The GRADE Working Group clarifies the construct of certainty of evidence

Hultcrantz, Monica; Rind, David M.; Akl, Elie A.; Treweek, Shaun; Mustafa, Reem A.; Iorio, Alfonso; Alper, Brian S.; Meerpohl, Joerg J; Murad, M. Hassan; Ansari, Mohammed; Katikireddi, Srinivasa Vittal; Östlund, Pernilla; Tranæus, Sofia; Christensen, Robin; Gartlehner, Gerald; Brožek, Jan; Izcovich, Ariel; Schünemann, Holger J.; Guyatt, Gordon

doi:10.1016/j.jclinepi.2017.05.006

Cited by 480 publications

(425 citation statements)

References 14 publications

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“…The few reported definitions mainly focus on the confidence in a direct estimate of the effect of an intervention—a definition initially suggested by GRADE. It is worth noting here that the most recent publication of the GRADE Working Group clarifies this definition of the quality of a body of evidence based on a priori defined threshold and the context of the review The revised guidance suggests 3 types of ratings: noncontextualized, partly contextualized, and fully contextualized (see Table for more details).…”

Section: Discussionmentioning

confidence: 99%

Rating the quality of a body of evidence on the effectiveness of health and social interventions: A systematic review and mapping of evidence domains

Movsisyan

Dennis

Rehfuess

et al. 2018

Research Synthesis Methods

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IntroductionRating the quality of a body of evidence is an increasingly common component of research syntheses on intervention effectiveness. This study sought to identify and examine existing systems for rating the quality of a body of evidence on the effectiveness of health and social interventions.MethodsWe used a multicomponent search strategy to search for full‐length reports of systems for rating the quality of a body of evidence on the effectiveness of health and social interventions published in English from 1995 onward. Two independent reviewers extracted data from each eligible system on the evidence domains included, as well as the development and dissemination processes for each system.ResultsSeventeen systems met our eligibility criteria. Across systems, we identified 13 discrete evidence domains: study design, study execution, consistency, measures of precision, directness, publication bias, magnitude of effect, dose‐response, plausible confounding, analogy, robustness, applicability, and coherence. We found little reporting of rigorous procedures in the development and dissemination of evidence rating systems.ConclusionWe identified 17 systems for rating the quality of a body of evidence on intervention effectiveness across health and social policy. Existing systems vary greatly in the domains they include and how they operationalize domains, and most have important limitations in their development and dissemination. The construct of the quality of the body of evidence was defined in a few systems largely extending the Grading of Recommendations Assessment, Development, and Evaluation approach. Grading of Recommendations Assessment, Development, and Evaluation was found to be unique in its comprehensive guidance, rigorous development, and dissemination strategy.

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Section: Discussionmentioning

confidence: 99%

Rating the quality of a body of evidence on the effectiveness of health and social interventions: A systematic review and mapping of evidence domains

Movsisyan

Dennis

Rehfuess

et al. 2018

Research Synthesis Methods

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“…One of the essential requirements of a trustworthy guideline2 is that it should be based on systematic reviews of the best available evidence and includes assessment of the quality of evidence. This construct, quality of evidence, has been described as the certainty that a true effect lies on one side of a specified threshold or within a chosen range 6. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) Working Group has provided an approach for evaluating the quality of evidence depending on several discrete domains, which include study limitations, indirectness, imprecision, inconsistency and publication bias 5…”

Section: Introductionmentioning

confidence: 99%

What does expert opinion in guidelines mean? a meta-epidemiological study

et al. 2017

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Guidelines often use the term expert opinion (EO) to qualify recommendations. We sought to identify the rationale and evidence type in EO recommendations. We searched multiple databases and websites for contemporary guidelines published in the last decade that used the term EO. We identified 1106 references, of which 69 guidelines were included (2390 recommendations, of which 907 were qualified as EO). A rationale for using EO designation was not provided in most (91%) recommendations. The most commonly cited evidence type was extrapolated from studies that did not answer guideline question (40% from randomised trials, 38% from observational studies and 2% from case reports or series). Evidence extrapolated from populations that were different from those addressed in the guideline was found in 2.5% of EO recommendations. We judged 5.6% of EO recommendations as ones that could have been potentially labelled as good practice statements. None of the EO recommendations were explicitly described as being solely dependent on the clinical experience of the panel. The use of EO as a level of evidence in guidelines remains common. A rationale for such use is not explicitly provided in most instances. Most of the time, evidence labelled as EO was indirect evidence and occasionally was very low-quality evidence derived from case series. We posit that the explicit description of evidence type, as opposed to using the label EO, may add clarity and transparency and may ultimately improve uptake of recommendations.

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“…As witnessed by the very low quality of evidence supporting the suggestions of this guideline, there is large uncertainty on the balance between the benefits and harms when using inotropic agents in adult patients with acute circulatory failure 48. Several interventions, which are common practice in the ICU, have been adopted based on the perception of improved physiological parameters and physiological reasoning.…”

Section: Discussionmentioning

confidence: 99%

Scandinavian SSAI clinical practice guideline on choice of inotropic agent for patients with acute circulatory failure

Møller

Granholm

Junttila

et al. 2018

Acta Anaesthesiol Scand

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BackgroundAdult critically ill patients often suffer from acute circulatory failure and those with low cardiac output may be treated with inotropic agents. The aim of this Scandinavian Society of Anaesthesiology and Intensive Care Medicine guideline was to present patient‐important treatment recommendations on this topic.MethodsThis guideline was developed according to GRADE. We assessed the following subpopulations of patients with shock: (1) shock in general, (2) septic shock, (3) cardiogenic shock, (4) hypovolemic shock, (5) shock after cardiac surgery, and (6) other types of shock, including vasodilatory shock. We assessed patient‐important outcome measures, including mortality and serious adverse reactions.ResultsFor all patients, we suggest against the routine use of any inotropic agent, including dobutamine, as compared to placebo/no treatment (very low quality of evidence). For patients with shock in general, and in those with septic and other types of shock, we suggest using dobutamine rather than levosimendan or epinephrine (very low quality of evidence). For patients with cardiogenic shock and in those with shock after cardiac surgery, we suggest using dobutamine rather than milrinone (very low quality of evidence). For the other clinical questions, we refrained from giving any recommendations or suggestions.ConclusionsWe suggest against the routine use of any inotropic agent in adult patients with shock. If used, we suggest using dobutamine rather than other inotropic agents for the majority of patients, however, the quality of evidence was very low, implying high uncertainty on the balance between the benefits and harms of inotropic agents.

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The GRADE Working Group clarifies the construct of certainty of evidence

Abstract: It is desirable for systematic review authors, guideline panelists, and health technology assessors to specify the threshold or ranges they are using when rating the certainty in evidence.

Cited by 480 publications

References 14 publications

Rating the quality of a body of evidence on the effectiveness of health and social interventions: A systematic review and mapping of evidence domains

Rating the quality of a body of evidence on the effectiveness of health and social interventions: A systematic review and mapping of evidence domains

What does expert opinion in guidelines mean? a meta-epidemiological study

Scandinavian SSAI clinical practice guideline on choice of inotropic agent for patients with acute circulatory failure

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