Question/recommendation:  Should comprehensive (in-house) medical management vs. off-site medical referrals be used to reduce injury rate in professional dancers Population: Professional dancers (ballet and modern) Intervention: Comprehensive In-house Medical Management (including Injury audit/Screening/Intervention programs) vs. offsite medical referrals Setting: Professional dance companies Decision domain Judgement Reason for judgement Sub domains influencing judgement Yes No Balance of desirable and undesirable outcomes: Given the best estimate of typical values and preferences, are you confident that the benefits outweigh the harms and burdens or vice versa? x   The desirable outcomes are a reduction of injury rate. There is no evidence to suggest the use of in house comprehensive medical management would be detrimental to the patient group The size and specialities within the comprehensive medical management has not been established. Similarly if differences are needed for various sub-group populations, i.e. ballet or modern? Confidence in estimates of effect (quality of evidence): Is there high or moderate quality evidence   x The evidence profile for this outcome is very low for the desired outcome. There is no evidence to any detrimental/harm  outcome through utilising this intervention Key reasons for rating down of evidence is through the use of observational studies with certain limitations in the GRADE rating factors Values and preferences: Are you confident about the typical values and preferences and are they similar across the target population? x   We can be confident that professional dancers place a high value on a reduction in injury rate as their livelihood is dependent on their ability to dance The increasing number of higher quality studies into injury rate reflects the position of the dance environment Resource implications: Are the resources worth the expected net benefit from following the recommendation? x   There is a resource need to provide in-house medical provision. This has been demonstrated to reduce the overall medical costs and outweigh the costs of its implementation. Although not explicitly examined as part of the review, the use of in-house medical teams are becoming more common place- the implementation of injury audits, screening and program interventions could be seen as sunk costs. Cost per resource unit needs to be established.    Overall strength of recommendation Strong The author recommends that the injury rate of dancers in professional companies will be reduced through the use of comprehensive medical management. Evidence to recommendation synthesis The high  value placed on injury reduction through comprehensive medical management versus harm outweighed the lower evidence profile in the absence of stronger evidence

Table 5: GRADE Recommendation for Injury Reduction.