GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

Guyatt, Gordon; Oxman, Andrew D; Vist, Gunn Elisabeth; Kunz, Regina; Falck‐Ytter, Yngve; Alonso‐Coello, Pablo; Schünemann, Holger J.

doi:10.1136/bmj.39489.470347.ad

Cited by 15,876 publications

(11,700 citation statements)

References 9 publications

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“…The strengths of this clinical practice guideline include the application of current standards for trustworthy guidelines, including the GRADE methodology which support a systematic and transparent process,9 and use of TSA to assess the risk of random errors 13. The limitations include the reliance upon existing systematic reviews for some recommendations, including the risk of trial heterogeneity, indirectness, and bias.…”

Section: Discussionmentioning

confidence: 99%

“…We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for formulating clinical questions, assessing the quality of evidence, generating anticipated absolute effects, and for moving from evidence to recommendations 9. In brief, we downgraded the quality of evidence (our confidence in the effect estimates) for an intervention for identified risks of bias (including baseline imbalance, lack of blinding, academic/financial conflicts of interest, or early termination of trials), inconsistency (unexplained heterogeneity), indirectness (including extrapolation from other patient populations or use of surrogate outcomes), imprecision (wide confidence interval around the effect estimate), or publication bias.…”

Section: Methodsmentioning

confidence: 99%

“…GRADE classifies recommendations as ‘strong’ when virtually all informed patients would choose the recommended management strategy. ‘Weak’ recommendations apply when fully informed patients would choose different management strategies, and reflects a close call between benefits and harms, uncertainty regarding treatment effects, questionable cost effectiveness, or variability in values and preferences 9, 14. The author group agreed upon all the recommendations in this guideline.…”

Section: Methodsmentioning

confidence: 99%

“…The aim was to summarize the available evidence and provide recommendations according to current standards for trustworthy guidelines 7, 8, 9

An electronic version of this guideline can be accessed at http://www.ssai.info/guidelines/

…”

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confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

“…The aim was to summarize the available evidence and provide recommendations according to current standards for trustworthy guidelines 7, 8, 9

An electronic version of this guideline can be accessed at http://www.ssai.info/guidelines/

…”

mentioning

confidence: 99%

See 2 more Smart Citations

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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“…We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence provided by the meta-analyses [21]. The following domains were evaluated: study design, risk of bias, inconsistency, indirectness, imprecision, and other considerations.…”

Section: Methodsmentioning

confidence: 99%

Efficacy, adverse events, and inter-drug comparison of mepolizumab and reslizumab anti-IL-5 treatments of severe asthma – a systematic review and meta-analysis

Henriksen

Bødtger

Sidenius³

et al. 2018

European Clinical Respiratory Journal

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Background: New, complex, and expensive therapies targeting Interleukin-5 (IL-5) to treat severe eosinophilic asthma are emerging.Objective: To assess efficacy, adverse events, and inter-drug comparison of mepolizumab and reslizumab for treating severe eosinophilic asthma.Design: A systematic review and meta-analysis on randomized, placebo-controlled, clinical trials elucidating two critical (exacerbation rate and oral corticosteroid (OCS) use) and six important clinical outcomes on the efficacy and safety of mepolizumab and reslizumab.Results: Five studies (N = 2197) contributed with data for exacerbation rate, showing a reduction of 53% (95% CI 46; 59) in favour of anti-IL-5, corresponding to –0.94 annual exacerbations (95% CI –1.08;–0.82), thus exceeding the predefined minimal clinical important difference (MCID) of 25% reduction of the estimated ≥2 annual exacerbations. Quality of evidence was considered moderate, with low heterogeneity in study findings (I2 = 0%). One study (N = 135) contributed with data on percentage of patients experiencing ≥50% reduction inoral corticosteroid treatment, showing an effect of 20% (95% CI 2.3;47) in favour of anti-IL-5 treatment (mepolizumab), thus exceeding the predefined MCID of 10%. Quality of evidence was considered low.Compared to placebo, anti-IL-5 showed significant improvements in lung function, asthma control, and asthma-related quality of life, but below the MCIDs. No differences were observed for serious adverse events and number of patients, who dropped out. No studies evaluating sickleave or head-to-head comparisons were identified. By indirect comparison, we found no significant difference between mepolizumab and reslizumab in any ofthe predefined clinical outcomes. OCS treatment reduction could not be compared due to lack of reslizumab studies investigating this outcome.Conclusions: Mepolizumab and reslizumab provide significant and clinically relevant improvements in exacerbation rate and OCS reduction. Indirect, inter-study comparisons revealed no differences between the anti-IL-5 drugs in efficacy or safety measures.

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Efficacy and Safety of Finasteride Therapy for Androgenetic Alopecia

Mella¹,

Perret²,

Manzotti³

et al. 2010

Arch Dermatol

196

123

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GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

Cited by 15,876 publications

References 9 publications

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

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

Efficacy, adverse events, and inter-drug comparison of mepolizumab and reslizumab anti-IL-5 treatments of severe asthma – a systematic review and meta-analysis

Efficacy and Safety of Finasteride Therapy for Androgenetic Alopecia

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