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Considerations in grading a recommendation

This guide outlines key considerations in grading recommendation evidence quality, including methodological integrity, likelihood of bias, and the trade-off between benefits and risks. It discusses the hierarchy of study designs, reinforcing the need for strong randomized controlled trials (RCTs) versus observational studies. The framework for downgrading evidence includes aspects like implementation quality, consistency, and reporting biases. Moreover, it details grades of recommendations based on risk-benefit evaluations, emphasizing the importance of understanding patient values and preferences in therapeutic decisions.

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Considerations in grading a recommendation

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Presentation Transcript

  1. Considerations in grading a recommendation • methodological quality of evidence • likelihood of bias • trade-off between benefits and risks

  2. Methodological quality specific to an outcome • benefits • often have RCTS • risks • often limited to observational studies

  3. Possible levels of quality • strong • intermediate • weak • very weak

  4. Quality of evidence,Where to start? • basic study design • randomized trials • strong evidence • observational studies • weak evidence

  5. Downgrading quality,weak implementation • detailed design and execution • concealment • balance in known prognostic factors • intention to treat principle observed • blinding • completeness of follow-up

  6. Downgrading qualityinconsistency • evidence weaker if results differ from study to study • subjective judgement • you will be told

  7. Downgrading quality, indirectness • indirect treatment comparisons • interested in A versus B • have A versus C and B versus C • different patient population • different intervention • different outcome

  8. Downgrading quality, reporting bias, sparse data • what if you have a biased sample of studies? • publication bias • what if one study with 10 people?

  9. What can increase strength of evidence? • large association can upgrade • very large, 2 levels • large with no plausible confounders, 1 level • dose-response gradient • can upgrade one level

  10. Grade of Recommendations • do it or don’t do it • strong recommendation • probably do it, or probably don’t • weaker recommendation

  11. Risk/Benefit tradeoff • seriousness of outcome • magnitude of effect • precision of treatment effect • risk of target event • risk of adverse events • cost of therapy • values and preferences

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