Thread by @JBI_GRADE

For #WorldEBHCDay we wanted to share our first #Tweetorial about the 5 determinants to consider when downgrading the certainty that we have in our evidence from RCTs when following the #GRADE approach @JBIEBHC @WorldEBHCDay (1/8)

Certainty in the evidence starts as high when following the #GRADE approach. However it may be necessary to downgrade the certainty in this evidence. We do this by assessing the following 5 determinants Guidance: shorturl.at/qxB68 #Tweetorial #WorldEBHCDay (2/8)

Study limitations. Consider the methodological quality of the included studies providing evidence of a particular outcome. Consider how each study contributes to the magnitude of effect and downgrade conservatively Guidance: shorturl.at/aepO1 #Tweetorial #WorldEBHCDay (3/8)

Inconsistency. Widely different and unexplained estimates of effect may warrant downgrading the certainty of the evidence. Wide variance in point estimates, minimal CI overlap, and high I2 indicate inconsistency. Guidance: shorturl.at/cntGT #Tweetorial #WorldEBHCDay (4/8)

Imprecision. If we have an imprecise effect estimate we may downgrade our certainty. Imprecision could be the result of a small sample size, small no. of events and are identified by wide CIs or an OIS. Guidance: shorturl.at/wDFT9 #Tweetorial #WorldEBHCDay (5/8)

Indirectness. Certainty in the evidence is decreased when we have indirect evidence. Ask: Is the evidence synthesised applicable to our q? Look at the population, intervention, comparisons and outcomes measured. Guidance: shorturl.at/pqABM #Tweetorial #WorldEBHCDay (6/8)

Publication bias. Systematic under- or over-estimation of the underlying effects due to selective publication of studies. If pub bias is suspected we can downgrade our certainty in the evidence. Guidance: shorturl.at/kpK46 #Tweetorial #WorldEBHCDay (7/8)

Some considerations to close. Be conservative in downgrading the certainty. Reviewers will face close-call situations and should acknowledge these. All decisions for downgrading should be made transparent #Tweetorial #WorldEBHCDay (8/8)