Perpetuating Prejudice against Preterms: 2. The GRADE approach is inappropriate, but at least do it right.

Towards the end of last year the Canadian Pediatric Society published a new ‘position statement’. These are official proclamations of the society, supposedly based on the best available evidence to guide practice, and which become de facto standards of care. This particular one ‘Counselling and management for anticipated extremely preterm birth’ presented an opportunity to update a 20 year old statement. This is part 2 of my response.

As noted in the previous post the new CPS recommendations are accompanied by a notation that they are either ‘strong recommendation’ or a ‘weak recommendation’.

The authors of the statement say that they are using the GRADE recommendation system to come up with these labels. But in fact they did not.

A review of the GRADE publications makes it clear that they are totally unsuited to a guideline such as this.

Here is a description of what GRADE is all about: ‘The GRADE approach involves making separate ratings for quality of evidence for each patient important outcome and identifies five factors that can lower the quality of the evidence. These limitations can downgrade the quality of observational studies as well as randomised controlled trials’.

No such process was used in developing this position statement.

The GRADE system, which is generally considered the most appropriate system for developing evidence based guidelines for deciding among active treatment options, is described in a series of 13 articles published in the Journal of Clinical Epidemiology ( it requires an extensive and explicit systematic review of all of the evidence, the construction of “Summary of findings tables”, an exhaustive process of rating the quality and extent of the evidence, and finally the construction of recommendations according to the strength of the available evidence.

That is not the same as making a “Strong Recommendation” because you feel strongly about something.

It is very questionable whether the GRADE system is appropriate for discussions of the ethics of making active treatment decision or not, as such discussions have more to do with values than with evidence.

The brief table presented in the position statement as an outline of the GRADE recommendation system is clear evidence that the statement simply appropriates the GRADE terminology without using the GRADE methodology.

Criteria for recommendations using GRADE (Grading of Recommendations Assessment, Development and Evaluation)
  • based on moderate to high quality evidence
  • benefits outweigh harms
  • clinician and patient values and preferences are consistent
  • cost of the intervention is reasonable
  • based on low quality evidence
  • uncertainty in estimates of benefits and harms
  • clinician and patient values are not consistent
  • cost of the intervention is high

How can a strong recommendation be made for letting all 22 week gestation babies die?  A strong recommendation means that it is “based on moderate to high quality evidence; benefits outweigh harms; clinician and patient values and preferences are consistent ; the cost of the intervention is reasonable”

Is the idea that it is ethically appropriate to not offer care to any baby born before 22 weeks, 6 days and 23 hours based on moderate to high quality evidence? Clearly not. Do the benefits outweigh the harms? Not for the baby, unless you think that being dead is a benefit. Are clinician and patient values and preferences consistent? I don’t think the preferences of the baby were considered in this statement. Is the cost reasonable? I guess you could at least make a case for this, it is certainly cheaper to let babies die.

The recommendations as listed in this position statement do not satisfy any kind of objective evaluation of the factors listed in the table.

This statement did not use the GRADE evaluation process, and, as a result, should not have used the GRADE ‘grading’ system for the recommendations.

About Keith Barrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
This entry was posted in The CPS antenatal counselling statement. Bookmark the permalink.

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