Book
Management of Hip Fractures in the Elderly
- Evidence assessment
According to WHO Handbook for Guidelines, we used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to assess the quality of a body of evidence, develop and report recommendations. GRADE methods are used by WHO because these represent internationally agreed standards for making transparent recommendations. Detailed GRADE information is available on the following sites:
• GRADE working group: https://www.gradeworkinggroup.org
• GRADE online training modules: https://macgrade.mcmaster.ca/grade-learning-hub/grade-for-guideline-development/
• GRADE profile software: https://www.gradepro.org
Quality of evidence was rated according to criteria in Table 1. Significance of the four levels of evidence and factors that determine how to upgrade or downgrade the quality of evidence are illustrated in Annex 1: GRADE’s approach to rating quality of evidence 8
Table 1: Quality of evidence in GRADE
Quality level | Definition |
High | We are very confident that the true effect lies close to that of the estimate of the effect. |
Moderate | We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. |
Low | Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. |
Very low | We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect. |
The strength of the recommendation
The strength of a recommendation communicates the importance of adherence to the recommendation.
Strong recommendations
With strong recommendations, the guideline communicates the message that the desirable effects of adherence to the recommendation outweigh the undesirable effects. This means that in most situations the recommendation can be adopted as policy.
Conditional recommendations
These are made when there is greater uncertainty about the four factors above or if local adaptation has to account for a greater variety in values and preferences, or when resource use makes the intervention suitable for some, but not for other locations. This means that there is a need for substantial debate and involvement of stakeholders before this recommendation can be adopted as policy.
When not to make recommendations
When there is lack of evidence on the effectiveness of an intervention, it may be appropriate not to make a recommendation.
