Friday, October 30, 2020

U.S. Guideline-Producing Organizations Show Some Promise, Room for Improvement in their Application of GRADE

As many as one-third of guideline-producing health organizations in the United States report using the GRADE framework, but exactly how closely these organizations follow the key tenets of GRADE - such as using evidence summaries of each identified outcome to inform the overall certainty of evidence, and linking this certainty to a strength of recommendation - is a matter of debate.

In study by Dixon and colleagues published earlier this year in the Journal of Clinical Epidemiology, the authors set out to evaluate the use of GRADE in U.S.-based guidelines published between 2011 and 2018 and available in the National Guidelines Clearinghouse. Assessing up to three of the most recent guidelines from each of 135 identified U.S.-based organizations, the authors used several criteria to examine how closely each of the 67 resulting guidelines adhered to core GRADE concepts, including:

  • defining the certainty of evidence,
  • explicitly considering the GRADE domains when assessing the certainty of evidence, and
  • consistently defining the strength of resulting recommendations as strong or weak/conditional.
While most (89.6%) defined the certainty of evidence in a matter consistent with GRADE, only 10.4% explicitly reported examining certainty through all 8 GRADE criteria. Only 13.4% of guidelines assessing the certainty of evidence sourced from non-randomized trials reported assessing the potential reasons to upgrade the certainty of evidence (i.e., large magnitude of effect, dose-response gradient, and residual confounding). Finally, only about half (53.7%) provided an evidence profile or summary of findings table describing the assessments, and while reporting of the certainty of evidence and the balance between desirable and undesirable effects was most common (100% and 97%, respectively), explicit consideration of resource use and patients' values and preferences were also fairly common (73.1% and 77.6%, respectively) .The use of GRADE in line with the authors' established criteria appeared to grow somewhat more frequent over time, indicating a general trend toward proper use of GRADE.

Figure from Dixon et al. shows the relative reporting frequency of the various GRADE criteria for assessing certainty of evidence in years 2011-14 versus 2015-18, suggesting a trend for improved reporting over time. Click to enlarge.

The authors conclude that continued training of guideline developers and dissemination of education on the appropriate application of GRADE should further improve adherence, including the explicit consideration of all eight domains for assessing the certainty of evidence and of all aspects that inform the translation of this evidence into clinical recommendations.

Dixon C, Dixon PE, Sultan S, Mustafa R, Morgan RL, Murad MH, Falck-Ytter Y, and Dahm P. (2020). Guideline developers in the United States were inconsistent in applying criteria for appropriate Grading of Recommendations, Assessment, Development and Evaluation use. J Clin Epidemiol 124:193-199.

Manuscript available at the publisher's website here.