New GRADE Evidence-to-Decision Framework for Pairwise and Multiple Comparisons (GRADE Guidance 45)

Area of Science:

• Health research methodology
• Clinical guideline development
• Evidence-based practice

Background:

• Evidence-based decision-making in healthcare often involves comparing multiple treatment options.
• The original GRADE evidence-to-decision (EtD) framework was designed for pairwise comparisons, limiting its use with network meta-analyses.
• Current GRADE guidance has evolved, necessitating an updated EtD framework.

Purpose of the Study:

• To develop a new EtD framework accommodating multiple comparisons.
• To integrate current GRADE guidance into the EtD framework.
• To improve the structure and usability of the EtD framework for guideline developers.

Main Methods:

• Iterative discussion, feedback, and refinement by the GRADE EtD Project Group and GRADE Working Group.
• Incorporation of experiences and examples from guideline developers and methodological experts.
• Approval of the revised framework by the GRADE Working Group.

Main Results:

• A new EtD framework with two parts: one for pairwise and one for multiple comparisons.
• The framework includes updated components for question definition, assessment (including a "net effect" criterion), and conclusion.
• Examples and presentation suggestions for findings in multiple comparison reviews are provided.

Conclusions:

• The revised GRADE EtD framework effectively addresses multiple comparisons in health decisions.
• The framework enhances the application of GRADE methodology in guideline development involving complex evidence syntheses.
• Further testing across diverse guideline contexts is needed to fully assess usability.