Agoritsas Thomas, Merglen Arnaud, Heen Anja Fog, Kristiansen Annette, Neumann Ignacio, Brito Juan P, Brignardello-Petersen Romina, Alexander Paul E, Rind David M, Vandvik Per O, Guyatt Gordon H
Division of General Internal Medicine, Department of Internal medicine, Rehabilitation and Geriatrics, University Hospitals of Geneva, Geneva, Switzerland.
Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland.
BMJ Open. 2017 Nov 16;7(11):e018593. doi: 10.1136/bmjopen-2017-018593.
UpToDate is widely used by clinicians worldwide and includes more than 9400 recommendations that apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. GRADE guidance warns against strong recommendations when certainty of the evidence is low or very low (discordant recommendations) but has identified five paradigmatic situations in which discordant recommendations may be justified.
Our objective was to document the strength of recommendations in UpToDate and assess the frequency and appropriateness of discordant recommendations.
Analytical survey of all recommendations in UpToDate.
We identified all GRADE recommendations in UpToDate and examined their strength (strong or weak) and certainty of the evidence (high, moderate or low certainty). We identified all discordant recommendations as of January 2015, and pairs of reviewers independently classified them either into one of the five appropriate paradigms or into one of three categories inconsistent with GRADE guidance, based on the evidence presented in UpToDate.
UpToDate included 9451 GRADE recommendations, of which 6501 (68.8%) were formulated as weak recommendations and 2950 (31.2%) as strong. Among the strong, 844 (28.6%) were based on high certainty in effect estimates, 1740 (59.0%) on moderate certainty and 366 (12.4%) on low certainty. Of the 349 discordant recommendations 204 (58.5%) were judged appropriately (consistent with one of the five paradigms); we classified 47 (13.5%) as good practice statements; 38 (10.9%) misclassified the evidence as low certainty when it was at least moderate and 60 (17.2%) warranted a weak rather than a strong recommendation.
The proportion of discordant recommendations in UpToDate is small (3.7% of all recommendations) and the proportion that is truly problematic (strong recommendations that would best have been weak) is very small (0.6%). Clinicians should nevertheless be cautious and look for clear explanations-in UpToDate and elsewhere-when guidelines offer strong recommendations based on low certainty evidence.
UpToDate在全球临床医生中被广泛使用，包含9400多条应用推荐分级评估、制定与评价（GRADE）框架的建议。GRADE指南警告，当证据确定性低或非常低时（不一致的建议）不要给出强推荐，但已确定了五种典型情况，在这些情况下不一致的建议可能是合理的。
我们的目的是记录UpToDate中建议的强度，并评估不一致建议的频率和适当性。
对UpToDate中的所有建议进行分析性调查。
我们确定了UpToDate中所有的GRADE建议，并检查其强度（强或弱）以及证据的确定性（高、中或低确定性）。我们确定了截至2015年1月的所有不一致建议，两位评审员根据UpToDate中提供的证据，独立地将它们分类为五个适当范式之一，或分类为与GRADE指南不一致的三个类别之一。
UpToDate包含9451条GRADE建议，其中6501条（68.8%）被制定为弱推荐，2950条（31.2%）为强推荐。在强推荐中，844条（28.6%）基于对效应估计的高确定性，1740条（59.0%）基于中等确定性，366条（12.4%）基于低确定性。在349条不一致建议中，204条（58.5%）被判断为适当（与五个范式之一一致）；我们将47条（13.5%）归类为良好实践声明；38条（10.9%）在证据至少为中等确定性时将其错误分类为低确定性，60条（17.2%）应给出弱推荐而非强推荐。
UpToDate中不一致建议的比例较小（占所有建议的3.7%），真正有问题的比例（本应是弱推荐却为强推荐）非常小（0.6%）。然而，当指南基于低确定性证据给出强推荐时，临床医生仍应谨慎，并在UpToDate及其他地方寻找清晰的解释。
