GRADE Guidance 34: update on rating imprecision using a minimally contextualized approach

Zeng, Linan; Brignardello‐Petersen, Romina; Hultcrantz, Monica; Mustafa, Reem A.; Murad, Mohammad Hassan; Iorio, Alfonso; Traversy, Gregory; Akl, Elie A.; Mayer, Martin; Schünemann, Holger J.; Guyatt, Gordon

doi:10.1016/j.jclinepi.2022.07.014

Cited by 74 publications

(54 citation statements)

References 16 publications

(29 reference statements)

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“…Two reviewers reached consensus through discussion on the certainty about conclusions in relation to our thresholds of effect of the relative effects for each outcome, guided by GRADE. [21, 22] We started the evidence at high certainty [23] and down rated to lower levels (i.e., moderate, low, and very low certainty) based on study quality in five domains (i.e., risk of bias, indirectness, inconsistency, imprecision, reporting biases). For each domain, we rated down by 0, 1, or 2 levels depending on the seriousness of the concerns, i.e., how much the domain appeared to impact the conclusions.…”

Section: Methodsmentioning

confidence: 99%

Associations between SARS-CoV-2 infection and incidence of new chronic condition diagnoses: a systematic review

Gaudet

Pillay

Saba

et al. 2023

Preprint

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Because of the large number of infected individuals, an estimate of the future burdens of the long-term consequences of SARS-CoV-2 infection is needed. This systematic review examined associations between SARS-CoV-2 infection and incidence of categories of and selected chronic conditions, by age and severity of infection (inpatient vs. outpatient/mixed care). MEDLINE and EMBASE were searched (Jan 1, 2020 to Oct 4, 2022) and reference lists scanned. We included observational studies from high-income OECD countries with a control group adjusting for sex and comorbidities. Identified records underwent a two-stage screening process. Two reviewers screened 50% of titles/abstracts, after which DistillerAI acted as second reviewer. Two reviewers then screened the full texts of stage one selections. One reviewer extracted data and assessed risk of bias; results were verified by another. Random-effects meta-analysis estimated pooled hazard ratios (HR). GRADE assessed certainty of the evidence. Twenty-five studies were included. Among the outpatient/mixed SARS-CoV-2 care group, there is high certainty of a small-to-moderate increase (i.e., HR 1.26 to 1.99) among adults ≥65 years of any cardiovascular condition, and of little-to-no difference (i.e., HR 0.75 to 1.25) in anxiety disorders for individuals <18, 18-64, and ≥65 years old. Among 18-64 and ≥65 year-olds receiving outpatient/mixed care there are probably (moderate certainty) large increases (i.e., HR ≥2.0) in encephalopathy, interstitial lung disease, and respiratory failure. After SARS-CoV-2 infection, there is probably an increased risk of diagnoses for some chronic conditions; whether the magnitude of risk will remain stable into the future is uncertain.

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Section: Methodsmentioning

confidence: 99%

Associations between SARS-CoV-2 infection and incidence of new chronic condition diagnoses: a systematic review

Gaudet

Pillay

Saba

et al. 2023

Preprint

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“…Accordingly, we judged the pooled effect for EVT alone versus combination therapy as imprecise as the 95% CI ranged from 5.4% more to 2.5% less recovering with no impairment; a range that includes both important benefits and harms associated with EVT alone and thus warranted rating down twice for imprecision according to the GRADE approach. 38 The ESO–ESMINT guideline, alternatively, applied a non-inferiority margin of 1.3% and concluded that non-inferiority was not met and did not rate down for imprecision. The same issue affected the assessment of mortality.…”

Section: Resultsmentioning

confidence: 99%

Endovascular thrombectomy with or without intravenous alteplase for acute ischemic stroke due to large vessel occlusion: a systematic review and meta-analysis of randomized trials

Wang

Busse

et al. 2022

Stroke Vasc Neurol

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BackgroundAmong patients who had an ischaemic stroke presenting directly to a stroke centre where endovascular thrombectomy (EVT) is immediately available, there is uncertainty regarding the role of intravenous thrombolysis agents before or concurrently with EVT. To support a rapid guideline, we conducted a systematic review and meta-analysis to examine the impact of EVT alone versus EVT with intravenous alteplase in patients who had an acute ischaemic stroke due to large vessel occlusion.MethodsIn November 2021, we searched MEDLINE, Embase, PubMed, Cochrane, Web of Science, clincialtrials.gov and the ISRCTN registry for randomised controlled trials (RCTs) comparing EVT alone versus EVT with alteplase for acute ischaemic stroke. We conducted meta-analyses using fixed effects models and assessed the certainty of evidence using the GRADE approach.ResultsIn total 6 RCTs including 2334 participants were eligible. Low certainty evidence suggests that, compared with EVT and alteplase, there is possibly a small decrease in the proportion of patients independent with EVT alone (risk ratio (RR) 0.97, 95% CI 0.89 to 1.05; risk difference (RD) −1.5%; 95% CI −5.4% to 2.5%), and possibly a small increase in mortality with EVT alone (RR 1.07, 95% CI 0.88 to 1.29; RD 1.2%, 95% CI −2.0% to 4.9%) . Moderate certainty evidence suggests that there is probably a small decrease in symptomatic intracranial haemorrhage (sICH) with EVT alone (RR 0.75, 95% CI 0.52 to 1.07; RD −1.0%; 95%CI −1.8% to 0.27%).ConclusionsLow certainty evidence suggests that there is possibly a small decrease in the proportion of patients that achieve functional independence and a small increase in mortality with EVT alone. Moderate certainty evidence suggests that there is probably a small decrease in sICH with EVT alone. The accompanying guideline provides contextualised guidance based on this body of evidence.PROSPERO registration numberCRD42021249873.

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“…The current meta-epidemiological study attempted to align with the recent GRADE guidance about imprecision 29. This GRADE guidance about minimally contextualised imprecision relates the CI of the pooled estimate to a threshold that is considered by stakeholders to be clinically important, and de-emphasises the null as a threshold of importance.…”

Section: Discussionmentioning

confidence: 99%

Different meta-analysis methods can change judgements about imprecision of effect estimates: a meta-epidemiological study

Wang

Alzuabi

Mustafa

et al. 2023

BMJ EBM

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ObjectivesTo empirically evaluate five commonly used meta-analysis methods and their impact on imprecision judgements about effect estimates. The two fixed-effect model methods were the inverse variance method based on normal distribution and the Mantel-Haenszel method. The three random-effects model methods were the DerSimonian and Laird, the Hartung-Knapp-Sidik-Jonkman and the profile likelihood approaches.DesignMeta-epidemiological study.SettingMeta-analyses published between 2007 and 2019 in the 10 general medical journals with the highest impact factors that evaluated a medication or device for chronic medical conditions and included at least 5 randomised trials.Main outcome measuresDiscordance in the judgements of imprecision of effect estimates based on two definitions: when either boundary of 95% CI of the OR changed by more than 15% or changed in relation to the null.ResultsWe analysed 88 meta-analyses including 1114 trials with an average of 12.60 trials per meta-analysis and average I2of 26% (range: 0%–96%). The profile likelihood failed to converge in three meta-analyses (3%). Discordance in imprecision judgements based on the two definitions, respectively, occurred between the fixed normal distribution and fixed Mantel-Haenszel method (8% and 2%), between the DerSimonian and Laird and Hartung-Knapp-Sidik-Jonkman methods (19% and 10%), between the DerSimonian and Laird and profile likelihood methods (9% and 5%), and between the Hartung-Knapp-Sidik-Jonkman and profile likelihood methods (5% and 13%). Discordance was greater when fewer studies and greater heterogeneity was present.ConclusionEmpirical evaluation of studies of chronic medical conditions showed that conclusions about the precision of the estimates of the efficacy of a drug or device frequently changed when different pooling methods were used, particularly when the number of studies within a meta-analysis was small and statistical heterogeneity was substantial. Sensitivity analyses using more than one method may need to be considered in these two scenarios.

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GRADE Guidance 34: update on rating imprecision using a minimally contextualized approach

Cited by 74 publications

References 16 publications

Associations between SARS-CoV-2 infection and incidence of new chronic condition diagnoses: a systematic review

Associations between SARS-CoV-2 infection and incidence of new chronic condition diagnoses: a systematic review

Endovascular thrombectomy with or without intravenous alteplase for acute ischemic stroke due to large vessel occlusion: a systematic review and meta-analysis of randomized trials

Different meta-analysis methods can change judgements about imprecision of effect estimates: a meta-epidemiological study

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