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The GRADE System for Rating Clinical Guidelines
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The Policy Forum allows health policy makers around the world to discuss challenges and opportunities for improving health
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“The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to rate the quality of the body of evidence presented in this meta-analysis (27).”
From Optimal Dose and Type of Physical Activity to Improve Glycemic Control in People Diagnosed With Type 2 Diabetes: A Systematic Review and Meta-analysis (2024) · cites this paper as [27]
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Early goal-directed therapy in the treatment of severe sepsis and septic shock
Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., Peterson, E., & Tomlanovich, M. (2001) · New England Journal of Medicine · doi:10.1056/nejmoa010307 · Cited by 10,743 · cited 1×
“, on the basis of the protocol of a commonly cited single-centre study”
BackgroundIntensive insulin therapy in critically ill patients.
Van den Berghe, G., Wouters, P., Weekers, F., Verwaest, C., Bruyninckx, F., Schetz, M., Vlasselaers, D., Ferdinande, P., Lauwers, P., & Bouillon, R. (2001) · New England Journal of Medicine · doi:10.1056/nejmoa011300 · Cited by 9,977 · cited 1×
“. No evidence exists for moderate glucose control in this context, whereas the value of tight control was supported by one single-centre randomized controlled trial (RCT)”
BackgroundGrading quality of evidence and strength of recommendations
(2004) · BMJ · doi:10.1136/bmj.328.7454.1490 · Cited by 8,477 · cited 5×
“Given also that the GRADE criteria are conveyed as ‘‘explicit and clear’’ [6], there should be little need for intensive methodological consultation from the GRADE group when experts produce guidelines.”
BackgroundInfluentialDellinger, R. P., Levy, M. M., Carlet, J. M., Bion, J., Parker, M. M., Jaeschke, R., Reinhart, K., Angus, D. C., Brun‐Buisson, C., Beale, R. J., et al. (2007) · Intensive Care Medicine · doi:10.1007/s00134-007-0934-2 · Cited by 6,789
Intensive versus Conventional Glucose Control in Critically Ill Patients
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“14) [24].”
Intensive insulin therapy in the medical ICU
Van den Berghe, G., Wilmer, A., Hermans, G., Meersseman, W., Wouters, P. J., Milants, I., Van Wijngaerden, E., Bobbaers, H., & Bouillon, R. (2006) · New England Journal of Medicine · doi:10.1056/nejmoa052521 · Cited by 3,639 · cited 2×
“, intensive insulin therapy) in most intensive care unit (ICU) patients [18–21].”
BackgroundResultSurviving Sepsis Campaign guidelines for management of severe sepsis and septic shock
Dellinger, R. P., Carlet, J. M., Masur, H., Gerlach, H., Calandra, T., Cohen, J., Gea‐Banacloche, J., Keh, D., Marshall, J. C., Parker, M. M., et al. (2004) · Intensive Care Medicine · doi:10.1007/s00134-004-2210-z · Cited by 3,309
What is ‘quality of evidence’ and why is it important to clinicians?
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Users' Guides to the Medical Literature
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Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock
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“In 2004 the SSC guidelines recommended that for serious sepsis, intravenous antibiotic therapy should be rapidly instituted [10]; this guideline was given a grade ‘‘E.”
BackgroundMethodInfluential
Cited by
Sorted by citations
Clinical Practice Guidelines We Can Trust
Board on Health Care Services (2011) · National Academies Press eBooks · doi:10.17226/13058 · Cited by 3,146
Association of the Extent of Resection With Survival in Glioblastoma
Brown, T. J., Brennan, M., Li, M. J., Church, E. W., Brandmeir, N. J., Rakszawski, K. L., Patel, A. S., Rizk, E., Suki, D., Sawaya, R. A., et al. (2016) · JAMA Oncology · doi:10.1001/jamaoncol.2016.1373 · Cited by 1,138
Guidelines International Network: Toward International Standards for Clinical Practice Guidelines
Qaseem, A., Forland, F., Macbeth, F., Ollenschläger, G., Phillips, S., van der Wees, P., & for the Board of Trustees of the Guidelines International Network* (2012) · Annals of Internal Medicine · doi:10.7326/0003-4819-156-7-201204030-00009 · Cited by 902
“Clear identification of the quality of evidence helps, and strength of clinical recommendations increases the trustworthiness and improves the implementation of clinical guidelines (32, 43, 76).”
BackgroundGuiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians
American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity (2012) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2012.04188.x · Cited by 681
Non-surgical management of knee osteoarthritis: comparison of ESCEO and OARSI 2019 guidelines
Arden, N., Perry, T. A., Bannuru, R. R., Bruyère, O., Cooper, C. C., Haugen, I. K., Hochberg, M. C., McAlindon, T. E., Mobasheri, A., & Reginster, J. (2020) · Nature Reviews Rheumatology · doi:10.1038/s41584-020-00523-9 · Cited by 598
Murray, M. J., DeBlock, H. F., Erstad, B. L., Gray, A. W., Jacobi, J., Jordan, C. J., McGee, W. T., McManus, C., Meade, M. O., Nix, S. A., et al. (2016) · Critical Care Medicine · doi:10.1097/ccm.0000000000002027 · Cited by 524
“The Task Force used the GRADE system to rate the quality of evidence and strength of the recommendation for each clinical practice question (8).”
MethodDigital health: a path to validation
Mathews, S. C., McShea, M. J., Hanley, C. L., Ravitz, A., Labrique, A. B., & Cohen, A. B. (2019) · npj Digital Medicine · doi:10.1038/s41746-019-0111-3 · Cited by 508
Li, X., Meng, X., Timofeeva, M. N., Tzoulaki, I., Tsilidis, K. K., Ioannidis, J. P. A., Campbell, H. J., & Τheodoratou, E. (2017) · BMJ · doi:10.1136/bmj.j2376 · Cited by 402
Annane, D., Pastores, S. M., Rochwerg, B. N., Arlt, W., BALK, R. A., Beishuizen, A., Briegel, J., Carcillo, J. A., Christ‐Crain, M., Cooper, M. S., et al. (2017) · Intensive Care Medicine · doi:10.1007/s00134-017-4919-5 · Cited by 380
“Each recommendation was designated either “strong” or “conditional” according to the GRADE approach [7].”
BackgroundAnnane, D., Pastores, S. M., Rochwerg, B. N., Arlt, W., BALK, R. A., Beishuizen, A., Briegel, J., Carcillo, J. A., Christ‐Crain, M., Cooper, M. S., et al. (2017) · Critical Care Medicine · doi:10.1097/ccm.0000000000002737 · Cited by 348
American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity (2012) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2012.04187.x · Cited by 316
ESPEN endorsed recommendations: Nutritional therapy in major burns
Rousseau, A.-F., Losser, M.-R., Ichai, C., & Berger, M. M. (2013) · Clinical Nutrition · doi:10.1016/j.clnu.2013.02.012 · Cited by 388
The challenge of de‐labeling penicillin allergy
Stone, C. A., Trubiano, J. A., Coleman, D. T., Rukasin, C. R. F., & Phillips, E. J. (2019) · Allergy · doi:10.1111/all.13848 · Cited by 270
Gallardo-Gómez, D., del Pozo-Cruz, J., Noetel, M., Álvarez-Barbosa, F., Alfonso-Rosa, R. M., & del Pozo Cruz, B. (2022) · Ageing Research Reviews · doi:10.1016/j.arr.2022.101591 · Cited by 268
“The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to rate the quality of evidence (Kavanagh, 2009).”
Hegyi, P. J., Petersen, O. H., Holgate, S. T., Erőss, B. M., Garami, A., Szakács, Z., Dobszai, D., Balaskó, M., Kemény, L. V., Peng, S., et al. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9051532 · Cited by 243
“, the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system) when rating quality of evidence and formulating the strength of recommendations (main target audience: clinical practitioners and scientists) [43,44].”
BackgroundTacconelli, E., Mazzaferri, F., de Smet, A. M. G. A., Bragantini, D., Eggimann, P., Huttner, B. D., Kuijper, E. J., Lucet, J. C., Mutters, N. T., Sanguinetti, M., et al. (2019) · Clinical Microbiology and Infection · doi:10.1016/j.cmi.2019.01.005 · Cited by 241
“Evidence certainty of controlled studies was classified as high, moderate, low or very low, and recommendation strength was classified as strong or conditional according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system [37].”
MethodConsensus guidelines for the diagnosis and management of invasive aspergillosis, 2021
Douglas, A. P., Smibert, O. C., Bajel, A. R., Halliday, C. L., Lavee, O., McMullan, B. J., Yong, M. K., van Hal, S. J., & Chen, S. C. ‐. (2021) · Internal Medicine Journal · doi:10.1111/imj.15591 · Cited by 188
Poonacha, T. K., & Go, R. S. (2010) · Journal of Clinical Oncology · doi:10.1200/jco.2010.31.6414 · Cited by 158
Monitoring nutrition in the ICU
Berger, M. M., Reintam-Blaser, A., Calder, P. C., Casaer, M., Hiesmayr, M. J., Mayer, K., Montejo, J. C., Pichard, C., Preiser, J.-C., van Zanten, A. R. H., et al. (2019) · Clinical Nutrition · doi:10.1016/j.clnu.2018.07.009 · Cited by 171
Psychological treatment of dental anxiety among adults: A systematic review
Wide Boman, U., Carlsson, V., Westin, M., & Hakeberg, M. (2013) · European Journal of Oral Sciences · doi:10.1111/eos.12032 · Cited by 142
ESCMID rapid guidelines for assessment and management of long COVID
Yelin, D., Moschopoulos, C. D., Margalit, I., Gkrania‐Klotsas, E., Landi, F., Stahl, J. ‐., & Yahav, D. (2022) · Clinical Microbiology and Infection · doi:10.1016/j.cmi.2022.02.018 · Cited by 145
“We planned to classify evidence certainty per question as high, moderate, low, or very low and recommendation strength as strong or conditional according to the GRADE system [16].”
Low-Intensity Transcranial Current Stimulation in Psychiatry
Philip, N. S., Nelson, B. G., Frӧhlich, F., Lim, K. O., Widge, A. S., & Carpenter, L. L. (2017) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2017.16090996 · Cited by 139
“c The 21-itemquality checklist was developed (see supplements 1 and 2) on the basis of GRADE scoring guidelines (20).”
BackgroundMethodInfluentialEuropean Recommendations on Organisation of Interventional Care in Acute Stroke (EROICAS)
Fiehler, J., Cognard, C., Gallitelli, M., Jansen, O., Kobayashi, A., Mattle, H. P., Muir, K. W., Mazighi, M., Schaller, K., & Schellinger, P. D. (2016) · International Journal of Stroke · doi:10.1177/1747493016647735 · Cited by 132
“Similar to the GRADE approach,(15) quality of evidence was graded into high, moderate, low, and very low.”
BackgroundMethodBarbui, C., Dua, T., van Ommeren, M., Yasamy, M. T., Fleischmann, A., Clark, N. C., Thornicroft, G., Hill, S. R., & Saxena, S. (2010) · PLoS Medicine · doi:10.1371/journal.pmed.1000322 · Cited by 119
“In areas characterized by the presence of many randomized trials, however, such as antidepressants for major depression where single reviews may include more than 100 trials, this posed a practical problem, in terms of feasibility (to access all primary studies), and also in terms of reproducibility and consistency [1…”
BackgroundKhan, A. R., Khan, S., Zimmerman, V. A., Baddour, L. M., & Tleyjeh, I. M. (2010) · Clinical Infectious Diseases · doi:10.1086/656735 · Cited by 116
New and improved tuberculosis diagnostics: evidence, policy, practice, and impact
Pai, M., Minion, J., Steingart, K. R., & Ramsay, A. (2010) · Current Opinion in Pulmonary Medicine · doi:10.1097/mcp.0b013e328338094f · Cited by 114
Gallardo-Gómez, D., Salazar-Martínez, E., Alfonso-Rosa, R. M., Ramos-Munell, J., del Pozo-Cruz, J., del Pozo Cruz, B., & Álvarez-Barbosa, F. (2024) · Diabetes Care · doi:10.2337/dc23-0800 · Cited by 137
Grading Quality of Evidence and Strength of Recommendations: A Perspective
Ansari, M., Tsertsvadze, A., & Moher, D. (2009) · PLoS Medicine · doi:10.1371/journal.pmed.1000151 · Cited by 110
“In a new Policy Forum published in this issue of PLoS Medicine, Kavanagh [9] questions the external consistency of the GRADE framework by comparing the Surviving Sepsis Campaign (SSC) guideline recommendations developed in 2004 and”
MethodGuidelines for best practices in monitoring established coeliac disease in adult patients
Elli, L., Leffler, D. A., Cellier, C., Lebwohl, B., Ciacci, C., Schümann, M., Lundin, K. E. A., Zammit, S. C., Sidhu, R., Roncoroni, L., et al. (2023) · Nature Reviews Gastroenterology & Hepatology · doi:10.1038/s41575-023-00872-2 · Cited by 115
“The levels of certainty of the evidence and strength of the recommendations were defined for every part of the statement, according to the GRADE system using GRADEpro 23 .”
Statins and Multiple Noncardiovascular Outcomes
He, Y., Li, X., Gašević, D., Brunt, E., McLachlan, F., Millenson, M. E., Timofeeva, M. N., Ioannidis, J. P. A., Campbell, H. J., & Τheodoratou, E. (2018) · Annals of Internal Medicine · doi:10.7326/m18-0808 · Cited by 97
Zhu, F., Zhu, X., Bi, X., Kuang, D., Liu, B., Zhou, J., Yang, Y., & Ren, Y. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1133727 · Cited by 113
“” The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used in this study to judge the quality of evidence (27).”
MethodMethodological considerations of the GRADE method
Malmivaara, A. V. (2014) · Annals of Medicine · doi:10.3109/07853890.2014.969766 · Cited by 91
Devlin, J. W., Skrobik, Y. K., Rochwerg, B. N., Nunnally, M., Needham, D. M., Gélinas, C., Pandharipande, P. P., Slooter, A. J. C., Watson, P. L., Weinhouse, G. L., et al. (2018) · Critical Care Medicine · doi:10.1097/ccm.0000000000003298 · Cited by 88
Wright, J. D., Pawar, N., Gonzalez, J. S. R., Lewin, S. N., Burke, W. M., Simpson, L. L., Charles, A. S., D’Alton, M. E., & Herzog, T. J. (2011) · Obstetrics and Gynecology · doi:10.1097/aog.0b013e3182267f43 · Cited by 84
Use of Novel Strategies to Develop Guidelines for Management of Pyogenic Osteomyelitis in Adults
Spellberg, B. J., Aggrey, G., Brennan, M. B., Footer, B. W., Forrest, G. N., Hamilton, F., Minejima, E., Moore, J., Ahn, J., Angarone, M., et al. (2022) · JAMA Network Open · doi:10.1001/jamanetworkopen.2022.11321 · Cited by 83
“1-7 Instead, the group sought to incorporate the “humility of uncertainty”7 by only providing clear recommendations when reproducible, high-quality, hypothesis-confirming evidence is available, requiring at a minimum: (1) 1 properly conducted, adequately powered randomized controlled trial (RCT); and (2) at least 1 ot…”
BackgroundMethodNovel Therapies for Septic Shock Over the Past 4 Decades
Suffredini, A. F., & Munford, R. S. (2011) · JAMA · doi:10.1001/jama.2011.909 · Cited by 78
Functional foods modulating inflammation and metabolism in chronic diseases: a systematic review
Luvián‐Morales, J., Varela-Castillo, F. O., Flores‐Cisneros, L., Cetina, L., & Castro-Eguiluz, D. (2021) · Critical Reviews in Food Science and Nutrition · doi:10.1080/10408398.2021.1875189 · Cited by 85
“The quality of the trials was evaluated according to the GRADE system to decide which articles would be included in this systematic review (Kavanagh 2009).”
MethodHoenigl, M., Gangneux, J., Segal, E., Alanio, A., Chakrabarti, A., Chen, S. C. ‐., Govender, N. P., Hagen, F., Климко, Н. Н., Meis, J. F. G. M., et al. (2018) · Mycoses · doi:10.1111/myc.12836 · Cited by 73
Should patients with NAFLD/NASH Be surveyed for HCC?
Reig, M., Gambato, M., Man, N. K., Roberts, J. P., Victor, D., Orci, L. A., & Toso, C. (2019) · Transplantation · doi:10.1097/tp.0000000000002361 · Cited by 71
Tonelli, M. R., Curtis, J. R., Guntupalli, K. K., Rubenfeld, G. D., Arroliga, A. C., Brochard, L. J., Douglas, I. S., Gutterman, D. D., Hall, J. R., Kavanagh, B. P., et al. (2012) · American Journal of Respiratory and Critical Care Medicine · doi:10.1164/rccm.201204-0638st · Cited by 69
“Furthermore, attempts to incorporate these multiple factors into a single summary expression of “strength” of a recommendation is difficult, if not impossible (56).”
Going from evidence to recommendations: Can GRADE get us there?
Mercuri, M., Baigrie, B. S., & Upshur, R. E. G. (2018) · Journal of Evaluation in Clinical Practice · doi:10.1111/jep.12857 · Cited by 64
Expert System for Offline Clinical Guidelines and Treatment
Saba, T., Al-Zahrani, S., Rehman, A. U., & Islamic, S. (2012) · Cited by 58
Preeradication Vaccine Policy Options for Poliovirus Infection and Disease Control
Thompson, K. M., Pallansch, M. A., Tebbens, R. J. D., Wassilak, S. G. F., Kim, J., & Cochi, S. L. (2013) · Risk Analysis · doi:10.1111/risa.12019 · Cited by 58
“We evaluated various grading options,(40,41) and eventually collapsed our assessments into three grades.”
MethodSabha, M., & Hochberg, M. C. (2021) · Osteoarthritis and Cartilage Open · doi:10.1016/j.ocarto.2021.100232 · Cited by 60
“The GRADE methodology combines both the literature review as well as expert opinions [18].”
MethodA systematic review of neurocognitive dysfunction with overactive bladder medications
Duong, V., Iwamoto, A., Pennycuff, J. F., Kudish, B., & Iglesia, C. B. (2021) · International Urogynecology Journal · doi:10.1007/s00192-021-04909-5 · Cited by 58
“The aforementioned criteria were all taken into account in determining the overall quality of evidence using modified guidelines taken from the Grades for Recommendation, Assessment, Development and Evaluation (GRADE) system [31].”
MethodD'Souza, R. S., Kubrova, E., Her, Y. F., Barman, R. A., Smith, B. J., Alvarez, G. A. M., West, T., & Abd-Elsayed, A. A. (2022) · Advances in Therapy · doi:10.1007/s12325-022-02244-9 · Cited by 54
“Quality of Evidence The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) quality assessment criteria [17] were used to assess the level of evidence for DRG-S use for each specific neuropathic pain diagnosis.”
MethodTrace Element Supplementation Following Severe Burn Injury
Kurmis, R., Greenwood, J. E., & Aromataris, E. (2015) · Journal of Burn Care & Research · doi:10.1097/bcr.0000000000000259 · Cited by 53
A Critical Evaluation of Existing Diabetic Foot Screening Guidelines
Formosa, C., Gatt, A., & Chockalingam, N. (2016) · The Review of Diabetic Studies · doi:10.1900/rds.2016.13.158 · Cited by 54
“…for Clinical Systems Improvement (ICSI), USA 2014 ICSI, 1014 [17] Grading of Recommendations Assessment, Development and Evaluation (GRADE) system Kavanagh, 2009 [18] Foot Screening Guidelines American Diabetes Association (ADA), USA 2014, updated 2016 ADA, 2014, S47-S49 [19] Own (ADA) ADA,…”
BackgroundMethodInfluentialThe value of observational research in liver diseases
Lindor, R. A., & Lindor, K. D. (2010) · Hepatology · doi:10.1002/hep.24082 · Cited by 49
“Despite these shortcomings, RCTs are still touted as the preferred form of research by a number of influential bodies, such as the US Preventive Services Task Force, the Agency for Healthcare Research and Quality, and the World Health Organization.(3,4) The preference for RCT data over observational data can be at”
BackgroundSurgical Infection Society Guidelines for Antibiotic Use in Patients with Traumatic Facial Fractures
Forrester, J. D., Wolff, C. J., Choi, J., Colling, K. P., & Huston, J. M. (2020) · Surgical Infections · doi:10.1089/sur.2020.107 · Cited by 47
“For the qualitative synthesis, the quality and certainty of published evidence was evaluated using the GRADE defini-tions [7,8].”
BEVA primary care clinical guidelines: Analgesia
Bowen, M., Redpath, A., Dugdale, A., Burford, J. H., Lloyd, D., Watson, T., & Hallowell, G. D. (2019) · Equine Veterinary Journal · doi:10.1111/evj.13198 · Cited by 46
Cao, S.-J., Chen, D., Yang, L., & Zhu, T. (2019) · BMC Anesthesiology · doi:10.1186/s12871-019-0735-5 · Cited by 45
“We used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) [18] approach to rate the quality of the evidence for postoperative delirium, length of stay, readmission to hospital and admission to nursing home within 1 year.”
MethodSkrobik, Y. K., & Chanques, G. (2013) · Annals of Intensive Care · doi:10.1186/2110-5820-3-9 · Cited by 43
“experts [4].”
Venous leg ulcer clinical practice guidelines: what is AGREEd?
Tan, M. K. H., Luo, R., Onida, S., Maccatrozzo, S., & Davies, A. H. (2019) · European Journal of Vascular and Endovascular Surgery · doi:10.1016/j.ejvs.2018.08.043 · Cited by 43
Kupeli, N., Chatzitheodorou, G., Troop, N., McInnerney, D., Stone, P. C., & Candy, B. (2019) · BMC Palliative Care · doi:10.1186/s12904-019-0449-y · Cited by 52
Meloni, M., Giurato, L., Monge, L., Miranda, C., Scatena, A., Ragghianti, B., Silverii, G. A., Vermigli, C., CASSAI, A. D., Volpe, A., et al. (2024) · Acta Diabetologica · doi:10.1007/s00592-024-02246-9 · Cited by 41
“…(Associazione Medici Diabetologi, AMD), are being developed for inclusion in the Italian National Guideline System (INGS), designed as a standard reference for clinical practice in Italy using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach [12, 13].”
Robot-assisted laparoscopic pyeloplasty in children: a systematic review
Masieri, L., Sforza, S., Grosso, A. A., Valastro, F., Tellini, R., Cini, C., Landi, L., Taverna, M., Elia, A., Mantovani, A., et al. (2020) · Minerva Urologica e Nefrologica · doi:10.23736/s0393-2249.20.03854-0 · Cited by 41
Hartling, L., Fernandes, R. M., Seida, J. C., Vandermeer, B., & Dryden, D. M. (2012) · PLoS ONE · doi:10.1371/journal.pone.0034697 · Cited by 38
“Despite numerous publications about the GRADE tool (including some criticisms [16]), there have been few empirical and systematic evaluations of applying the tool in practice [17].”
MethodNarrative evidence and evidence‐based medicine
Misak, C. (2010) · Journal of Evaluation in Clinical Practice · doi:10.1111/j.1365-2753.2010.01407.x · Cited by 37
“The worries have piled on top of one another: EBM shifts the focus of clinical practice away from reflection on individual patients and towards populations with unhappy results for patients who are outliers [6,7]; medicine is full of grey areas where the risk benefit analysis of competing clinical options is incomplet…”
BackgroundPhysical functioning following spinal cord stimulation: a systematic review and meta-analysis
ElSaban, M., Kleppel, D. J., Kubrova, E., Alvarez, G. A. M., Hussain, N., & D'Souza, R. S. (2023) · Regional Anesthesia & Pain Medicine · doi:10.1136/rapm-2022-104295 · Cited by 36
Shugg, T., Pasternak, A. L., London, B., & Luzum, J. A. (2020) · npj Genomic Medicine · doi:10.1038/s41525-020-00156-7 · Cited by 35
Development and implementation of clinical guidelines: An artificial intelligence perspective
de Oliveira, T. C. R., Nováis, P., & Neves, J. (2013) · Artificial Intelligence Review · doi:10.1007/s10462-013-9402-2 · Cited by 34
Bergamot Oil: Botany, Production, Pharmacology
Valussi, M., Donelli, D., Firenzuoli, F., & Antonelli, M. (2021) · Encyclopedia · doi:10.3390/encyclopedia1010016 · Cited by 36
“Psoriasis Application on psoriatic plaques 30 min before UVB treatment (topical) C * Level of Evidence evaluated in accordance with the 4-tier GRADE system [78].”
MethodExercise training for improving outcomes post-burns: a systematic review and meta-analysis
Flores, O., Tyack, Z. F., Stockton, K. A., Ware, R. S., & Paratz, J. D. (2018) · Clinical Rehabilitation · doi:10.1177/0269215517751586 · Cited by 33
Restorative treatments of dystrophin expression in Duchenne muscular dystrophy: A systematic review
Pascual‐Morena, C., Cavero‐Redondo, I., Álvarez‐Bueno, C., Mesas, A. E., Pozuelo‐Carrascosa, D. P., & Martínez‐Vizcaíno, V. (2020) · Annals of Clinical and Translational Neurology · doi:10.1002/acn3.51149 · Cited by 33
“The strength of the evidence for main outcomes was assessed using the Grades of Recommendation, Assessment, Development and Evaluation tool (GRADE).(20) This tool considers three aspects: study design (i.”
MethodEuropean recommendations on organisation of interventional care in acute stroke (EROICAS)
Fiehler, J., Cognard, C., Gallitelli, M., Jansen, O., Kobayashi, A., Mattle, H. P., Muir, K. W., Mazighi, M., Schaller, K., & Schellinger, P. D. (2016) · European Stroke Journal · doi:10.1177/2396987316659033 · Cited by 33
Zhang, X., Liu, X., & Kang, D. (2015) · Scientific Reports · doi:10.1038/srep16582 · Cited by 32
Colling, K. P., Bessoff, K. E., Forrester, J. D., Kendrick, D. E., Mercier, P. J., & Huston, J. M. (2022) · Surgical Infections · doi:10.1089/sur.2021.207 · Cited by 31
Mumford, J., & Birchwood, J. (2020) · Pastoral Care in Education · doi:10.1080/02643944.2020.1855670 · Cited by 32
“Other approaches to the appraisal of qualitative evidence have been criticised for a lack of validity (Kavanagh, 2009).”
BackgroundD'Souza, R. S., Langford, B. J., Olsen, D. A., & Johnson, R. L. (2021) · Local and Regional Anesthesia · doi:10.2147/lra.s303827 · Cited by 30
Pinto, C. A., Iyer, V., Albitar, H. A. H., Anderson, A. L., Cajigas, H. R., Simonetto, D. A., Krowka, M. J., DuBrock, H. M., & de Moraes, A. G. (2021) · Respiratory Medicine and Research · doi:10.1016/j.resmer.2021.100852 · Cited by 30
Team learning and innovation in nursing, a review of the literature
Timmermans, O., van Linge, R. H., Petegem, P. V., Rompaey, B. V., & Denekens, J. (2011) · Nurse Education Today · doi:10.1016/j.nedt.2011.07.006 · Cited by 31
“The level of evidence in the included studies was defined through the grading system of the National Institute for Clinical Excellence (Kavanagh, 2009).”
BackgroundMethodHow can we improve the interpretation of systematic reviews?
Tricco, A. C., Straus, S. E., & Moher, D. (2011) · BMC Medicine · doi:10.1186/1741-7015-9-31 · Cited by 29
“Limitations of GRADE include that it requires training, provides limited guidance for examining non-intervention or non-diagnostic studies, and requires ‘scientific value judgments’ to be made about a body of evidence, which is often difficult for nonexperimental research (for example, observational studies, qualitati…”
BackgroundGuidelines for the prevention of travel-associated illness in older adults
Lee, T. K., Hutter, J. N., Masel, J., Joya, C., & Whitman, T. J. (2017) · Tropical Diseases Travel Medicine and Vaccines · doi:10.1186/s40794-017-0054-0 · Cited by 29
“We used the GRADE system to grade both the strength of the recommendations and the quality of the evidence [13].”
MethodDevelopment, Reporting, and Evaluation of Clinical Practice Guidelines
Benzon, H. T., Joshi, G. P., Gan, T. J., & Vetter, T. R. (2019) · Anesthesia & Analgesia · doi:10.1213/ane.0000000000004441 · Cited by 29
The American Society of Anesthesiologists Practice Parameter Methodology
Apfelbaum, J. L., & Connis, R. T. (2019) · Anesthesiology · doi:10.1097/aln.0000000000002551 · Cited by 28
Schmitter, M., Spijker, J., Smit, F., Tendolkar, I., Derksen, A.-M., Oostelbos, P., Wijnen, B. F. M., van Doesum, T., Smits, J. A. J., & Vrijsen, J. N. (2020) · BMC Psychiatry · doi:10.1186/s12888-020-02989-z · Cited by 27
Leclerc, T., Sjöberg, F., Jennes, S., Martínez-Méndez, J. R., van der Vlies, C. H., Battistutta, A., Basanta, J. A. L., Moiemen, N. S., & Almeland, S. K. (2022) · Burns · doi:10.1016/j.burns.2022.12.011 · Cited by 26
A treatment algorithm for the management of intraoral burns: A narrative review
Kang, S., Kufta, K., Sollecito, T. P., & Panchal, N. H. (2017) · Burns · doi:10.1016/j.burns.2017.09.006 · Cited by 26
The Use of Photoplethysmography in the Assessment of Mental Health: Scoping Review
Lyzwinski, L. N., Elgendi, M., & Menon, C. (2023) · JMIR Mental Health · doi:10.2196/40163 · Cited by 29
“This review followed the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines [30].”
MethodFernández‐Jiménez, R., Martín‐Masot, R., Cornejo-Pareja, I. M., Vegas-Aguilar, I. M., Herrador‐López, M., Tinahones, F. J., Navas‐López, V. M., Bellido, D., & García‐Almeida, J. M. (2023) · Reviews in Endocrine and Metabolic Disorders · doi:10.1007/s11154-023-09817-1 · Cited by 25
“It has been approved to reduce the risk of bias, inconsistency of results between studies, indirect evidence, imprecision and publication bias [16, 51].”
BackgroundHydronephrosis Associated With Pelvic Organ Prolapse: A Systematic Review
Siddique, M., Ingraham, C. F., Kudish, B., Iglesia, C. B., & Polland, A. R. (2019) · Urogynecology · doi:10.1097/spv.0000000000000683 · Cited by 24
“Copyright © 2020 Wolters Kluwer Health | Lippincott Williams & W and Evaluation) Working Group guidelines.(13) This approach grades studies based on design and limitations of the study design, evaluates heterogeneity of results and generalizability, and assesses imprecision, which may be affected by sample size.”
BackgroundŁątka, D., Miekisiak, G. J., Jarmużek, P., Lachowski, M., & Kaczmarczyk, J. (2015) · Neurologia i Neurochirurgia Polska · doi:10.1016/j.pjnns.2015.12.001 · Cited by 25
“Ten RCTs on safety and effectiveness of techniques and materials limiting the development of epidural adhesions were identified and analyzed [75–83].”
BackgroundInfluentialD'Souza, R. S., Johnson, R. L., Bettini, L. M., Schulte, P. J., & Burkle, C. M. (2019) · Mayo Clinic Proceedings · doi:10.1016/j.mayocp.2019.02.026 · Cited by 23
Modifying the GRADE framework could benefit public health
Dürrheim, D. N., & Reingold, A. L. (2010) · Journal of Epidemiology & Community Health · doi:10.1136/jech.2009.103226 · Cited by 22
“The merits and limitations of the GRADE framework for systematically evaluating the quality of evidence for guiding clinical practice guidelines have recently been eloquently debated.(2) 3 We will not dwell on the methodological allegations that GRADE suffers from external and internal inconsistency, potential for bia…”
BackgroundCuyper, K. D., Vanlinthout, E., Vanhoof, J. M. M., van Achterberg, T., Opgenhaffen, T., Nijs, S. L. P., Peeters, T., Put, J., Maes, B., & Audenhove, C. V. (2022) · Journal of Psychiatric and Mental Health Nursing · doi:10.1111/jpm.12890 · Cited by 23
Mercuri, M., & Gafni, A. (2018) · Journal of Evaluation in Clinical Practice · doi:10.1111/jep.12998 · Cited by 21
the Board of Trustees of the Guidelines International Network (G-I-N), van der Wees, P. J., Qaseem, A., Kaila, M., Ollenschlaeger, G., & Rosenfeld, R. M. (2012) · Systematic Reviews · doi:10.1186/2046-4053-1-3 · Cited by 20
“Use of an explicit and transparent strategy to evaluate evidence helps users to interpret the relative strength of the evidence [28,29].”
BackgroundBalossier, A., Sahgal, A., Kotecha, R. R., Fariselli, L., Gorgulho, A. A., Levivier, M., Ma, L., Paddick, I., Pollock, B. E., Sheehan, J. P., et al. (2023) · Neuro-Oncology · doi:10.1093/neuonc/noad253 · Cited by 20
Laparoscopic hysterectomy for benign indications: clinical practice guideline
Sandberg, E. M., Hehenkamp, W. J. K., Geomini, P. M. A. J., Janssen, P. F., Jansen, F. W., & Twijnstra, A. R. H. (2017) · Archives of Gynecology and Obstetrics · doi:10.1007/s00404-017-4467-9 · Cited by 20
“This point has been raised previously by other authors [32] and the GRADE working group [33] has stated that on occasion even low available evidence can lead to strong recommendations.”
Resultde Rijk, F. E. M., Kempeneers, M. A., Bruno, M. J., Besselink, M. G., van Goor, H., Boermeester, M. A., van Geenen, E. J., van Hooft, J. E., van Santvoort, H. C., Verdonk, R. C., et al. (2020) · United European Gastroenterology Journal · doi:10.1177/2050640620937610 · Cited by 20
“This resulted in a list of 39 ‘quality indicators’ (QIs), graded as strong recommendations and as high-quality evidence according to the Grading of Recommendations Assessment, Development and Evaluation system.(20) Not all QIs were applicable to every patient.”
MethodSiristatidis, C. S., Papapanou, M., Karageorgiou, V., Martins, W. P., Bellos, I., Teixeira, D. M., & Vlahos, N. (2022) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.26019 · Cited by 19
Current Recommendations for Perioperative Brain Health: A Scoping Review
Wooding, D. J., Field, T. S., Schwarz, S. K. W., MacDonell, S.-Y., Farmer, J. B., Rajan, S., & Flexman, A. M. (2022) · Journal of Neurosurgical Anesthesiology · doi:10.1097/ana.0000000000000861 · Cited by 19
Genova, P., Brunetti, F., Béquignon, É., Landi, F., Lizzi, V., Esposito, F., Charpy, C., Caldéraro, J., Azoulay, D., & de’Angelis, N. (2016) · World Journal of Surgical Oncology · doi:10.1186/s12957-016-0941-2 · Cited by 19
Phase angle and COVID-19: A systematic review with meta-analysis
Cornejo-Pareja, I. M., Vegas-Aguilar, I. M., Fernández‐Jiménez, R., García, C. G., Bellido, D., Tinahones, F. J., & García‐Almeida, J. M. (2023) · Reviews in Endocrine and Metabolic Disorders · doi:10.1007/s11154-023-09793-6 · Cited by 19
“Many organizations have endorsed GRADE method to decrease the risk of bias, inconsistency of results across studies, indirectness of evidence, imprecision and publication bias [30].”
MethodClinical trials for cognition in Parkinson's disease: Where are we and how can we do better?
Bayram, E., Batzu, L., Tilley, B. S., Gandhi, R., Jagota, P., Biundo, R., Garon, M., Prasertpan, T., Lazcano‐Ocampo, C., Chaudhuri, К. R., et al. (2023) · Parkinsonism & Related Disorders · doi:10.1016/j.parkreldis.2023.105385 · Cited by 18
“Phase 2 and 3 trials with positive results were then assessed using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) approach [22].”
A Critical Review of Grading Systems: Implications for Public Health Policy
Irving, M., Eramudugolla, R., Cherbuin, N., & Anstey, K. J. (2017) · Evaluation & the Health Professions · doi:10.1177/0163278716645161 · Cited by 20
“It has been argued that grading systems are not necessarily inherently logical (Kavanagh, 2009).”
BackgroundThe Use of Bayesian Networks to Assess the Quality of Evidence from Research Synthesis: 1.
Stewart, G. B., Higgins, J. P. T., Schünemann, H. J., & Meader, N. (2015) · PLoS ONE · doi:10.1371/journal.pone.0114497 · Cited by 17
“GRADE is not without detractors [18].”
All That Glitters Is Not a Golden Recommendation
Prielipp, R. C., & Coursin, D. B. (2015) · Anesthesia & Analgesia · doi:10.1213/ane.0000000000000499 · Cited by 17
Gastine, S., Rashed, A. N., Hsia, Y., Jackson, C., Barker, C. I. S., Mathur, S., Tomlin, S., Lutsar, I., Bielicki, J. A., Standing, J. F., et al. (2019) · Expert Review of Clinical Pharmacology · doi:10.1080/17512433.2019.1695600 · Cited by 16
“Acknowledging GRADE philosophy [31], that evidence in the medical literature should be rated by finding categories of reliability for individual studies, we developed and employed an explicit, potentially reproducible methodology (the GAPPS system) for the assessment of PKPD studies.”
Method
Metadata
- Authors
- Kavanagh, B. P.
- Affiliations
- University of Toronto (CA)
- Corresponding author
- Kavanagh, Brian P.
- Venue
- PLoS Medicine
- Publisher
- Public Library of Science (PLoS)
- Published
- 2009-09-15
- Volume
- 6
- Issue
- 9
- Pages
- e1000094
- ISSN
- 1549-1277 (ISSN-L)
- 1549-1676
- PMC
- PMC2735782
- OpenAlex
- W1991363364
- Cited by
- 246
- References
- 61
- Citations by year
- 2026: 17 · 2025: 18 · 2024: 19 · 2023: 17 · 2022: 18 · 2021: 20 · 2020: 16 · 2019: 19 · 2018: 21 · 2017: 14 · 2016: 10 · 2015: 7 · 2014: 7 · 2013: 15 · 2012: 8
- FWCI
- 9.41
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- PLoS Medicine (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- American Thoracic Society
- World Health Organization
- University of Pennsylvania
- Society of Thoracic Surgeons
- European Respiratory Society
- Agency for Healthcare Research and Quality
- Socialstyrelsen
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Meta-analysis and systematic reviews
- Social Sciences › Sociology and Political Science › Delphi Technique in Research
- Keywords
- GRADE system, guideline quality assessment, evidence-based medicine, health policy
- MeSH terms
- Humans, Respiration, Artificial, Respiratory Distress Syndrome, Practice Guidelines as Topic, Sepsis, Evidence-Based Medicine
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