The GRADE process begins with asking a clinically relevant, well-designed clinical question composed of four
elements: a patient, problem, or population; an intervention;
a comparison intervention; and an outcome. The second step
in the GRADE system is to gather the best evidence to answer
the question. The third step is assessing the quality of evidence and the confidence in the estimates of the treatment.
Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts, USA and 2Department of Dermatology, Harvard Medical School
and Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
Correspondence: Mayra Buainain de Castro Maymone, 609 Albany Street, J-209, Boston, Massachusetts 02118, USA. E-mail: mayrabcm@bu.edu
www.jidonline.org
Table 1. Comparison between GRADE and SORT with regard to the strength of recommendation and the quality of evidence
GRADE
Strength of recommendation
Strong for = benefits outweigh risks
of the intervention
SORT
2. Treatment effects
Summary of best available evidence, focusing on critical outcomes
3. Quality of evidence
Assessment of confidence in the estimate of treatment effect
5. Recommendation
(Estimate of effect, confidence estimate and the patient perspective)
Figure. 1. The GRADE process. Adapted with permission from Guyatt et al.,
2013.
Judgment
Resource implications
Are the resources worth the expected net
benefit from following the
recommendation?
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Whereas GRADE and SORT evaluate the body of evidence to establish sound guidelines, the AGREE instrument assesses the quality of the development of clinical
practice guidelines. The quality of guidelines is based on
the confidence that potential biases have been addressed
adequately, that recommendations are both internally
and externally valid, and that they are feasible for practice. New or existing guidelines and updates of existing
guidelines may be appraised with AGREE. It is a validated tool with a 4-point numerical scoring system, ranging from 1 (representing strongly disagree) to 4 (strongly
agree). Scores reflecting inadequate quality are assigned
a score 2. This instrument can be applied to any disease
area, including those in diagnosis, health promotion, and
treatment.
AGREE is composed of 23 key items encompassed
within six domains. Each domain is intended to capture
a different dimension of the guideline quality: scope and
purpose, stakeholder involvement, rigor of development,
clarity and presentation, applicability, and editorial independence. The domain score is calculated by adding all
of the individual item scores in a domain and standardizing the total as a percentage of the maximum possible
score for that domain. Each domain score may be useful for comparing guidelines and will aid in the decision
whether to use that guideline. There is no set threshold for
the domain score by which to define a good or bad
guideline. Finally, an overall assessment is made as to the
quality of the guideline, taking each of the appraisal criteria into account and rating it as strongly recommend,
recommend (with provisos or alteration), would not
recommend, or unsure (AGREE Collaboration, 2001).
Recently, AGREE was modified to AGREE II. The purpose
of this updated version was to improve reliability, validity,
and supporting documentation. The newer version continues to have 23 items and six domains, whereas the rating
scale for each domain has become more detailed, using a
7-point rather than 4-point scale. Score 1 is assigned when
there is no relevant information; scores between 2 and 6
are given when the domain does not meet the full criteria;
and a maximum score of 7 is given to exceptional reports
(AGREE Next Steps Consortium, 2009).
4
QUESTIONS
This article has been approved for 1 hour of Category 1 CME credit.
To take the quiz, with or without CME credit, follow the link under
the CME ACCREDITATION heading.
SUMMARY
The AGREE instrument has been applied towards the critical appraisal of clinical practice guidelines and adaptation
in evidence-based guidelines for prevention of skin cancer
by the German Guideline Program in Oncology. The rigorous inclusion criteria required by the AGREE instrument narrows the 480 citations related to the topic "prevention of skin
cancer" to only 12 studies. The strict criteria needed to be
fulfilled by the AGREE tool demonstrate that methodological
flaws are an important obstacle in the development of practical guidelines (Petrarca et al., 2013). The AGREE instrument
was also chosen as the appraisal tool for evaluation of quality
of clinical practical guidelines for treatment of psoriasis vulgaris, 2006-2009 (Tan et al., 2010).
GRADE and SORT are two methods of evaluating a body
of evidence and the quality of studies to create a comprehensive recommendation. The AGREE instrument is a validated
quantitative scoring method created to systematically assess
the quality of practice guidelines. Knowledge of these commonly applied grading systems is important for the informed
dermatologist and clinician to understand for clinical practice and guideline development.
CONFLICT OF INTEREST
CME ACCREDITATION
This CME activity has been planned and implemented in accordance with
the Essential Areas and Policies of the Accreditation Council for Continuing
Medical Education through the Joint Sponsorship of ScientiaCME and
Educational Review Systems. ScientiaCME is accredited by the ACCME
to provide continuing medical education for physicians. ScientiaCME
designates this educational activity for a maximum of one (1) AMA PRA
Category 1 Credit. Physicians should claim only credit commensurate with
the extent of their participation in the activity.
SUPPLEMENTARY MATERIAL
REFERENCES
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