![]() ![]() They described the general framework that was followed however, they failed to address all of GRADE's factors or provide enough information to allow replication of their GRADEing process for prognostic studies. They used the framework and definitions of GRADE to rate the quality of evidence for prognostic studies evaluating cold hyperalgesia as a prognostic factor in whiplash-associated disorders. Recently, Goldsmith and colleagues have also proposed using GRADE as a framework for prognostic studies. The GRADE framework, widely used by researchers working on reviews and guidelines, and groups providing recommendations for health care professionals such as NICE, has also been formally adapted for use in grading the quality of evidence and strength of recommendation for diagnostic research. When making judgments about the quality of evidence, the GRADE approach considers five factors that can decrease our confidence in estimates of effects: (1) study design and limitations in study design, (2) inconsistency of results across studies, (3) indirectness of the evidence, (4) imprecision and (5) publication bias and three factors that can increase our confidence in estimates of effects from observational studies: (1) large estimates of treatment, (2) a dose–response gradient and (3) plausible confounding that would increase confidence in an estimate. GRADE was first developed to provide methodological guidance in reviewing intervention research specifically, how to rate the quality associated with estimated effects of an intervention on a specific outcome, and how to grade the strength of recommendations regarding the intervention as part of a guideline development process. GRADE: a framework to guide the judgment about the quality of evidence in a systematic review ![]() ![]() We suggest that Grading of Recommendations Assessment, Development and Evaluation (GRADE) can be adapted for the assessment of evidence derived from prognostic factor research. This manuscript presents a system that can help reviewers judge the evidence derived from prognostic factor research. Due to the important implications of this research for improving health outcomes, providing guidelines about how to judge the evidence of this widely varied research is necessary. However, these standards are often not followed causing confusion about the prognostic value of individual factors and limiting research application. Standards have been proposed to guide the design, procedures, analysis and reporting of this research in an attempt to minimize the variability and improve the quality of the primary studies. Individual study differences may be due to, for example, small sample sizes, adjustments for different variables in the analyses, or consideration of different subsets within the same population. Synthesizing results from prognosis research for these potential uses is, however, often challenging as primary study results are often inconsistent and difficult to interpret. The evidence about the progression of a health condition derived from prognosis research is crucial to make informed decisions about the process to identify individuals who are at risk for poor outcomes, to facilitate early intervention and guide the development of preventive interventions that target modifiable prognostic factors. Prognosis research examines the progression of a health condition over time in order to identify risk and protective factors that can alter the likelihood of a future event during the course of such a condition. These recommendations require further investigation and testing. We describe criteria for evaluating the potential impact of each of these factors on the quality of evidence when conducting a review including a narrative synthesis or a meta-analysis. We propose six factors that can decrease the quality of evidence (phase of investigation, study limitations, inconsistency, indirectness, imprecision, publication bias) and two factors that can increase it (moderate or large effect size, exposure-response gradient). We propose modifications to the GRADE framework for use in prognosis research along with illustrative examples from an ongoing systematic review in the pediatric pain literature. This article presents a proposed adaptation of Grading of Recommendations Assessment, Development and Evaluation (GRADE), which was developed to rate the quality of evidence in intervention research, to judge the quality of prognostic evidence. Standards aimed at improving the quality of primary studies on the prognosis of health conditions have been created, but these standards are often not adequately followed causing confusion about how to judge the evidence. ![]() It is often challenging to judge the overall quality of research evidence in systematic reviews about prognosis due to the nature of the primary studies. Prognosis research aims to identify factors associated with the course of health conditions. ![]()
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