GRADE系统简介专题知识.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,GRADE系统简介专题知识,Background:Too many systems,Guideline developers use a bewildering variety of systems to rate the quality of the evidence underlying their recommendations.,As a result,guideline users have faced challenges,Example,Recommendation for use of oral anticoagulation in patients with atrial fibrillation and rheumatic mitral valve disease:,ORGANIZATION,EVIDENCE,RECOMMENDATION,American Heart Association(AHA),B,Class I,American College of Clinical Pharmacy(ACCP),A,1,Scottish Intercollegiate Guidelines Network(SIGN),IV,C,The same evidence different classification,Grading of Recommendations Assessment,Development and Evaluation(GRADE),A systematic method of assessing the quality of studies included in a systematic review and developing recommendations or guidelines based upon the evidence,GRADE Working Group formed in 2023,Aim:to develop a common,transparent and sensible system for grading the quality of evidence and the strength of recommendations,GRADE uptake,Agency for Health Care Research and Quality(AHRQ),Allergic Rhinitis in Asthma Guidelines(ARIA),American College of Chest Physicians,American College of Physicians,American Thoracic Society,British Medical Journal,Canadian Agency for Drugs and Technology in Health,Clinical Evidence,Cochrane Collaboration,European Society of Thoracic Surgeons,Infectious Diseases Society of America(IDSA),National Institute Clinical Excellence(NICE),UpToDate,World Health Organization,Many other organizations,Quality of evidence,“The extent to which one can be confident that an estimate of effect or association is correct.”,Authors of systematic reviews grade quality of a body of evidence separately for,each,patient-important outcome.,Authors of systematic reviews do not grade the,overall,quality of evidence across outcomes:that is the role of guideline developers.,Determinants of quality,Study design is critical to judgments about the quality of evidence.,Randomized trials provide,in general,far stronger evidence than observational studies,Rigorous observational studies provide stronger evidence than uncontrolled case series.,In the GRADE approach to quality of evidence:,Randomized trials without important limitations provide high quality evidence,Observational studies without special strengths provide low quality evidence,Limitations or special strengths can,however,modify,the quality of the evidence of both randomized trials and observational studies.,The GRADE system classifies the quality of evidence in one of four grades:,GRADE,DEFINITION,High,Further research is very unlikely to change our confidence in the estimate of effect.,Moderate,Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.,Low,Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.,Very Low,Any estimate of effect is very uncertain.,GRADEprofiler(GRADEpro),Software developed by the GRADE Working Group,Three kinds of evidence tables:,GRADE evidence profile,Cochrane Summary of Findings(SoF)table,Cochrane Overview of Reviews table,SoF Table is the most useful for most Cochrane reviews,Evidence Profile vs.Summary of Findings Table,GRADE Evidence profile,Particularly useful for guideline developers,Presents information about the body of evidence(e.g.number of studies),the judgments about the underlying quality of evidence,key statistical results,and a grade for the quality of evidence for each outcome,Summary of Findings Table,Most relevant to(and designed for use in)Cochrane reviews,Present the main findings of a systematic review in a transparent and simple tabular format,Provides key information concerning the quality of evidence,the magnitude of effect of the interventions examined,and the sum of available data on most important outcomes.,GRADE Evidence Profile,In some ways,more instructive than SoF Tables,Not yet feasible to present in Cochrane reviews(technical/formatting issues),Oriented more for presentations to guideline developers,May eventually be possible for use in Cochrane reviews.,In the mean time,use SoF tables for Cochrane reviews.,GRADEevidenceprofile,SoF Table,There are 3 key components of a SoF table:,Information about the review,Summary of the statistical results,Grade of the quality of evidence.,Authors of systematic reviews can use GRADEpro to create a SoF table in two ways:,Import most of the data from a RevMan 5 file,Enter data manually,Regardless of how you enter the data,you will need to edit data and manually enter your assessment of the quality of evidence for each outcome,When SoF table is finished,you can import it into RevMan.,SoF Table,SoF tables include seven columns:,Outcomes:,list of important desirable and undesirable outcomes(up to 7 outcomes),Assumed risk:,a measure of the typical burden of these outcomes,Corresponding risk:,a measure of the burden of the outcomes after the intervention is applied,Relative magnitude of effect:,for dichotomous outcomes the table will usually provide risk ratio,odds ratio,or hazard ratio,Number of participants and studies,addressing these outcomes,Rating of the quality of evidence for each outcome,(which may vary by outcome),Comments,(if needed),Footnotes,for transparency about your decision-making,Reviews with more than one main comparison require separate SoF tables for each comparison.,SoFtable,How to make a Summary of Findings Table,(over-simplified),Open GRADEpro,Create profiles,Import data from RevMan 5 into GRADEpro,Create SoF table.Author makes decisions about information to present and GRADEs the evidence,Export table from GRADEpro and import into RevMan 5,Working in GRADEpro,GRADEpro has an excellent“Help”file,GRADE Resources,The Cochrane HIV/AIDS Group maintains a page with many articles and other resources about GRADE:,References for this presentation:,Guyatt GH,Oxman AD,Vist GE,Kunz R,Falck-Ytter Y,Alonso-Coello P,Schnemann HJ;GRADE Working Group.GRADE:an emerging consensus on rating quality of evidence and strength of recommendations.BMJ.2023 Apr 26;336(7650):924-6.,Guyatt GH,Oxman AD,Kunz R,Falck-Ytter Y,Vist GE,Liberati A,Schnemann HJ;GRADE Working Group.Going from evidence to recommendations.BMJ.2023 May 10;336(7652):1049-51.,Schnemann H,Broek J,Oxman A,editors.GRADE handbook for grading quality of evidence and strength of recommendations.Version 3.2 updated March 2023.The GRADE Working Group,2023.Available from.,Schnemann H.Preparing Summary of Findings tables for Cochrane Reviews(PowerPoint presentation).Cochrane Applicability and Recommendations Methods Group,2023.,GRADE Working Group:,Sturt AS,Dokubo EK,Sint TT.Antiretroviral therapy(ART)for treating HIV infection in ART-eligible pregnant women.Cochrane Database of Systematic Reviews,2023:3(forthcoming),