Evidence map›Paper›PMID 28529184›Full record

GuidelineJournal of clinical epidemiology2017

The GRADE Working Group clarifies the construct of certainty of evidence.

Monica Hultcrantz, David Rind, Elie A Akl, Shaun Treweek, Reem A Mustafa, Alfonso Iorio, Brian S Alper, Joerg J Meerpohl, M Hassan Murad, Mohammed T Ansari and 9 more

Registry-linked trialAbstract readPractice Guideline
PubMed Full text at PMC Publisher
In one paragraph

Guideline in Journal of clinical epidemiology, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to trial NCT05237635 (Defining Decision Thresholds for Judgments on Health Benefits and Harms Using the GRADE Evidence to Decision), which is not on this map. Cited by 387 papers, 109 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
387citing papers in PubMed, 109 pooled it
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

NCT05237635 naunknown statusnot on this mapstarted 2020, after this paper: background citation

Defining Decision Thresholds for Judgments on Health Benefits and Harms Using the GRADE Evidence to Decision (EtD) Frameworks: Protocol for a Randomized Methodological Study (GRADE-THRESHOLD)

TypeinterventionalSponsorMcMaster UniversityRan2020 to 2022Enrolled1,406ConditionsDecision Support Techniques, GRADE ApproachArmsdescriptive case-scenarios
3 · Its place in the literature

Who cites it

387 citing papers in PubMed, 109 syntheses or guidelines pooled it.

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  3. Strategies to improve recruitment to randomised trials.The Cochrane database of systematic reviews · 2026
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  14. Major Adverse Cardiac Events with Ondansetron: A Systematic Review.Clinical pharmacology and therapeutics · 2026
    Pooled it
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  17. Guideline
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  20. Effect of patient education in improving quality of life, fatigue and anxiety in people diagnosed with lung cancer: systematic review.Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer · 2026
    Pooled it

327 more citing papers are in PubMed but not listed here.

4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

19 authors.

Monica HultcrantzSwedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), S:t Eriksgatan 117, SE-102 33, Stockholm, Sweden; Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodav. 18 A, SE-171 77, Stockholm, Sweden. Electronic address: monica.hultcrantz@sbu.se.
David RindInstitute for Clinical and Economic Review, Two Liberty Square, 9(th) Floor, Boston, MA 02109, USA; Harvard Medical School Beth Israel Deaconess Medical Center, 330 Brookline Avenue Boston, MA 02215, USA.
Elie A AklDepartment of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Internal Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Riad-El-Solh, Beirut 1107 2020, Lebanon.
Shaun TreweekHealth Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK.
Reem A MustafaDepartment of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Medicine, Division of Nephrology and Hypertension, University of Kansas Medical Center, 3901 Rainbow Blvd, MS3002, Kansas City, KS 66160, USA.
Alfonso IorioDepartment of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
Brian S AlperEBSCO Health, EBSCO Publishing, 10 Estes Street, Ipswich, MA, 01938 USA; Department of Family and Community Medicine, School of Medicine, University of Missouri-Columbia, One Hospital Drive, Columbia, MO 65212, USA.
Joerg J MeerpohlCochrane Germany, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Strasse 153,79110 Freiburg, Germany; Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité - U1153, Inserm / Université Paris Descartes; Cochrane France; Hôpital Hôtel-Dieu, 1 place du Parvis Notre Dame, 75181 Paris Cedex 04, France.
M Hassan MuradMayo Clinic Evidence-based Practice Center, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA.
Mohammed T AnsariSchool of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of Ottawa, 600 Peter Morand Crescent, Ottawa, Ontario K1G 5Z3, Canada.
Srinivasa Vittal KatikireddiMRC/CSO Social & Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3QB, UK.
Pernilla ÖstlundSwedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), S:t Eriksgatan 117, SE-102 33, Stockholm, Sweden; Health Technology Assessment - Odontology (HTA-O), Faculty of Odontology, Malmö University, Carl Gustafs Väg 34, SE-214 21, Malmö, Sweden.
Sofia TranæusSwedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), S:t Eriksgatan 117, SE-102 33, Stockholm, Sweden; Health Technology Assessment - Odontology (HTA-O), Faculty of Odontology, Malmö University, Carl Gustafs Väg 34, SE-214 21, Malmö, Sweden; Division of Cariology and Endodontology, Department of Dental Medicine, Karolinska institutet, Alfred Nobels Allé 8, SE-141 52, Huddinge, Sweden.
Robin ChristensenMusculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Nordre Fasanvej 57, DK-2000 Copenhagen F, Denmark.
Gerald GartlehnerDanube University, Department for Evidence-based Medicine and Clinical Epidemiology, Dr. Karl Dorrekstrasse 30, 3500 Krems, Austria; RTI International, Research Triangle Park, 3040 East Cornwallis Rd, Research Triangle Park 27709, NC, USA.
Jan BrozekDepartment of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
Ariel IzcovichInternal Medicine Service, German Hospital, Pueyrredón 1640, Buenos Aires C1118AAT, Argentina.
Holger SchünemannDepartment of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
Gordon GuyattDepartment of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.

Funding

Chief Scientist Office HSRU2Chief Scientist Office SCAF/15/02Chief Scientist Office SPHSU13Medical Research Council MC_UU_12017/13Medical Research Council MC_UU_12017/15
6 · The paper itself

Abstract

objectiveTo clarify the grading of recommendations assessment, development and evaluation (GRADE) definition of certainty of evidence and suggest possible approaches to rating certainty of the evidence for systematic reviews, health technology assessments, and guidelines. STUDY DESIGN AND

settingThis work was carried out by a project group within the GRADE Working Group, through brainstorming and iterative refinement of ideas, using input from workshops, presentations, and discussions at GRADE Working Group meetings to produce this document, which constitutes official GRADE guidance.

resultsCertainty of evidence is best considered as the certainty that a true effect lies on one side of a specified threshold or within a chosen range. We define possible approaches for choosing threshold or range. For guidelines, what we call a fully contextualized approach requires simultaneously considering all critical outcomes and their relative value. Less-contextualized approaches, more appropriate for systematic reviews and health technology assessments, include using specified ranges of magnitude of effect, for example, ranges of what we might consider no effect, trivial, small, moderate, or large effects.

conclusionIt is desirable for systematic review authors, guideline panelists, and health technology assessors to specify the threshold or ranges they are using when rating the certainty in evidence.

Indexed as

Review Literature as TopicEvidence-Based MedicineHumansTechnology Assessment, BiomedicalCertainty of evidenceGRADEGuidelinesHealth technology assessmentSystematic reviewsThresholds

Identifiers

PMID28529184
PMCPMC6542664

What OpenQuestion holds

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Registered trials

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.