Grade Is Subjective
GRADE cannot be implemented mechanically; there is by necessity a considerable amount of subjectivity in each decision.
Two persons evaluating the same body of evidence might reasonably come to different conclusions about its certainty.
What GRADE does provide is a reproducible and transparent framework for grading certainty in evidence.
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How Does It Work?
First, the authors decide what the clinical question is, including the population that the question applies to, the two or more alternatives, and the outcomes that matter most to those faced with the decision.
A study – ideally a systematic review – provides the best estimate of the effect size for each outcome, in absolute terms (e.g., a risk diff.
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What Increases Confidence in The Evidence?
In rare circumstances, certainty in the evidence can be rated up (see Table 2).
First, when there is a very large magnitude of effect, we might be more certain that there is at leasta small effect.
Second, when there is a clear dose-response gradient.
Third, when residual confounding is likely to decrease rather than increase the magnitude of effec.
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What Makes Evidence Less Certain?
For each of risk of bias, imprecision, inconsistency, indirectness, and publication bias, authors have the option of decreasing their level of certainty one or two levels (e.g., from high to moderate).
The GRADE Domains for rating down:.
1) Risk of bias Bias occurs when the results of a study do not represent the truth because of inherent limitation.
