GRADE

Abbreviations.

BMJ: British Medical Journal.

GTG: Green-top Guideline.

NICE: National Institute for Health and Clinical Excellence.

What is GRADE?

GRADE is a new system for grading evidence.

Experts think it likely that it will soon be the standard method.

The BMJ adopted it in 2006 for papers about clinical guidelines.

As I write in 2010, I understand that both NICE and the RCOG’s GTG development people are looking at adopting it too.

The acronym stands for: “Grading of Recommendations Assessment, Development and Evaluation”.

As it is a system for grading evidence, “GRADE” is brilliant.

But I am not sure that “Grading of Recommendations Assessment, Development and Evaluation” immediately explains what it is about.

And I am not sure that it is all that memorable.

So, another acronym that falls far short of 10 out of 10.

I think whoever devised it thought the acronym “GRADE” was so good that it had to be used, however tortured the expanded form.

What is wrong with the present systems of grading?

We are all familiar with the grading system in use for the GTGs.

It looks at the quality of the trial.

So at the top or the pile are:

“high-quality meta-analyses,

systematic reviews of randomised controlled trials

or randomised controlled trials with a very low risk of bias”

And at the bottom is “expert opinion” where the research evidence base is limited or non-existent.

This seems good.

But you could have a brilliantly conducted piece of research into the effect of black cohosh on the sleep patterns of Welsh sheep.

Its conclusion might have a very high chance of being accurate.

But your response might be “who cares”.

You don't often worry about the sleep problems of sheep.

And you would not be able to draw any conclusions for your patients from the research population.

And you might not have many patients looking for remedies to deal with sleep problems.

But a slightly less well-conducted trial that suggested that a new drug:

radically reduced premature delivery rates

with great benefit to the babies

and no obvious adverse effects

might have you phoning your colleagues in excitement.

So, an ideal grading system has to widen the things it looks at.

And also give importance to issues like:

the clinical significance of the research,

whether you can extrapolate from the research population to patients in general

and so on.

What do you need for the MRCOG examination?

You are not going to get an essay or a complete OSCE station on GRADE.

But it could get a few marks in a viva discussing critical appraisal or a station in which you have been asked to do critical appraisal of a paper.

Even if there were no marks, you would impress the examiner and get any discretionary marks available.

There might be a mark or two in the MCQs and an EMQ on critical appraisal might include it as an option.

Suggested reading.

The website of the GRADE Working Party has load of information; more than you need.