Meling; Breivik, Lars; Dalen, Ingvild; Steintorsdottir, Sandra Dis; Kildal, Simon & Nermoen, Ingrid [Show all 30 contributors for this article] (2026). Risk and outcomes of adrenal crisis in primary adrenal insufficiency: Evidence from a 24‐year nationwide cohort study. Journal of Internal Medicine. ISSN 0954-6820. 300(5), p. 675–688. doi: 10.1111/joim.70153. Full text in Research Archive Show summary

  Background: Adrenal crisis is a life‐threatening emergency. Despite preventive strategies, previous reports suggest increasing incidence and substantial mortality, but robust validated data are limited. Objective: To assess temporal trends in adrenal crisis incidence and identify associated risk factors. Methods: We studied 1040 patients with autoimmune or idiopathic primary adrenal insufficiency enrolled in the Norwegian Addison Registry. Medical records were reviewed for crisis‐related hospitalizations between 2000 and 2023. Overt adrenal crisis was defined by acute clinical deterioration with hemodynamic or biochemical abnormalities, whereas incipient crisis was defined by typical symptoms without objective abnormalities. Results: During a median follow‐up of 15 years, 660 patients (63%) experienced crisis‐related hospitalizations, and 265 (25%) had an overt adrenal crisis after diagnosis. The incidence of overt crises was 3.2 per 100 person‐years and that of incipient crises was 6.9 per 100 person‐years. Admission rates for incipient crises increased significantly over time ( p  < 0.001), whereas overt crisis rates remained stable. Among 1754 admissions, five deaths (0.3%) were attributed to adrenal crisis. Both younger and older age ( p  < 0.001) and type 1 diabetes (incidence rate ratio 2.09, 95% confidence interval 1.45–3.01; p  < 0.001) were associated with increased overt crisis risk. Daily corticosteroid dose was not associated with crisis risk. Prehospital stress dosing was used in about 50% of admissions. Conclusions: Overt adrenal crisis was uncommon and crisis‐related in‐hospital mortality was exceptionally low. Crisis risk was independent of replacement dose but increased in patients with type 1 diabetes. Strengthening education and implementation of prehospital stress dosing may further reduce the burden of adrenal crises.

• Chu, Xiajing; Mubasher, Javeria; Chen, Lina; Chu, Alexandro W.L.; Oykhman, Paul & Brignardello-Petersen, Romina [Show all 31 contributors for this article] (2025). Patient Values and Preferences in Chronic Urticaria Treatment: A Systematic Review. JAMA dermatology. ISSN 2168-6068. doi: 10.1001/jamadermatol.2025.3663. Full text in Research Archive
• Lima, João Pedro; Mbuagbaw, Lawrence; Prasad, Manya; Kumar, Amit; Wafeu, Guy Sadeu & Bonnet, Romain [Show all 19 contributors for this article] (2025). Determinants of treatment decisions in advanced dementia: a protocol for a cross-cultural mixed-methods study. BMJ Open. 15(12), p. e105188–e105188. doi: 10.1136/bmjopen-2025-105188. Full text in Research Archive
• Loor-Torres, Ricardo; Bui, Yvonne; Steffensen, Karina Dahl; Heen, Anja Fog; Agoritsas, Thomas & Kunneman, Marleen [Show all 11 contributors for this article] (2025). Leading with options or issues to support purposeful shared decision-making in clinical practice. BMJ Evidence-Based Medicine. ISSN 2515-446X. doi: 10.1136/bmjebm-2024-113322. Full text in Research Archive
• Hunskaar, Birk Bårdson Stokke; Løvsletten, Per Olav; Achille, Frankie Alexander Spencer; Heen, Anja Fog; Agoritsas, Thomas & Vandvik, Per Olav (2024). MATCH-IT: A decision support tool for multiple comparisons presenting data from network meta-analysis to facilitate guideline development. Clinical and Public Health Guidelines. 1(4). doi: 10.1002/gin2.70003. Full text in Research Archive Show summary

  Introduction: Network meta‐analysis (NMA) provides unprecedentedopportunities to compare multiple treatment options (multiple comparisons)and are increasingly being used to inform clinical practice guidelines.However, the overwhelming amount of data generated from NMAs ischallenging to present in comprehensible overviews for end‐users, guidelinepanelists included. Acknowledging these challenges, we developedMATCH‐IT—an interactive evidence summary displaying NMA results formultiple comparisons. In this study, we conducted user‐testing and furtherdeveloped MATCH‐IT to support guideline panels in moving from NMAevidence to recommendations.Methods: We user‐tested the tool with guideline panelists and observed theuse of the tool in panel meetings. User‐testing sessions and guidelinemeetings were recorded, transcribed, and analyzed. The analysis informedthe iterative development in the tool.Results: We included four guideline panels and tested the tool with 15panelists (four chairs, four methodologists, five clinic

• Mikaelsen, Helena Zaitzow; Ulla, Ingeborg Hjalland; Karimi, David; Mathiesen, Liv; Viktil, Kirsten Kilvik & Syversen, Malin Olsen [Show all 14 contributors for this article] (2024). Medication Discrepancies in Hospitalised Medical Patients – Status After a Decade With Targeted Medication Reconciliation Measures, a Cross-sectional Multicenter Study. Health Services Insights (HSI Journal). 17, p. 1–8. doi: 10.1177/11786329241254202. Full text in Research Archive Show summary

  Several targeted medication reconciliation (MR) initiatives have been introduced to reduce the number of medication discrepancies (MDs). The real-life quality of medication lists at hospital admission has however not been comprehensively investigated in the last decade. We aimed to examine the frequency and potential clinical relevance of MDs at hospital admission and investigate whether certain characteristics are associated with MDs. Patients ⩾18 years old admitted to medical wards at 4 hospitals in Norway were included. MR was performed, and discrepancies between the reconciled medication list and the medication chart were identified. The potential clinical relevance was assessed in a short-term and long-term perspective. We included 250 patients and 201 (80%) had 1 or more MDs, mean 3.2 (SD 2.9) per patient. Out of 824 identified MDs, 171 (20.8%) and 362 (43.9%) were of moderate, major, or extreme potential clinical relevance in short- and long-term perspective, respectively. The risk of MDs increased with increasing age, increasing number of medications, and the use of multidose drug dispensing. Although several targeted MR initiatives have been launched, the frequency of MDs upon hospital admission is still high. However, the potential clinical relevance of the MDs seems less severe, which indicates an improvement.

• Agarwal, Arnav; Zeng, Xiaoxi; Li, Sheyu; Rayner, Daniel; Foroutan, Farid & Aertgeerts, Bert [Show all 18 contributors for this article] (2024). Sodium-glucose cotransporter-2 (SGLT-2) inhibitors for adults with chronic kidney disease: a clinical practice guideline. BMJ (Clinical Research Edition). ISSN 0959-8138. 387. doi: 10.1136/bmj-2024-080257. Full text in Research Archive
• Løvsletten, Per Olav; Hunskaar, Birk Bårdson Stokke; Heen, Anja Fog; Bekkering, Geertruida; Poel, Louise Vanden & Zeraatkar, Dena [Show all 13 contributors for this article] (2024). Physicians found an interactive tool displaying structured evidence summaries for multiple comparisons understandable and useful: a qualitative user testing study. Journal of Clinical Epidemiology. ISSN 0895-4356. 172. doi: 10.1016/j.jclinepi.2024.111399. Full text in Research Archive
• Maleki-Yazdi, Keon Andre; Heen, Anja Fog; Zhao, Irene X.; Guyatt, Gordon H.; Suzumura, Erica A. & Makhdami, Nima [Show all 30 contributors for this article] (2023). Values and Preferences of Patients and Caregivers Regarding Treatment of Atopic Dermatitis (Eczema): A Systematic Review. JAMA dermatology. ISSN 2168-6068. 159(3), p. 320–330. doi: 10.1001/jamadermatol.2022.6045. Full text in Research Archive
• Hartasanchez, Sandra A.; Heen, Anja Fog; Kunneman, Marleen; García-Bautista, Andrea; Hargraves, Ian G. & Prokop, Larry J. [Show all 8 contributors for this article] (2022). Remote shared decision making through telemedicine: A systematic review of the literature. Patient Education and Counseling. ISSN 0738-3991. 105(2), p. 356–365. doi: 10.1016/j.pec.2021.06.012. Full text in Research Archive
• Kasper, Jürgen; Stensdal, Lilli-Ann; Kienlin, Simone Maria; Eiring, Øystein; Neset, Tore & Andersen-Hollekim, Tone [Show all 7 contributors for this article] (2022). New status report from Norway: Implementation of patient involvement in Norwegian health care. Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen. ISSN 1865-9217. 171, p. 105–112. doi: 10.1016/j.zefq.2022.04.021. Full text in Research Archive Show summary

  In Norway, shared decision-making (SDM) is on the top of the priorities announced by the health authorities. Accountability for implementing this priority has been delegated to the four health regions, and from there into particular departments, hospital trusts, working groups or SDM coordinators. Using abundant public funding, different approaches to producing and implementing patient decision aids have been developed. However, none of these is implemented by any Norwegian services on a regular basis, while the accessible decision aids on the national health platform are not quality approved and in very little use. An ongoing new project is aimed to resolve this dilemma. Health professional training has been developed as a meta-curriculum with multiple modules, adaptive to setting and user group, and designed as an open-source learning platform, based upon the experience of “SDM Ambassadors” delivering the training. Most of the modules are already implemented on a regular basis in the South-Eastern Health Region, and 5000 health care professionals have already graduated from the training modules. However, in the standard patient pathways, and in most of the national medical guidelines, the patient is still considered to be a passive receiver of directives or recommendations, rather than an active participant in their own health decisions. Considerable structural implementation has been done in the education guidelines of all health professions on all levels to embed SDM principles. Teaching in SDM skills, quality of information and evidence-based nursing has become standard in most of the programs at Norwegian universities. Nevertheless, we currently still have no reliable estimate on the degree to which patients are actually involved in their own health decision-making. Further efforts in the process of implementing the patient’s choice in the health system should involve the municipal services, follow a research-based strategy, include monitoring and consider the quality level of the informational environment of health-related decisions.

• Hao, Qiukui; Aertgeerts, Bert; Guyatt, Gordon; Bekkering, Geertruida E; Vandvik, Per Olav & Khan, Safi U [Show all 27 contributors for this article] (2022). PCSK9 inhibitors and ezetimibe for the reduction of cardiovascular events: A clinical practice guideline with risk-stratified recommendations. The BMJ. 2022(377). doi: 10.1136/bmj-2021-069066. Full text in Research Archive
• Heen, Anja Fog; Lytvyn, Lyubov; Shapiro, Michael; Guyatt, Gordon; Siemieniuk, Reed Alexander Cunningham & Zhang, Yuan [Show all 9 contributors for this article] (2021). Patient values and preferences on valve replacement for aortic stenosis: A systematic review. Heart. ISSN 1355-6037. p. 1–7. doi: 10.1136/heartjnl-2020-318334. Full text in Research Archive Show summary

  Abstract The review aims to summarise evidence addressing patients’ values, preferences and practical issues on deciding between transcatheter aortic valve insertion (TAVI) and surgical aortic valve replacement (SAVR) for aortic stenosis. We searched databases and grey literature until June 2020. We included studies of adults with aortic stenosis eliciting values and preferences about treatment, excluding medical management or palliative care. Qualitative findings were synthesised using thematic analysis, and quantitative findings were narratively described. Evidence certainty was assessed using CERQual (Confidence in the Evidence from Reviews of Qualitative Research) and GRADE (Grading of Recommendations Assessment, Development and Evaluation). We included eight studies. Findings ranged from low to very low certainty. Most studies only addressed TAVI. Studies addressing both TAVI and SAVR reported on factors affecting patients’ decision-making along with treatment effectiveness, instead of trade-offs between procedures. Willingness to accept risk varied considerably. To improve their health status, participants were willing to accept higher mortality risk than current evidence suggests for either procedure. No study explicitly addressed valve reintervention, and one study reported variability in willingness to accept shorter duration of known effectiveness of TAVI compared with SAVR. The most common themes were desire for symptom relief and improved function. Participants preferred minimally invasive procedures with shorter hospital stay and recovery. The current body of evidence on patients’ values, preferences and practical issues related to aortic stenosis management is of suboptimal rigour and reports widely disparate results regarding patients’ perceptions. These findings emphasise the need for higher quality studies to inform clinical practice guidelines and the central importance of shared decision-making to individualise care fitted to each patient.

• Heen, Anja Fog; Vandvik, Per Olav; Brandt, Linn; Achille, Frankie; Guyatt, Gordon Henry & Akl, Elie A. [Show all 8 contributors for this article] (2021). Decision aids linked to evidence summaries and clinical practice guidelines: results from user-testing in clinical encounters. BMC Medical Informatics and Decision Making. 21, p. 1–15. doi: 10.1186/s12911-021-01541-7. Full text in Research Archive Show summary

  Abstract Background: Tools for shared decision-making (e.g. decision aids) are intended to support health care professionals and patients engaged in clinical encounters involving shared decision-making. However, decision aids are hard to produce, and onerous to update. Consequently, they often do not refect best current evidence, and show limited uptake in practice. In response, we initiated the Sharing Evidence to Inform Treatment decisions (SHARE-IT) project. Our goal was to develop and refne a new generation of decision aids that are generically produced along digitally structured guidelines and evidence summaries. Methods: Applying principles of human-centred design and following the International Patient Decision Aid Standards (IPDAS) and GRADE methods for trustworthy evidence summaries we developed a decision aid prototype in collaboration with the Developing and Evaluating Communication strategies to support Informed Decisions and practice based on Evidence project (DECIDE). We iteratively user-tested the prototype in clinical consultations between clinicians and patients. Semi-structured interviews of participating clinicians and patients were conducted. Qualitative content analysis of both user-testing sessions and interviews was performed and results categorized according to a revised Morville’s framework of user-experience. We made it possible to produce, publish and use these decision aids in an electronic guideline authoring and publication platform (MAGICapp). Results: Direct observations and analysis of user-testing of 28 clinical consultations between physicians and patients informed four major iterations that addressed readability, understandability, usability and ways to cope with information overload. Participants reported that the tool supported natural fow of the conversation and induced a positive shift in consultation habits towards shared decision-making. We integrated the functionality of SHARE-IT decision aids in MAGICapp, which has since generated numerous decision aids. Conclusion: Our study provides a proof of concept that encounter decision aids can be generically produced from GRADE evidence summaries and clinical guidelines. Online authoring and publication platforms can help scale up production including continuous updating of electronic encounter decision aids, fully integrated with evidence summaries and clinical practice guidelines. Keywords: Decision aids, Shared decision-making, Clinical practice guidelines.

• Busse, Jason W.; Vankrunkelsven, Patrick; Zeng, Linan; Heen, Anja Fog; Merglen, Arnaud & Campbell, Fiona [Show all 22 contributors for this article] (2021). Medical cannabis or cannabinoids for chronic pain: A clinical practice guideline. The BMJ. 374. doi: 10.1136/bmj.n2040. Full text in Research Archive Show summary

  Abstract Clinical question: What is the role of medical cannabis or cannabinoids for people living with chronic pain due to cancer or non-cancer causes? Current practice: Chronic pain is common and distressing and associated with considerable socioeconomic burden globally. Medical cannabis is increasingly used to manage chronic pain, particularly in jurisdictions that have enacted policies to reduce use of opioids; however, existing guideline recommendations are inconsistent, and cannabis remains illegal for therapeutic use in many countries. Recommendation: The guideline expert panel issued a weak recommendation to offer a trial of non-inhaled medical cannabis or cannabinoids, in addition to standard care and management (if not sufficient), for people living with chronic cancer or non-cancer pain. How this guideline was created: An international guideline development panel including patients, clinicians with content expertise, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation (MAGIC) provided methodological support. The panel applied an individual patient perspective. The evidence: This recommendation is informed by a linked series of four systematic reviews summarising the current body of evidence for benefits and harms, as well as patient values and preferences, regarding medical cannabis or cannabinoids for chronic pain. Understanding the recommendation: The recommendation is weak because of the close balance between benefits and harms of medical cannabis for chronic pain. It reflects a high value placed on small to very small improvements in self reported pain intensity, physical functioning, and sleep quality, and willingness to accept a small to modest risk of mostly self limited and transient harms. Shared decision making is required to ensure patients make choices that reflect their values and personal context. Further research is warranted and may alter this recommendation. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

• Zeng, Linan; Lytvyn, Lyubov; Wang, Xiaoqin; Kithulegoda, Natasha; Agterberg, Silvana & Shergill, Yaad [Show all 11 contributors for this article] (2021). Values and preferences towards medical cannabis among people living with chronic pain: A mixed-methods systematic review. BMJ Open. 11(9). doi: 10.1136/bmjopen-2021-050831. Full text in Research Archive
• Heen, Anja Fog; Vandvik, Per Olav; Brandt, Linn; Montori, Victor M.; Lytvyn, Lyubov & Guyatt, Gordon [Show all 8 contributors for this article] (2020). A framework for practical issues was developed to inform shared decision-making tools and clinical guidelines. Journal of Clinical Epidemiology. ISSN 0895-4356. 129, p. 104–113. doi: 10.1016/j.jclinepi.2020.10.002. Full text in Research Archive Show summary

  Objectives: The objective of the study was to develop and test feasibility of a framework of patient-important practical issues. Study design and setting: Guidelines and shared decision-making tools help facilitate discussions about patient-important outcomes of care alternatives, but typically ignore practical issues patients consider when implementing care into their daily routines. Using grounded theory, practical issues in the HealthTalk.org registry and in Option Grids were identified and categorized into a framework. We integrated the framework into the MAGIC authoring and publication platform and digitally structured authoring and publication platform and appraised its use in The BMJ Rapid Recommendations. Results: The framework included the following 15 categories: medication routine, tests and visits, procedure and device, recovery and adaptation, coordination of care, adverse effects, interactions and antidote, physical well-being, emotional well-being, pregnancy and nursing, costs and access, food and drinks, exercise and activities, social life and relationships, work and education, travel and driving. Implementation in 15 BMJ Rapid Recommendations added 283 issues to 35 recommendations. The most frequently used category was procedure and device, and the least frequent was social life and relationship. Conclusion: Adding practical issues systematically to evidence summaries is feasible and can inform guidelines and tools for shared decision-making. How this inclusion can improve patient-centered care remains to be determined. Keywords: Clinical practice guidelines; Decision aids; Patient experience; Patient-important outcomes; Shared decision-making tools. Copyright © 2020 The Authors

• Ye, Zhikang; Blaser, Annika Reintam; Lytvyn, Lyubov; Wang, Ying; Guyatt, Gordon & Mikita, J. Stephen [Show all 20 contributors for this article] (2020). Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline. BMJ (Clinical Research Edition). ISSN 0959-8138. 368, p. 1–17. Full text in Research Archive Show summary

  Clinical question: What is the role of gastrointestinal bleeding prophylaxis (stress ulcer prophylaxis) in critically ill patients? This guideline was prompted by the publication of a new large randomised controlled trial. Current practice: Gastric acid suppression with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) is commonly done to prevent gastrointestinal bleeding in critically ill patients. Existing guidelines vary in their recommendations of which population to treat and which agent to use. Recommendations: This guideline panel makes a weak recommendation for using gastrointestinal bleeding prophylaxis in critically ill patients at high risk (>4%) of clinically important gastrointestinal bleeding, and a weak recommendation for not using prophylaxis in patients at lower risk of clinically important bleeding (≤4%). The panel identified risk categories based on evidence, with variable certainty regarding risk factors. The panel suggests using a PPI rather than a H2RA (weak recommendation) and recommends against using sucralfate (strong recommendation). How this guideline was created: A guideline panel including patients, clinicians, and methodologists produced these recommendations using standards for trustworthy guidelines and the GRADE approach. The recommendations are based on a linked systematic review and network meta-analysis. A weak recommendation means that both options are reasonable. The evidence: The linked systematic review and network meta-analysis estimated the benefit and harm of these medications in 12 660 critically ill patients in 72 trials. Both PPIs and H2RAs reduce the risk of clinically important bleeding. The effect is larger in patients at higher bleeding risk (those with a coagulopathy, chronic liver disease, or receiving mechanical ventilation but not enteral nutrition or two or more of mechanical ventilation with enteral nutrition, acute kidney injury, sepsis, and shock) (moderate certainty). PPIs and H2RAs might increase the risk of pneumonia (low certainty). They probably do not have an effect on mortality (moderate certainty), length of hospital stay, or any other important outcomes. PPIs probably reduce the risk of bleeding more than H2RAs (moderate certainty). Understanding the recommendation: In most critically ill patients, the reduction in clinically important gastrointestinal bleeding from gastric acid suppressants is closely balanced with the possibility of pneumonia. Clinicians should consider individual patient values, risk of bleeding, and other factors such as medication availability when deciding whether to use gastrointestinal bleeding prophylaxis. Visual overviews provide the relative and absolute benefits and harms of the options in multilayered evidence summaries and decision aids available on MAGICapp. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

• Helsingen, Lise M.; Vandvik, Per Olav; Jodal, Henriette C.; Agoritsas, Thomas; Lytvyn, Lyubov & Anderson, Joseph C. [Show all 21 contributors for this article] (2019). Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: A clinical practice guideline. The BMJ. 367:I5515, p. 1–16. doi: 10.1136/bmj.l5515. Full text in Research Archive Show summary

  Abstract CLINICAL QUESTION: Recent 15-year updates of sigmoidoscopy screening trials provide new evidence on the effectiveness of colorectal cancer screening. Prompted by the new evidence, we asked: "Does colorectal cancer screening make an important difference to health outcomes in individuals initiating screening at age 50 to 79? And which screening option is best?" CURRENT PRACTICE: Numerous guidelines recommend screening, but vary on recommended test, age and screening frequency. This guideline looks at the evidence and makes recommendations on screening for four screening options: faecal immunochemical test (FIT) every year, FIT every two years, a single sigmoidoscopy, or a single colonoscopy. RECOMMENDATIONS: These recommendations apply to adults aged 50-79 years with no prior screening, no symptoms of colorectal cancer, and a life expectancy of at least 15 years. For individuals with an estimated 15-year colorectal cancer risk below 3%, we suggest no screening (weak recommendation). For individuals with an estimated 15-year risk above 3%, we suggest screening with one of the four screening options: FIT every year, FIT every two years, a single sigmoidoscopy, or a single colonoscopy (weak recommendation). With our guidance we publish the linked research, a graphic of the absolute harms and benefits, a clear description of how we reached our value judgments, and linked decision aids. HOW THIS GUIDELINE WAS CREATED: A guideline panel including patients, clinicians, content experts and methodologists produced these recommendations using GRADE and in adherence with standards for trustworthy guidelines. A linked systematic review of colorectal cancer screening trials and microsimulation modelling were performed to inform the panel of 15-year screening benefits and harms. The panel also reviewed each screening option's practical issues and burdens. Based on their own experience, the panel estimated the magnitude of benefit typical members of the population would value to opt for screening and used the benefit thresholds to inform their recommendations. THE EVIDENCE: Overall there was substantial uncertainty (low certainty evidence) regarding the 15-year benefits, burdens and harms of screening. Best estimates suggested that all four screening options resulted in similar colorectal cancer mortality reductions. FIT every two years may have little or no effect on cancer incidence over 15 years, while FIT every year, sigmoidoscopy, and colonoscopy may reduce cancer incidence, although for FIT the incidence reduction is small compared with sigmoidoscopy and colonoscopy. Screening related serious gastrointestinal and cardiovascular adverse events are rare. The magnitude of the benefits is dependent on the individual risk, while harms and burdens are less strongly associated with cancer risk. UNDERSTANDING THE RECOMMENDATION: Based on benefits, harms, and burdens of screening, the panel inferred that most informed individuals with a 15-year risk of colorectal cancer of 3% or higher are likely to choose screening, and most individuals with a risk of below 3% are likely to decline screening. Given varying values and preferences, optimal care will require shared decision making.

• Bekkering, Geertruida E.; Agoritsas, Thomas; Lytvyn, Lyubov; Heen, Anja Fog; Feller, Martin & Moutzouri, Elisavet [Show all 21 contributors for this article] (2019). Thyroid hormones treatment for subclinical hypothyroidism: A clinical practice guideline. The BMJ. 365. doi: 10.1136/bmj.l2006. Full text in Research Archive Show summary

  ABSTRACT Clinical question What are the benefits and harms of thyroid hormones for adults with subclinical hypothyroidism (SCH)? This guideline was triggered by a recent systematic review of randomised controlled trials, which could alter practice. Current practice Current guidelines tend to recommend thyroid hormones for adults with thyroid stimulating hormone (TSH) levels >10 mIU/L and for people with lower TSH values who are young, symptomatic, or have specific indications for prescribing. Recommendation The guideline panel issues a strong recommendation against thyroid hormones in adults with SCH (elevated TSH levels and normal free T4 (thyroxine) levels). It does not apply to women who are trying to become pregnant or patients with TSH >20 mIU/L. It may not apply to patients with severe symptoms or young adults (such as those ≤30 years old). How this guideline was created A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach. The evidence The systematic review included 21 trials with 2192 participants. For adults with SCH, thyroid hormones consistently demonstrate no clinically relevant benefits for quality of life or thyroid related symptoms, including depressive symptoms, fatigue, and body mass index (moderate to high quality evidence). Thyroid hormones may have little or no effect on cardiovascular events or mortality (low quality evidence), but harms were measured in only one trial with few events at two years’ follow-up. Understanding the recommendation The panel concluded that almost all adults with SCH would not benefit from treatment with thyroid hormones. Other factors in the strong recommendation include the burden of lifelong management and uncertainty on potential harms. Instead, clinicians should monitor the progression or resolution of the thyroid dysfunction in these adults. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of thyroid hormones in multilayered evidence summaries and decision aids available in MAGIC (https://app.magicapp.org/) to support shared decisions and adaptation of this guideline.

• Heen, Anja Fog & Montori, Victor M. (2019). Achieving care: promoting alternatives to industrial healthcare. Swiss Medical Weekly. ISSN 1424-7860. p. 1–3. doi: 10.4414/smw.2019.20115. Full text in Research Archive Show summary

  Abstract We march toward industrial healthcare. With different intensities and speeds depending on the nature of each healthcare system, most countries exhibit features of industrialisation. Perhaps this is the case because industrial healthcare may represent the final common pathway for any system that becomes underfunded as a result of austerity or profit extraction. Industrial healthcare is cruel to those at the frontline. It displaces the language of care, which in turn affects how we think and decide. It is time to reframe the conversation, change the language and draw from the traditions of the caring sciences. By focusing on care, developing models for caring and learning based on the actions of people rather than on data, and developing data based on the problems of care rather than on the advancement of decontextualised knowledge, we can advance toward careful and kind care for all.

• Agoritsas, Thomas; Farhoumand, Pauline Darbellay; Siemieniuk, Reed; Heen, Anja Fog; Lytvyn, Lyubov & MacDonald, Helen [Show all 9 contributors for this article] (2019). The BMJ rapid recommendations: Towards a new model for the production of clinical practice guidelines. Revue Medicale Suisse. ISSN 1660-9379. 15(634), p. 149–155. Full text in Research Archive
• Tikkinen, Kari A.O.; Dahm, Philipp; Lytvyn, Lyubov; Heen, Anja Fog; Vernooij, Robin W.M. & Siemieniuk, Reed A.C. [Show all 19 contributors for this article] (2019). Prostate cancer screening with prostate-specific antigen (PSA) test: A clinical practice guideline. The BMJ. 362:k3581. doi: 10.1136/bmj.k3581. Full text in Research Archive Show summary

  What is the role of prostate-specific antigen (PSA) screening in prostate cancer? An expert panel produced these recommendations based on a linked systematic review.1 The review was triggered by a large scale, cluster randomised trial on PSA screening in men without a previous diagnosis of prostate cancer published in 2018 (box 1).2 It found no difference between one-time PSA screening and standard practice in prostate cancer mortality but found an increase in the detection of low risk prostate cancer after a median follow-up of 10 years. Although the results of this study suggest screening is not worthwhile, several guidelines advocate offering screening in some cases. The study was much larger than previous studies, and existing trials had published more extended follow-up results, and the BMJ Rapid Recommendations team felt these merited a new appraisal of the body of evidence. This guideline aims to promptly and transparently translate potentially practice-changing evidence to usable recommendations for clinicians and patients, based on the GRADE framework and following standards for trustworthy guidelines. The panel suggests against systematic PSA screening (weak recommendation). The panel members judged that most men will decline screening because the benefit is small and uncertain and there are clear harms. However, there is likely considerable variation in values and preferences. Men with family history of prostate cancer, African descent or of lower socioeconomic status, having higher baseline risk of prostate cancer death, may be more likely to choose PSA screening. Shared decision-making is needed for men considering screening. Box 2 shows all of the articles and evidence linked in this Rapid Recommendation package. The main infographic provides an overview of the absolute benefits and harms of PSA screening. The table at the end of the article shows any evidence that has emerged since the publication of this guideline.

• Prasad, Kameshwar; Siemieniuk, Reed Alexander C.; Hao, Quikui; Guyatt, Gordon H.; O'Donnell, Martin & Lytvyn, Lyubov [Show all 20 contributors for this article] (2018). Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline. BMJ - General Practice Edition. ISSN 0959-8154. 363(k5130). doi: 10.1136/bmj.k5130. Full text in Research Archive
• Agoritsas, Thomas; Merglen, Arnaud; Heen, Anja Fog; Kristiansen, Annette; Neumann, Ignacio & Brito, Juan Pablo [Show all 11 contributors for this article] (2018). UpToDate adherence to GRADE criteria for strong recommendations: an analytical survey. BMJ Open. 7(11). doi: 10.1136/bmjopen-2017-018593. Full text in Research Archive
• Kasper, Jürgen; Lager, Anne Regine; Rumpsfeld, Markus; Kienlin, Simone Maria; Smestad, Kristine Hoel & Bråthen, Tone [Show all 15 contributors for this article] (2017). Statusbericht aus Norwegen: Implementierung von Patientenbeteiligung im norwegischen Gesundheitswesen [Status report from Norway: Implementation of patient involvement in Norwegian health care]. Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen. ISSN 1865-9217. 123-124, p. 75–80. doi: 10.1016/j.zefq.2017.05.015. Full text in Research Archive
• Agoritsas, Thomas; Heen, Anja Fog; Brandt, Linn; Alonso-Coello, Pablo; Kristiansen, Annette & Akl, Elie A. [Show all 13 contributors for this article] (2015). Decision aids that really promote shared decision making: the pace quickens. The BMJ. doi: 10.1136/bmj.g7624. Full text in Research Archive
• Vandvik, Per Olav; Heen, Anja Fog & Brandt, Linn (2014). Una nueva generación de guías de práctica clínica confiables a través de Magic. Revista Peruana de Medicina de Experimental y Salud Publica. ISSN 1726-4642. 31(1), p. 118–126. doi: 10.17843/rpmesp.2014.311.17. Full text in Research Archive
• Vandvik, Per Olav; Brandt, Linn; Alonso-Coello, Pablo; Treweek, Shaun; Akl, Elie A. & Kristiansen, Annette [Show all 10 contributors for this article] (2013). Creating clinical practice guidelines we can trust, use, and share : a new era is imminent. Chest. ISSN 0012-3692. 144(2), p. 381–389. doi: 10.1378/chest.13-0746. Full text in Research Archive

View all works in NVA

• Agarwal, Arnav; Mustafa, Reem; Manja, Veena; Agoritsas, Thomas; MacDonald, Helen & Li, Sheyu [Show all 24 contributors for this article] (2025). Cardiovascular, kidney related, and weight loss effects of therapeutics for type 2 diabetes: A living clinical practice guideline. The BMJ. 390. doi: 10.1136/bmj-2024-082071. Full text in Research Archive
• Hunskaar, Birk Bårdson Stokke; Løvsletten, Per Olav; Agoritsas, Thomas; Heen, Anja Fog; Achille, Frankie Alexander Spencer & Vandvik, Per Olav (2023). User-testing of a decision support tool for multiple treatment options with NMA data to facilitate guideline development: A qualitative study. Full text in Research Archive Show summary

  Background: While network meta-analysis (NMA) presents unprecedented opportunities for comparative effectiveness research, data output from NMAs is often overwhelming, even for researchers. Little is known on how to best present NMA data to guideline panelists. Objectives: To employ and user test the MATCH-IT tool – an interactive Summary of Findings table (iSoF) presenting data from NMA for multiple interventions – in guideline panels to further answer their information needs and facilitate guideline development. Methods: We performed user testing sessions with semi-structured interviews of panel members in preparation for or after panel meetings in 4 different guideline panels. We also observed the use of the MATCH-IT tool during panel meetings. Interviews and meetings were transcribed, coded and analyzed using directed content analysis to capture the user experience and use of the tool. The analysis informed iterative developments of the tool. Results: User-testing of 15 panel members (3 chairs, 9 clinical experts, 3 patient partners) and 3 observed panel meetings resulted in 4 iterations of the tool including both new features and refinements from the initial prototype. Key improvements included adding color coding as well as new data elements such as 95 % confidence intervals. In the final two rounds of development, chairs and participating panelists expressed that the tool contributed significantly to facilitating the meeting. Conclusions: This study suggests that iSoFs, in this case the MATCH-IT tool, can facilitate guideline development by making data from NMA in systematic reviews easier to understand and navigate.

• Kasper, Jürgen; Finbråten, Hanne Søberg; Guttersrud, Øystein; Heen, Anja Fog & Kienlin, Simone Maria (2023). Approaching an abbreviation of the self-administered patient scale, MAPPIN‘SDM. Full text in Research Archive
• Løvsletten, Per Olav; Hunskaar, Birk Bårdson Stokke; Bekkering, Geertruida; Poel, Louise Vanden; Zeraatkar, Dena & Busse, Jason W. [Show all 10 contributors for this article] (2023). Evaluation and development of a novel interactive Summary of Findings table for network meta-analysis. A qualitative user-testing study with clinicians. Full text in Research Archive Show summary

  Background: Clinicians often need to evaluate comparative effectiveness of relevant treatment options for their patients. Network meta-analyses (NMAs) provide an important resource for clinicians to guide decision-making; however, these analyses are complex, and interpretation may prove challenging for users. Objectives: To evaluate and develop a novel interactive Summary of Findings table (the MATCH-IT tool) for network meta-analysis results, to support clinicians in interpreting and applying comparative effectiveness evidence into decision-making. Methods: We performed qualitative user-testing with a convenience sample of practicing physicians working in hospitals and general practice in Norway, Belgium, and Canada. User testing entailed a brief introduction with a clinical scenario, which was a think aloud session with participant-tool-interaction followed by a semi-structured interview. The tests were recorded, transcribed, and analysed using directed content analysis. The results informed the iterative development process of the MATCH-IT tool. Results: Five rounds of user-testing, with 26 participants in total, have resulted in four iterations with updates in the tutorial, layout, navigation functionality, and interphase, as well as the practical-issues-section. We have also added an FAQ section. Clinicians who participated in user-testing had been in clinical practice from 0 to 30 years (median 6, IQR 3-11). Most had little or no prior experience with interpretation of NMA results and sparse knowledge about GRADE methodology. Most clinicians perceived MATCH-IT as easy to interpret and navigate and appreciated its ability to provide overview of the evidence, although some of the interactive features proved to be difficult to discover intuitively. They perceived pictograms and inclusion of practical-issues-information as potentially useful features when interacting with patients. Categorization of results with colour coding to indicate both certainty of evidence and relative effectiveness of interventions was appreciated, and filtering functionality allowed participants to efficiently browse and focus in on the interventions believed to be most relevant for a given clinical scenario. Conclusions: MATCH-IT shows promise in supporting decision-making for clinicians when presented with results from NMAs. The tool has already been published within Cochrane systematic reviews and clinical practice guidelines. Patient, public, and/or healthcare consumer involvement: Clinicians were the subject for user testing, ensuring user friendliness for this key consumer group. Network meta-analysis

• Løvsletten, Per Olav; Hunskaar, Birk Bårdson Stokke; Zeraatkar, Dena; Bekkering, Geertruida; Busse, Jason W. & Agoritsas, Thomas [Show all 8 contributors for this article] (2022). Making Alternative Treatment CHoices Intuitive and Trustworthy (MATCH-IT) for Clinicians: Development of a new decision support tool for multiple comparisons from network meta-analyses. Preliminary results from qualitative user-testing. Full text in Research Archive Show summary

  Background The massive increase in published network meta-analyses (NMAs) over the last decade provide new opportunities to empower clinicians and their patients to evaluate comparative effectiveness of relevant treatment options. The amount and complexity of evidence from NMAs present challenges for condensing results into interpretable formats for clinicians. Objective To evaluate and improve a new interactive presentation format for multiple comparisons (the MATCH- IT tool), to support clinicians in interpreting and applying NMA evidence in decision-making. Methods We performed qualitative user-testing with a convenience sample of clinicians working in hospitals and general practice in Norway, Belgium and Canada. User-testing entailed; brief introduction, a think aloud session with participant-tool-interaction followed by a semi-structured interview. The tests were recorded, transcribed and analysed applying directed content analysis. The results informed the iterative development process of the MATCH-IT tool. Results We have completed 21 user-tests. Most participants had little or no prior experience with interpretation of NMA results. The tool is perceived by most as easy interpretable and its ability to provide overview of the evidence were positively appraised. Pictograms and inclusion of practical-issues-information were perceived as potentially useful features when interacting with patients. The testing has led to updates in tutorial, practical-issues-section and interactive features of the tool. Key challenges remain, such as how to best cope with > 10 interventions and ranking of interventions. Discussion The MATCH-IT tool shows promise in supporting decision-making for clinicians when presented with results from NMAs. Future studies will explore its role in shared decision-making and guideline development.

• Montori, Victor M; Allwood, Dominique & Heen, Anja Fog (2021). A moratorium on strong recommendations is needed. BMJ. British Medical Journal. ISSN 0959-8146. 375. doi: 10.1136/bmj.n2887. Full text in Research Archive
• Heen, Anja Fog & M.H., Sandberg Hanne (2019). Kvalitetsforbedringsprosjekt for kurveføring og samstemming på Lovisenberg Diakonale Sykehus. Full text in Research Archive
• Helsingen, Lise M.; Vandvik, Per Olav; Jodal, Henriette C.; Murphy, Silje Bjerkelund; Heen, Anja Fog & Kalager, Mette [Show all 7 contributors for this article] (2019). Tarmkreftscreening, eller ikke? 139(15). doi: 10.4045/tidsskr.19.0323. Full text in Research Archive
• Heen, Anja Fog; Vandvik, Per Olav & Agoritsas, Thomas (2018). Including practical issues and patient perspectives in Rapid Recommendations. BMJ. British Medical Journal. ISSN 0959-8146. 363. doi: 10.1136/bmj.k4871. Full text in Research Archive
• Vandvik, Per Olav; Brandt, Linn; Kristiansen, Annette; Heen, Anja Fog & Berntsen, Christopher Friis (2014). Relating clinical decisions to the evidence. Full text in Research Archive
• Vandvik, Per Olav; Heen, Anja Fog; Berntsen, Christopher Friis; Brandt, Linn & Kristiansen, Annette (2014). Workshop: Development of decision aids linked to guidelines (SHARE- IT). Full text in Research Archive
• Vandvik, Per Olav; Berntsen, Christopher Friis; Heen, Anja Fog; Kristiansen, Annette & Brandt, Linn (2014). Workshop: Intro to MAGIC platform - Developing a top layer for health professionals. Full text in Research Archive
• Brandt, Linn; Kristiansen, Annette; Berntsen, Christopher Friis; Heen, Anja Fog & Vandvik, Per Olav (2014). Workshop: Intro to MAGIC platform. Full text in Research Archive
• Brandt, Linn; Vandvik, Per Olav; Kristiansen, Annette; Heen, Anja Fog & Berntsen, Christopher Friis (2014). Workshop og foredrag: Udvikling af evidensbaserede retningslinjer. Full text in Research Archive
• Vandvik, Per Olav; Kristiansen, Annette; Heen, Anja Fog; Berntsen, Christopher Friis; Brandt, Linn & Agoritsas, Thomas (2014). Workshop: Producing and Using Generic Decision Aids Linked to Guideline Recommendations to Enhance Shared-Decision Making in Clinical Consultations. Full text in Research Archive
• Alemayohu, Orion; Solberg, Helene; Nasar, Arham; Milosavljevic, Irena; Skar, Petter & Woie, Marthe [Show all 8 contributors for this article] (2026). Poliklinisk behandling og oppfølging som alternativ ved infeksiøs endokarditt. Universitetet i Oslo. Full text in Research Archive Show summary

  Tema/problemstilling: Infeksiøs endokarditt er anbefalt behandlet med intravenøs antibiotika på sykehus i 4-6 uker (1). Dette er dagens praksis ved Lovisenberg Diakonale sykehus (LDS). Behandlingen er både ressurs- og tidkrevende. Vi har vurdert muligheten for overgang til poliklinisk behandling av stabile pasienter som en løsning på denne problemstillingen. Kunnskapsgrunnlag: Det ble utført et Pyramidesøk via Helsebibliotekets søkemotor for å identifisere gjeldende retningslinjer og kliniske oppslagsverk. Dette ble supplert med et semisystematisk litteratursøk i PubMed. Europeiske og norske retningslinjer fra 2023 åpner opp for at selekterte pasienter med infeksiøs endokarditt kan følges opp og behandles ved poliklinikk (1). Dette fordrer at pasienten er klinisk stabil, infeksjonen er under kontroll og det ikke foreligger noen komplikasjoner. Tiltak og kvalitetsindikator: Vi foreslår en overgang fra antibiotikabehandling på sengepost til oppfølging ved poliklinikk med intravenøs antibiotika for klinisk stabile pasienter med endokarditt ved LDS. Effekten av tiltaket kan måles i form av reduksjon av antall liggedøgn, samt reduksjon i iatrogene skader, økt pasienttilfredshet og raskere tilbakevending til dagligdagse aktiviteter. Ledelse og organisering: Vi har tatt utgangspunkt i Helsebibliotekets modell for kvalitetsforbedring for å sikre en strukturert tilnærming til ledelse og organisering. Denne tar for seg de fem stegene i et kvalitetsforbedringsprosjekt og er tenkt anvendt i flere omganger for å sikre en robust forankring av tiltaket i mikrosystemet. Det er skissert en prosjektgruppe som skal ha ansvaret for innføringen av forbedringstiltaket, hvor ulike faggrupper fra mikrosystemet er representert. Konklusjon: Fordelene med prosjektet overgår utfordringene, og vår samlede vurdering er at prosjektet gjennomføres. Formålet er å effektivisere ressursbruk, redusere risiko for iatrogen skade og samtidig forbedre pasienttilfredshet.

• Eidsnes, Gustav Aleksander; Butt, Hania Muqaddas; Sannes, Ida; Dajani, Mariam Amina Kvernberg; Hoff, Oliver Fagerli & Mæland, Stine Nes [Show all 8 contributors for this article] (2026). Reorganisering av supervisjonsmodellen for LIS3 med sikte på å optimalisere tilgjengelighet for veiledning. Et kvalitetsforbedringsprosjekt ved ØNH-poliklinikken på Ahus. Universitetet i Oslo. Full text in Research Archive Show summary

  Dette kvalitetsforbedringsprosjektet omhandler en reorganisering av supervisjonsmodellen for leger i spesialisering 3 (LIS3) ved Øre-nese-hals-poliklinikken (ØNH-poliklinikken) på Akershus universitetssykehus (Ahus), med fokus på neseseksjonen. Dagens praksis er en parallellpoliklinikk hvor overlegen som har ansvar for veiledning av LIS3, samtidig har egen pasientliste. En konsekvens av dette for LIS3 er blant annet mindre tilgjengelig supervisjon, som igjen gir økt usikkerhet ved beslutningstaking og dermed hyppigere oppsatte kontrolltimer. Kvalitetsforbedringstiltaket blir en omorganisering av poliklinikken med én overlege, frigjort fra egen pasientliste, som veileder tre LIS3, en såkalt 1:3-modell. Primære indikatorer vil være andelen polikliniske LIS3-konsultasjoner som resulterer i ny kontrolltime, samt LIS3 sin opplevde supervisjonstilgjengelighet og kliniske trygghet målt ved spørreskjemaer. Ventetid og tilfredshet blant LIS3 og overleger kan inngå som supplerende mål på arbeidsflyt og gjennomførbarhet. Disse indikatorene er målbare, relevante og egnet for å evaluere både supervisjonstilgjengelighet, kontrollrate og gjennomførbarhet. I litteraturen ble det ikke funnet studier som evaluerer den konkrete 1:3-modellen. Flere studier beskriver likevel mekanismene som modellen legger til rette for med mer tilgjengelig veiledning, raskere tilbakemeldinger, korte pre-/debriefs, strukturert praksisnær undervisning og økt klinisk trygghet hos LIS3. Empiriske studier viser også at overlegens direkte involvering kan føre til redusert antall oppfølgingstimer satt av LIS3. Prosjektet bør gjennomføres som et organisert forbedringsarbeid med en prosjektgruppe ledet av avdelingsleder, inkludert minst én overlege og LIS3-representant, samt tydelige før/etter‑målinger for å dokumentere lokal effekt og sikre forsvarlig ressursbruk. Den nye strukturen foreslås først testet som pilotprosjekt over to enkeltdager med én ukes mellomrom, med samme overlege og LIS-leger involvert. Deretter kan tiltaket gjennomføres etter Helsebibliotekets Plan-Do-Study-Act‑modell for kvalitetsforbedring, først i neseseksjonen og eventuelt senere i de andre seksjonene, øre og hals. Evaluering og eventuell justering foreslås etter 3, 6, 9 og 12 måneder. Prosjektet er lederforankret og samsvarer med krav i spesialistforskriften om ressursfestet, kvalifisert og dokumentert veiledning. Selv om evidens på systemnivå for akkurat denne type supervisjonsorganisering mangler, gir det samlede kunnskapsgrunnlaget, kombinert med nasjonale veiledningskrav, en plausibel støtte for at den foreslåtte modellen vil ha positiv virkning. Dette gjelder særlig bedre veiledningspraksis, redusert antall kontrolltimer og mer effektiv arbeidsflyt.

View all works in NVA