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When making health policy decisions, policymakers and stakeholders must evaluate the relative benefits and downsides of different strategies. Decision makers will be influenced not only by the best estimates of the expected advantages and disadvantages, but also by their confidence in these estimates – in other words, by the quality of the evidence. The GRADE system is a structured and transparent framework for making judgements about the quality of evidence from systematic reviews.7
In the GRADE framework, separate ratings of evidence quality are made for each important outcome. The first framework rating is for the study design. Randomised trials, in general, provide stronger evidence than observational studies. Therefore randomised trials without important limitations constitute high-quality evidence. Observational studies without special strengths or important limitations generally provide low-quality evidence.
There are a number of factors in a study that can reduce or increase confidence in the estimates of effect of the intervention being studied. The GRADE framework considers five factors that can lower the quality of the evidence, namely:
And three factors that can increase the quality of evidence:
(More
detailed descriptions of each of these factors are provided in
the ‘Additional resources’
section of this guide.)
The GRADE framework provides a clearly articulated and comprehensive approach for rating and summarising the quality of evidence that supports health care delivery recommendations. Although judgements will always be required for every step, the systematic and transparent GRADE approach allows for scrutiny and debate about those judgements.
Even though the details of these judgements do not need to be fully reported in a policy brief, keeping a judgement ‘audit trail’ can be helpful when producing a policy brief. It will help to ensure greater reliability and credibility, protecting against the introduction of biased judgements, and may be helpful to have in case these judgements are subsequently called into question or debated further.
Worksheets for making such judgements are also provided in the ‘Additional resources’ section of this guide. Further guidance on making and summarising judgements about the quality of evidence can be found at http://ims.cochrane.org/revman/other-resources/gradepro/resources.
Example of how a Ugandan team decided on policy options and gathered evidence |
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Harriet Nabudere of the Ugandan REACH Team describing how they decided on policy options and gathered evidence, their experience of using the GRADE framework to assess the quality of the evidence, and how they summarised the findings in a policy brief on task shifting |
