Introduction
What is new?
Key pointsGRADE requires a rating of confidence in effect estimates (quality of evidence) for each outcome.
Rating of confidence of evidence requires a gestalt that simultaneously considers all eight domains (risk of bias, precision, consistency, and so forth)
Guideline developers using GRADE will subsequently make an overall rating of confidence in effect estimates across all outcomes based on those outcomes they consider critical to their recommendation.
Optimal application of GRADE requires making the reasons for key judgments transparent.
In prior studies in this series devoted to exploring GRADE’s approach to rating confidence in estimates of effect (quality of evidence) and grading strength of recommendations (guidance for practice) we have dealt with issues of framing the question [1]; introduced GRADE’s conceptual approach to rating the confidence in a body of evidence [2]; and presented five reasons for rating down the confidence in effect estimates (risk of bias [3], imprecision [4], inconsistency [5], indirectness [6], and publication bias [7]) and three reasons for rating up the confidence in effect estimates [8] (a large magnitude of effect, a dose-response gradient, and a situation in which plausible biases, if present, would serve to increase our confidence in the effect estimate), as well as dealing with issues specific to resource use. This 11th article in the series will focus on (1) summarizing the confidence in effect estimates across a single outcome for each important or critical outcome and (2) determining the confidence in effect estimates across all critical outcomes.