1. Research Techniques Made Simple: Evaluating the Strength of Clinical Recommendations in the Medical Literature: GRADE, SORT, and AGREE
Mayra Buainain de Castro Maymone1,
Stephanie D. Gan1,
Michael Bigby2
1Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts, USA
2Department of Dermatology, Harvard Medical School and Beth Israel Deaconess Medical Center,
Boston, Massachusetts, USA

2. Grading of Recommendations Assessment, Development, and Evaluation (GRADE)
Adopted by more than 65 organizations worldwide as an international standard for guideline development
Explicitly evaluates relevant outcomes and considers risks, benefits, patient expectations, and resource utilization in reaching recommendations

3. 4. Trade-off between benefits and risks
The GRADE Process
1. Framing the questions
Using PICO (patient/intervention/comparator/outcome)
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
4. Trade-off between benefits and risks
(values and preferences)
5. Recommendation
(estimate of effect, confidence estimate, and patient perspective)
Adapted with permission from Journal of Thrombosis and Haemostasis (Guyatt et al., 2013)

4. Grading of Recommendations Assessment, Development, and Evaluation (GRADE)
Quality of the evidence
Strength of Recommendation
Strong: benefits outweigh risks of the intervention
Weak: most informed people would choose this recommendation, but a substantial number would not
High
Moderate
Low
Very Low

5. Strength of Recommendation Taxonomy (SORT)
Simple and easily applied by authors and physicians
Advocates the use of patient-oriented over disease-oriented outcomes
Adopted by the American Academy of Dermatology

6. Strength of Recommendation Taxonomy (SORT)
Quality of the Evidence
A= Based on consistent and good-quality patient- oriented evidence
B= Based on inconsistent or limited-quality patient-oriented evidence
C= Based on consensus, usual practice, opinion, disease-oriented evidence or case series
Level 1: good quality
Level 2: limited quality
Level 3: others

7. AGREE
Validated instrument that assesses the quality of guidelines development
Assesses 6 domains in guideline development: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence
Uses a 4-point numerical scoring system, ranging from 1 (strongly disagree) to 4 (strongly agree). Scores reflecting inadequate quality are assigned a score ≤2.

8. GRADE, SORT, and AGREE
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

9. Limitations of GRADE, SORT, and AGREE
GRADE is complicated and requires an expertise in statistics
SORT is an overly simplified instrument that is not applied internationally
 AGREE has no set minimum domain scores to differentiate high- versus poor-quality guidelines