Challenges in applying GRADE to health systems and public health interventions

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Abstract text
Background:
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group has developed and tested a rigorous, systematic and transparent framework for making judgements about the quality of evidence and strength of recommendations. However, there has been some debate about the ‘fit-for-purpose’ of the GRADE framework for health systems/public health interventions.

Objective:
To identify significant challenges to the use of the GRADE framework in the field of health systems/public health.

Methods:
We conducted qualitative interviews with individuals that have applied the GRADE framework in the context of systematic reviews or guidelines in the fields of health systems and public health. Potential participants were initially contacted by e-mail. Responses were obtained by telephone interview or email, and written interview summaries were validated with participants. Data were analysed across interviews qualitatively to distil common themes.

Results:
We conducted 22 interviews and obtained 15 in-depth responses relating to specific systematic review or guideline projects. All respondents that have used GRADE appreciated the systematic and transparent process of assessing the quality of the evidence, suggesting that GRADE principles are suitable to health systems/public health interventions. The rating of individual experiences, however, varied greatly from GRADE being applied without significant challenges to being used with major challenges. Specific challenges reported relate to the nature of public health interventions, the nature of public health evidence, GRADE terminology and the characteristics of the guideline development processes.

Conclusions:
GRADE principles seem to be applicable to health systems/public health interventions. However, users suggest that a combination of carefully revisiting concepts and terminology, better guidance on how to apply GRADE to complex interventions and some modifications to the existing grading scheme could improve the applicability of the GRADE approach to health systems/public health interventions.
Authors
Rehfuess E1, Pantoja T2
1 Institute for Medical Informatics, Biometry and Epidemiology, University of Munich, Germany
2 Department of Family Medicine & Health Policy and Systems Research Unit, School of Medicine, Pontificia Universidad Católica de Chile, Chile
Presenting author and contact person
Presenting author: 
Tomas Pantoja
Contact person Affiliation Country
Tomas Pantoja (Contact this person) Department of Family Medicine, School of Medicine, Pontificia Universidad Catolica de Chile Chile