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JU INSIGHT GRADE Reporting in Systematic Reviews Published in the Urological Literature (2009-2021)

By: Brett Norling, BS, University of Minnesota School of Medicine, Minneapolis; Jae Hung Jung, MD, PhD, Yonsei University Wonju College of Medicine, Republic of Korea Center of Evidence Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Republic of Korea; Eu Chang Hwang, MD, PhD, Chonnam National University Medical School, Hwasun, Republic of Korea; Mi Ah Han, MD, PhD, College of Medicine, Chosun University, Gwangju, Republic of Korea; Sari Khaleel, MD, Memorial Sloan Kettering Cancer Center, New York, New York; Holger J. Schünemann, MD, PhD, McMaster University, Ontario, Canada Humanitas University, Milan, Italy Michael G. DeGroote Cochrane Canada Centre & McMaster GRADE Centre, Hamilton, Ontario; Philipp Dahm, MD, MHSc, Minneapolis VA Healthcare System, Minnesota University of Minnesota School of Medicine, Minneapolis | Posted on: 19 Sep 2023

Figure. Total number of systematic reviews and the proportion of systematic reviews that have used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach since 1998. Percentages are presented on a per-group basis. During the first 3 time periods (1998-2000, 2001-2003, and 2004-2006) no systematic review reported the use of GRADE.

Norling B, Jung JH, Hwang EC, et al. GRADE reporting in systematic reviews published in the urological literature (2009-2021). J Urol. 2023;210(3):529-536.

Study Need and Importance

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach is a methodologically rigorous, transparent, and practical approach to rate the certainty of evidence provided by a body of evidence summarized in systematic reviews (SRs) and developing guidelines. The growing uptake of GRADE suggests a movement toward the use of a unified system of evidence reporting, increasing accessibility of high-quality data assessment for clinicians and policymakers. Increasing usage of GRADE is a positive development, though little work has been done to evaluate the rigor that users of GRADE apply to their evidence assessments.

What We Found

We found that GRADE was first used in urology SRs in 2009. Since then, its use has increased to approximately 1 in 4 SRs. Only half of SRs reported GRADE use in the abstract, and less than half qualified their results in the abstract with a certainty of evidence rating. Four in 10 SRs lacked a summary of findings table or an evidence profile, and only 1 in 3 SRs referenced the certainty of evidence in their results. GRADE reporting did not improve over time (see Figure).


We recognize that many important SRs that inform the practice of urology are published outside urology specialty journals and were therefore not included in the present study. It was beyond the scope of this study to determine whether GRADE had been applied appropriately; instead, we determined whether all critical aspects of the GRADE approach were reported transparently so that the users of these SRs could replicate the findings if they wanted to do so.

Interpretation for Patient Care

Failure to report critical elements of methodology for evidence assessment undermines the confidence we can place in the findings of SRs. These reviews lay the groundwork for clinical guidelines that influence patient care. Our findings suggest a need for improved evidence assessment training and improved reporting guidance.