Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines

Guyatt, Gordon; Gutterman, David D.; Baumann, Michael H.; Addrizzo-Harris, Doreen; Hylek, Elaine M.; Phillips, Barbara; Raskob, Gary E.; Lewis, Sandra Zelman; Schünemann, Holger J.

doi:10.1378/chest.129.1.174

Cited by 1,097 publications

(762 citation statements)

References 18 publications

(10 reference statements)

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“…Forced nasal expiration, like in Table 1. Grading recommendations (GRADE approach) modified from (18) Grade of recommendation Methodological quality of supporting evidence Implications frequently blowing the nose, can lead to a decrease in nasal patency possibly through neuronal pathways (29). Airborne irritants can lead to nasal congestion and therefore careful history taking should be performed regarding smoking habits, passive smoking and air pollutants (30)(31)(32).…”

Section: Subjective Methodsmentioning

confidence: 99%

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Evidence‐based recommendations regarding the differential diagnosis and assessment of nasal congestion: using the new GRADE system

Spronsen

Ingels

Jansen

et al. 2008

Allergy

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Nasal congestion is an important symptom in nasal pathology and can be defined as an objective restriction of nasal cavity airflow because of mucosal pathology and/or increased mucus secretion (excluding anatomical variants). Using the new Grading Recommendations Assessment, Development and Evaluation system, evidence‐based recommendations are made that will encompass different clinical questions regarding diagnostic modalities of nasal congestion: (i) their usefulness in assessment of presence and severity of congestion; (ii) their usefulness in assessment of etiological pathology responsible for congestion; and (iii) their usefulness in follow up and treatment effectiveness evaluation of nasal congestion.

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Section: Subjective Methodsmentioning

confidence: 99%

“…Many schemes have been used to grade levels of evidence and the strength of recommendations (15,18,19). The new Grading Recommendations Assessment, Development, and Evaluation (GRADE) approach (20) is recommended by the WHO and is being increasingly applied by a number of organizations (21).…”

Section: Evidence-based Medicine and Guidelinesmentioning

confidence: 99%

Evidence‐based recommendations regarding the differential diagnosis and assessment of nasal congestion: using the new GRADE system

Spronsen

Ingels

Jansen

et al. 2008

Allergy

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“…To supplement the report, relevant articles published up to December 2006 were retrieved and reviewed by the chair, and where appropriate, were incorporated in the report. The system of scoring recommendations followed the grading system described by Guyatt et al 12 (Table I). If the panelists were certain about the balance of the benefits vs the risks of rFVIIa therapy for a particular indication, they made a strong (grade 1) recommendation for or against the use of rFVIIa for that indication; otherwise, they made a weak (grade 2) recommendation.…”

Section: Methodsmentioning

confidence: 99%

The role of recombinant factor VIIa in on-pump cardiac surgery: Proceedings of the Canadian Consensus Conference

Karkouti

Beattie

Crowther

et al. 2007

Can J Anesth/J Can Anesth

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Purpose: Recombinant activated factor VII (rFVIIa) is currently not approved by Health Canada or the Food and Drug Administration for treating excessive blood loss in nonhemophiliac patients undergoing on-pump cardiac surgery, but is increasingly being used "off-label" for this indication. A Canadian Consensus Conference was convened to generate recommendations for rFVIIa use in on-pump cardiac surgery. Methods: The panel undertook a literature review of the use of rFVIIa in both cardiac and non-cardiac surgery. Appropriateness, timing, and dosage considerations were addressed for three cardiac surgery indications: prophylactic, routine, and rescue uses. Recommendations were based on evidence from the literature and derived by consensus following recognized grading procedures. Results: The panel recommended against prophylactic or routine use of rFVIIa, as there is no evidence at this time that the benefits of rFVIIa outweigh its potential risks compared with standard hemostatic therapies. On the other hand, the panel made a weak recommendation (grade 2C) for the use of rFVIIa (one to two doses of 35-70 µg·kg -1 ) as rescue therapy for blood loss that is refractory to standard hemostatic therapies, despite the lack of randomized controlled trial data for this indication. Conclusions: In cardiac surgery, the risks and benefits of rFVIIa are unclear, but current evidence suggests that its benefits may outweigh its risks for rescue therapy in selected patients. Methodologically rigorous studies are needed to clarify its riskbenefit profile in cardiac surgery patients. 200 Elizabeth Street, Toronto, Ontario M5G 2C4,; E-mail: keyvan.karkouti@uhn.on.ca Disclosure statement: Novo Nordisk (Mississauga, Ontario, Canada), the makers of rFVIIa, funded this project through an unrestricted educational grant. Novo Nordisk was not involved in the selection of the members of the consensus panel, nor were they involved in the panel's review process, deliberations, conclusions, or manuscript preparation. The panel's chair selected the panel members, with the objective of achieving relevant multi-disciplinary expertise (i.e., anesthesiology, cardiac surgery, hematology, intensive care, and clinical epidemiology). The manuscript was primarily written by the panel chair (Keyvan Karkouti) and was approved by all of the panel members. All of the authors received an honorarium for attending the consensus conference.

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“…However, the quality of the evidence is sometimes doubtful (Ackman et al, 2000;Watine, 2002;Burgers and van Everdingen, 2004), and schemes have been devised to grade the quality of the clinical trials, which form a large part of the evidence base (e.g., Psaty et al, 2000;Liberati et al, 2001;Michaels and Booth, 2001;Hess, 2003;Guyatt et al, 2006). Even when the guidelines have been published, they are sometimes criticised as inadequate (Jacobson, 1998;Norheim, 1999;Walker, 2001), insufficient (Toman et al, 2001) or they may become outdated (Shekelle et al, 2001).…”

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confidence: 99%

The impact of cancer research: how publications influence UK cancer clinical guidelines

Lewison

Sullivan

2008

Br J Cancer

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There has been a substantially increased interest in biomedical research impact assessment over the past 5 years. This can be studied by a number of methods, but its influence on clinical guidelines must rank as one of the most important. In cancer, there are 43 UK guidelines (and associated Health Technology Assessments) published (up to October 2006) across three series, each of which has an evidence base in the form of references, many of which are papers in peer-reviewed journals. These have all been identified and analysed to determine their geographical provenance and type of research, in comparison with overall oncology research published in the peak years of guideline references (1999 -2001). The UK papers were cited nearly three times as frequently as would have been expected from their presence in world oncology research (6.5%). Within the United Kingdom, Edinburgh and Glasgow stood out for their unexpectedly high contributions to the guidelines' scientific base. The cited papers from the United Kingdom acknowledged much more explicit funding from all sectors than did the UK cancer research papers at the same research level.

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Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines

Cited by 1,097 publications

References 18 publications

Evidence‐based recommendations regarding the differential diagnosis and assessment of nasal congestion: using the new GRADE system

Evidence‐based recommendations regarding the differential diagnosis and assessment of nasal congestion: using the new GRADE system

The role of recombinant factor VIIa in on-pump cardiac surgery: Proceedings of the Canadian Consensus Conference

The impact of cancer research: how publications influence UK cancer clinical guidelines

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