Use of GRADE for assessment of evidence about prognosis: rating confidence in estimates of event rates in broad categories of patients

Iorio, Alfonso; Spencer, Frederick A.; Falavigna, Maicon; Alba, Ana C.; Lang, E.; Burnand, Bernard; McGinn, Tom; Hayden, Jill A.; Williams, Katrina; Shea, Beverly; Wolff, Robert; Kujpers, Ton; Perel, Pablo; Vandvik, Per Olav; Glasziou, Paul; Schünemann, Holger J.; Guyatt, Gordon

doi:10.1136/bmj.h870

Cited by 565 publications

(449 citation statements)

References 31 publications

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“…In cases like the two described, reporting only the pooled mean ARR can be as uninformative or misleading as not reporting ARR at all, indicating that the assessment of the baseline risk in clinical decision making is crucial [19,20].…”

Section: Implications and Future Directionsmentioning

confidence: 99%

Authors seldom report the most patient-important outcomes and absolute effect measures in systematic review abstracts

Agarwal

Johnston

Vernooij

et al. 2017

Journal of Clinical Epidemiology

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Section: Implications and Future Directionsmentioning

confidence: 99%

Authors seldom report the most patient-important outcomes and absolute effect measures in systematic review abstracts

Agarwal

Johnston

Vernooij

et al. 2017

Journal of Clinical Epidemiology

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“…27,31 Given the high baseline risk we found for persistent pain after surgery for breast cancer (30%), we estimated that a 10% increase in the absolute risk would likely be sufficient for clinicians to address modifiable risk factors, which can be directly targeted in an effort to prevent persistent pain. We estimated that an absolute difference in risk of 20% between groups at low and high risk for persistent pain would be sufficient for clinicians to selectively target nonmodifiable risk factors to identify high-risk candidates for intervention.…”

Section: Quality Of Evidencementioning

confidence: 99%

“…29 Subgroup analyses, meta-regression and sensitivity analyses We evaluated heterogeneity for all pooled estimates through visual inspection of forest plots, 27 because statistical tests of heterogeneity can be misleading when sample sizes are large and CIs are therefore narrow. 30 We generated 4 a priori hypotheses to explain variability between studies, assuming larger association with persistent pain and (1) a high pain threshold (moderate to severe pain v. no to mild pain), (2) trials having greater risk of bias (on a component-by-component basis), (3) longer duration of follow-up and (4) larger proportion of patients lost to follow-up.…”

Section: Publication Biasmentioning

confidence: 99%

“…For meta-analyses with at least 10 studies, 22,27 we assessed publication bias by visual assess-ment of asymmetry of the funnel plot and performed the Begg rank correlation test 28 and the Egger test. 29 Subgroup analyses, meta-regression and sensitivity analyses We evaluated heterogeneity for all pooled estimates through visual inspection of forest plots, 27 because statistical tests of heterogeneity can be misleading when sample sizes are large and CIs are therefore narrow.…”

Section: Publication Biasmentioning

confidence: 99%

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Predictors of persistent pain after breast cancer surgery: a systematic review and meta-analysis of observational studies

Wang

Guyatt

Kennedy

et al. 2016

CMAJ

227

213

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D espite a 10-year survival rate of 83%, 1,2 between 25% and 60% of surviving patients who have undergone surgery for breast cancer experience persistent postsurgical pain, [3][4][5][6][7][8][9] which is associated with reduced quality of life and functional impairment. [10][11][12][13] Systematic reviews summarizing proposed risk factors for persistent pain after breast cancer surgery -including demographic, intraoperative and postoperative factors -have had several limitations, including outdated searches, inadequate attention to risk-of-bias assessment, lack of statistical pooling of measures of association and failure to evaluate the quality of evidence.5,10-14 We conducted a systematic review and meta-analysis of observational studies to identify risk factors for persistent pain after breast cancer surgery, addressing the limitations of previous reviews. MethodsWe completed our systematic review in accordance with the MOOSE statement 15 and registered our protocol with PROSPERO (registration CRD42014013338). Background: Persistent pain after breast cancer surgery affects up to 60% of patients. Early identification of those at higher risk could help inform optimal management. We conducted a systematic review and meta-analysis of observational studies to explore factors associated with persistent pain among women who have undergone surgery for breast cancer. Predictors of persistent pain after breast cancer surgery: a systematic review and meta-analysis of observational studies

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“…A systematic review of cohort studies within the field of prognosis has previously been argued at the start as evidence of high quality. 25 Iorio et al 25 support that GRADE's five domains of rating quality down (risk of bias and publication bias as detailed above, and imprecision, inconsistency and indirectness) and up (adaptation of two (large effect, dose-response gradient) of the three GRADE domains) apply equally to studies investigating prognosis. The GRADE domains of interest will be adapted for cohort studies as recommended by Iorio et al 25 This will enable a consistent method for evaluating confidence in estimates from the included studies in the review.…”

Section: Metabiasesmentioning

confidence: 92%

The natural course of pain and disability following primary lumbar discectomy: Protocol for a systematic review and meta-analysis

et al. 2016

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Introduction: Knowledge about the natural clinical course is needed to improve understanding of recovery postsurgery as outcome is poor for some patients. Knowledge of the natural clinical course of symptoms and disability will inform optimal timing and the nature of rehabilitation intervention. The objective of this study is to provide first evidence synthesis investigating the natural clinical course of disability and pain in patients aged >16 years post primary lumbar discectomy. Methods and analysis:A systematic review and data synthesis will be conducted. Prospective cohorts that include a well-defined inception cohort (point of surgery) of adult participants who have undergone primary lumbar discectomy/microdiscectomy will be included. Outcomes will include measurements reported on 1 or more outcomes of disability and pain, with a baseline presurgery measurement. Following development of the search strategy, 2 reviewers will independently search information sources, assess identified studies for inclusion, extract data and assess risk of bias. A third reviewer will mediate on any disagreement at each stage. The search will employ sensitive topic-based strategies designed for each database from inception to 31 January 2016. There will be no language or geographical restrictions. Risk of bias will be assessed using a modified QUality In Prognostic Studies (QUIPS) tool . Data will be extracted for time points where follow-up was at least 80%. Means and 95% CIs will be plotted over time for pain and disability. All results will be reported in the context of study quality.Ethics and dissemination: This review will provide the first rigorous summary of the course of pain and disability across all published prospective cohorts. The findings will inform our understanding of when to offer and how to optimise rehabilitation following surgery. Results will be published in an open access journal. The study raises no ethical issues.

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Use of GRADE for assessment of evidence about prognosis: rating confidence in estimates of event rates in broad categories of patients

Cited by 565 publications

References 31 publications

Authors seldom report the most patient-important outcomes and absolute effect measures in systematic review abstracts

Authors seldom report the most patient-important outcomes and absolute effect measures in systematic review abstracts

Predictors of persistent pain after breast cancer surgery: a systematic review and meta-analysis of observational studies

The natural course of pain and disability following primary lumbar discectomy: Protocol for a systematic review and meta-analysis

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