title: Adding a "GRADE" to the quality appraisal of rheumatoid arthritis guidelines identifies limitations beyond AGREE-II.
abstract: OBJECTIVE
  To assess how well treatment recommendations for rheumatoid arthritis (RA) address Grading of Recommendations Assessment, Development and Evaluation (GRADE) steps and determine whether these steps can be adequately appraised using Appraisal of Guidelines Research & Evaluation II (AGREE-II).
  
  
  METHODS
  We systematically reviewed English-language treatment recommendations for the pharmacologic management of RA since 2000, assessed how well GRADE steps were addressed, rated AGREE-II quality, and compared the findings.
  
  
  RESULTS
  GRADE steps were poorly addressed by the 44 included guidelines. Few guidelines discussed study limitations and/or risk of bias (23%), inconsistency (50%), indirectness (39%), imprecision (23%), or potential for publication bias (0%). Observational evidence was cited in 96% but rarely evaluated systematically. Only one guideline considered evidence on patients' preferences for health outcomes, and few provided an explicit justification for the strength of evidence or recommendation. The five GRADE steps that overlapped with AGREE-II questions were addressed more frequently (by 54-100% of guidelines) than the 13 GRADE steps not directly assessed by AGREE-II (0-50%). Among the nine guidelines rated as "Recommended for use" by AGREE-II, 8 of 13 GRADE steps were not addressed consistently by any guideline.
  
  
  CONCLUSIONS
  GRADE's steps are poorly addressed by RA recommendations. AGREE-II provides a broad assessment of quality but lacks sufficient granularity to assess how well a guideline addresses GRADE's steps.
authors.affiliation: Department of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, Alberta, Canada T2N1N1; Institute of Health Policy, Management and Evaluation, University of Toronto, 63 George Street, Toronto, Ontario M5S2Z9, Canada. Electronic address: glenhazlewood@gmail.com.
authors.forename: Glen S
authors.initials: GS
authors.lastname: Hazlewood
authors.affiliation: Division of Rheumatology, Mount Sinai Hospital, University of Toronto, 60 Murray Street, Toronto, Ontario M5T3L9, Canada.
authors.forename: Pooneh
authors.initials: P
authors.lastname: Akhavan
authors.affiliation: Department of Public Health Sciences, University of Toronto, 155 College Street, Toronto, Ontario M5T3M7, Canada.
authors.forename: Orit
authors.initials: O
authors.lastname: Schieir
authors.affiliation: Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada T2N4Z1.
authors.forename: Deborah
authors.initials: D
authors.lastname: Marshall
authors.affiliation: Toronto General Research Institute, University Health Network Toronto, 200 Elizabeth Street, Toronto, Ontario M5G2C4, Canada.
authors.forename: George
authors.initials: G
authors.lastname: Tomlinson
authors.affiliation: Hospital for Special Surgery, 525 East 71st Street, New York, NY 10021, USA.
authors.forename: Vivian
authors.initials: V
authors.lastname: Bykerk
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, 63 George Street, Toronto, Ontario M5S2Z9, Canada; Division of Rheumatology, Mount Sinai Hospital, University of Toronto, 60 Murray Street, Toronto, Ontario M5T3L9, Canada; Toronto General Research Institute, University Health Network Toronto, 200 Elizabeth Street, Toronto, Ontario M5G2C4, Canada; Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, Ontario M5G2C4, Canada.
authors.forename: Claire
authors.initials: C
authors.lastname: Bombardier
mesh_terms: D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D019317:Evidence-Based Medicine / Q000592:standards; D006801:Humans; D017410:Practice Guidelines as Topic / Q000592:standards*; D017594:Publication Bias; D016032:Randomized Controlled Trials as Topic / Q000592:standards
keywords: Evidence evaluation; Practice guidelines; Quality appraisal; Rheumatoid arthritis; Systematic review; Treatment recommendations