Guidelines From the American Thyroid Association Are Inconsistent With GRADE

Clinical guidelines from the American Thyroid Association are inconsistent with the GRADE framework in assigning strength of recommendations.

Clinical guidelines from the American Thyroid Association (ATA) are inconsistent with the Grading of Recommendations Assessment, Development, and Evaluations (GRADE) framework, according to study results published in the Journal of Clinical Epidemiology.

The GRADE framework is intended to guide the process of evaluating the evidence and strength of recommendations in the development of clinical guidelines. Investigators conducted a meta-epidemiologic study to characterize the recommendations in guidelines published by the ATA from 2012 to 2017 for adherence to GRADE.

Of the 7 clinical guidelines available from the ATA during the designated period, only 1 used the GRADE system to denote recommendations. Another 4 used the American College of Physicians (ACP) Guideline Grading System, which represents a modified version of GRADE based on similar parameters for evaluating evidence. Between the 5 guidelines, 518 recommendations were identified for analysis.

Of the 518 recommendations, 355 (69%) were labeled as strong and 163 (31%) received a weak classification. The majority of recommendations (293; 56%) were based on observational studies.

Over half (281; 54%) of recommendations were supported by low-quality evidence. Of these, 54% were labeled as strong recommendations and 46% were designated as weak. Almost half of the strong recommendations (43%) were based on low-quality evidence, and almost 14% did not cite supporting evidence.

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The GRADE system outlines 5 paradigmatic situations in which a strong recommendation based on low-quality evidence is appropriate. Of the 151 strong recommendations based on low-quality evidence in the ATA guidelines, 36 (24%) were in line with one of the GRADE paradigmatic situations.

The study authors noted that the classification of recommendations was based solely on justification provided within the clinical recommendations and not on additional consideration by the guideline authors, which may have resulted in erroneous classification.

“Strong recommendations based on low-quality of evidence are frequently made on the ATA guidelines,” the investigators concluded. “These findings abet for additional training in GRADE methods and for caution when implementing recommendations based on low quality evidence, for clinicians to be cautious of misapplying the evidence in healthcare, and for researchers to acknowledge these research gaps and orientate future research towards it.”

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Bautista-Orduno KG, Dorsey-Trevino EG, Gonzalez-Gonzalez JG, et al. American Thyroid Association guidelines are inconsistent with GRADE — a meta-epidemiological study [published online March 4, 2020]. J Clin Epidemiol. doi: 10.1016/j.jclinepi.2020.02.010