GRADE

Question 1

The GRADE process includes an examination of…

Answer 1

1. Risk of bias in study design (CONSORT)
2. Inconsistency in results across studies
3. Indirectness of evidence
4. Imprecision of the measurements
5. Publication bias

Question 2

A report that uses the GRADE process to evaluate the quality of science is called a..

Answer 2

Systematic review

Question 3

Conclusions about the effectiveness of the intervention

Answer 3

“Estimate of the effect”

Question 4

The believability of drawn conclusion in a systematic review

Answer 4

“Certainty of the evidence”

Question 5

The certainty/quality of the evidence can be rated as…

Answer 5

High - true effect is similar to the estimate of the effect

Moderate - true effect is probably close to the estimate of the effect; possibility of substantial difference

Low - the true effect might be very different from the estimate of the effect

Very Low - the true effect is probably very different to the estimate of the effect

Question 6

All evidence is initially assumed to be..

Answer 6

High certainty; downgraded for each serious problem found

Question 7

How might the collective risk of bias be presented in a systematic review?

Answer 7

Risk of bias summary table

Question 8

Inconsistency refers to..

Answer 8

Unexplained heterogeneity of results - individual RCTs within a body of evidence yield very different estimates of effect

Question 9

If no explanation for heterogeneity is found…

Answer 9

The evidence should be downgraded

Question 10

Criteria to downgrade for inconsistency..

Answer 10

• Large difference between means (point estimates) across studies
• Minimal/no overlap of confidence intervals; variation may be greater than expected by chance alone
• Tests of heterogeneity (ex. I² = no heterogeneity)

Question 11

Directness/indirectness is assessed with a focus on..

Answer 11

(P.I.C.O)
- Populations
- Interventions
- Controls
- Outcomes

Question 12

Things to consider when evaluating imprecision

Answer 12

1. Confidence intervals - small CI = precise estimate of treatment vs large CI = imprecise estimate (increases uncertainty of treatment effect)
2. Sample size
   - Optimal information size (OIS); downgrade if total participants in review is less sample size calculation for single adequate study
3. Number of events
   - May have had sufficient # of participants but not enough events to measure; sample size may therefore need to be based on number of events rather than participants in some studies

Question 13

How can publication bias be assessed in a systematic review?

Answer 13

Funnel plots; assess the likelihood that some of the evidence has withheld/not published/ignored