Evidence-Based Medicine: Grading of Recommendations

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Questions and Answers

According to the GRADE framework, what does the 'certainty' rating refer to?

The strength of the recommendation

Whether an estimate of association or effect is correct or true (correct)

The precision of the study results

The quality of the evidence

What is the primary purpose of the GRADE framework?

To summarize the results of a systematic review

To assess the risk of bias in individual studies

To provide a systematic approach to clinical decision making (correct)

To adjust for cofounders in observational studies

Which of the following is NOT a reason to 'rate down' the certainty of evidence according to GRADE?

Publication bias

Risk of bias

Study was randomized (correct)

Imprecision

What is the primary focus of GRADE when assessing imprecision?

The 95% confidence interval Signup and view all the answers

What is an example of risk of bias in a study?

A study not randomized, with loss to follow-up of participants Signup and view all the answers

What is the purpose of a funnel plot in assessing publication bias?

To detect publication bias and asymmetry Signup and view all the answers

What would increase the certainty of evidence according to GRADE?

A large magnitude of effect Signup and view all the answers

What is indirectness in the context of GRADE?

When the intervention of interest is not studied in the population of interest Signup and view all the answers

What does a weak recommendation imply?

There is likely to be variation in the decision made by informed people Signup and view all the answers

What are the two parts of the GRADE approach?

Certainty of Evidence and Recommendation Strength Signup and view all the answers

What is the primary concern associated with hypertension?

Cardiovascular disease Signup and view all the answers

What is the total number of participants included in the systematic review and meta-analysis?

41,633 participants Signup and view all the answers

What is the weighted mean difference (WMD) in systolic blood pressure (SBP) observed in the study?

−1.10 mmHg Signup and view all the answers

What is the minimum duration of intervention required for folic acid supplementation to have a significant effect on systolic blood pressure?

≤6 weeks Signup and view all the answers

What is the minimum dose of folic acid supplementation required for a significant effect on systolic blood pressure?

≥5 mg/d Signup and view all the answers

Study Notes

Grading the Evidence: GRADE Framework

GRADE is a transparent framework for developing and presenting summaries of evidence, providing a systematic approach to clinical decision making.

How GRADE Works

A clinical question is formulated in PICO format.
A systematic review provides an estimate of the effect size of an outcome.
The author rates the quality of the evidence and strength of recommendations.

GRADE Certainty Rating

Certainty refers to whether an estimate of association or effect is correct or true.
Categories of certainty: very low, low, moderate, high.
Very low: the true effect is probably markedly different from the estimated effect.
Low: the true effect might be markedly different from the estimated effect.
Moderate: the authors believe that the true effect is probably close to the estimated effect.
High: the authors have a lot of confidence that the true effect is similar to the estimated effect.

Factors that Decrease Certainty

Risk of bias: bias in the design of a study that causes inaccurate results.
Imprecision: results due to chance, few observed events or participants, and wide confidence intervals.
Inconsistency: inconsistent results across studies.
Indirectness: the intervention studied is not in the population of interest or does not report the outcome of interest.
Publication bias: selective publication of research results.

Factors that Increase Certainty

Large magnitude of effect.
Dose-response gradient.
All residual confounding would increase our confidence in an effect.
Large observational or non-randomized study without other limitations.

GRADE: 2 Parts

Certainty of evidence: how likely is it that something works?
Recommendation strength: should it be recommended for use?

Recommendations

Can be in favour or against an intervention.
Can be strong or weak.
If weak, likely to be variation in the decision made by informed people.

Example of GRADE in Action

A systematic review and dose-response meta-analysis of 41,633 participants showed that folic acid supplementation significantly decreased systolic blood pressure.

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Description

Learn about the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework and how it's used in evidence-based medicine to weigh evidence and make clinical decisions.