GRADE Certainty of Evidence Checklist

Work through this for each key outcome in your review. See our GRADE approach guide for the full explanation behind each item.

Step 1 — Starting point

Randomized trial evidence — start at High certainty

Observational evidence — start at Low certainty

Step 2 — Factors that can lower certainty

Risk of bias across included studies is serious or very serious

Inconsistency — substantial unexplained heterogeneity between studies

Indirectness — population, intervention, or outcome doesn't closely match your question

Imprecision — wide confidence intervals around the effect estimate

Publication bias suspected (e.g., funnel plot asymmetry, few small studies)

Step 3 — Factors that can raise certainty (observational evidence only)

Large or very large effect size observed

Dose-response gradient present

Plausible confounding would only reduce, not create, the observed effect

Step 4 — Final rating for this outcome

High — further research very unlikely to change the estimate

Moderate — further research may change the estimate

Low — further research likely to change the estimate

Very low — any estimate is very uncertain

Need GRADE assessment done for your review?

See GRADE Evidence Assessment Support

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