Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.
Department of Internal Medicine, Pulmonary and Allergy, UMDNJ-Rutgers New Jersey Medical School and Pulmonary and Allergy Associates, Morristown, New Jersey.
Ann Allergy Asthma Immunol. 2020 Jun;124(6):526-535.e2. doi: 10.1016/j.anai.2020.03.009. Epub 2020 Mar 19.
To review GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methods and discuss the clinical application of conditional recommendations in clinical guidelines, specifically in the context of anaphylaxis.
Articles that described GRADE, evidence synthesis, evidence to recommendation frameworks, and shared decision making were used to discuss conditional recommendations of the 2020 Anaphylaxis GRADE guideline.
A narrative review detailing concepts of GRADE and approaches to translate conditional recommendations to individualized and contextualized patient care.
GRADE methods encourage a nuanced relationship between certainty of evidence and strength of recommendations. Strength of recommendation must incorporate key factors, including the balance between benefits and harms, patient values and preferences, and resource allocation (costs), with equity, feasibility, and acceptability also often included as considerations. GRADE guidelines provide recommendations that are characterized by directionality (for or against) and strength (strong or conditional). A conditional recommendation is tailored to context and primarily applied through a lens of patient preferences related to the likelihood of outcomes of importance and a shared decision-making approach. Although the 2020 Anaphylaxis GRADE guideline better informs the practice of anaphylaxis prevention through (1) identification and mitigation of risk factors for biphasic anaphylaxis and (2) evaluation of the use of glucocorticoid and/or antihistamine pretreatment, all GRADE recommendations, although directional, are conditional and as such should not be universally applied to every circumstance.
Clinical guidelines provide an important opportunity to critically appraise evidence and translate evidence to practice. Patients, practitioners, and policy makers should appreciate the strength of recommendation and certainty of evidence and understand how this affects guideline applicability and implementation.
回顾 GRADE（推荐评估、制定与评价）方法，并讨论条件推荐在临床指南中的临床应用，特别是在过敏反应领域。
本文使用了描述 GRADE、证据综合、证据到推荐框架以及共同决策的文章，以讨论 2020 年过敏反应 GRADE 指南的条件推荐。
这是一篇详细描述 GRADE 概念和将条件推荐转化为个体化和情境化患者护理方法的叙述性综述。
GRADE 方法鼓励在证据确定性和推荐强度之间建立细致的关系。推荐强度必须纳入关键因素，包括收益与危害、患者价值观和偏好、资源分配（成本）之间的平衡，同时通常还包括公平性、可行性和可接受性等因素。GRADE 指南提供的推荐具有方向性（支持或反对）和强度（强或条件）。条件推荐是针对具体情况制定的，主要通过与重要结局相关的患者偏好以及共同决策方法的视角来应用。尽管 2020 年过敏反应 GRADE 指南通过（1）识别和减轻双相过敏反应的风险因素，以及（2）评估糖皮质激素和/或抗组胺药预处理的使用，更好地指导过敏反应预防实践，但所有 GRADE 推荐，尽管具有方向性，但都是有条件的，因此不应普遍适用于每种情况。
临床指南为批判性评估证据和将证据转化为实践提供了重要机会。患者、从业者和政策制定者应了解推荐强度和证据确定性，并理解这如何影响指南的适用性和实施。
