Developing guidelines in geriatric surgery: role of the grade system

In making healthcare management decisions, clinicians must weigh up the benefits and the harms of alternative strategies. Guidelines are useful tools for administrators, policy makers, managers, clinical leaders and care givers to achieve this aim. Guidelines recommendations may be produced in three different ways: small panels of experts, consensus conferences and on the basis of evidence. Expert clinicians and organisations offering recommendations to the clinical community have often erred as a result of not taking sufficient account of evidence. Moreover the so-called "evidence-based guidelines" are often inconsistent in how they rate the quality of evidence and the strength of recommendation. Systems used to assess quality of evidence in guidelines were only scales that reported the study design the evidence was provided from as a letter or a number (i.e. C1, IIb, etc).

This kind of evaluation gives great emphasis on RCTs and metanalysis as an "a priori" source of good evidence without a systematic evaluation of study quality. This drives to a lesser impact of observational studies, CCTs and case series of rare adverse events in guidelines. Geriatric patients are often excluded or underrepresented in trials mainly because comorbidity conditions and toxic effects of treatment are the greatest barriers to recruitment of older patients. Other studies have shown that physician refusal to enrol patients onto trials is among the top reasons for low protocol participation.

Thus evidences for geriatric guidelines are, according to such a rating scheme, of low level. Since 2006 the BMJ requested in its instruction to authors, that authors should preferably use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for grading evidence when submitting a clinical guidelines article. The GRADE system separates decisions regarding the quality of evidence from strength of recommendations and allows upgrading or down grading of – level of evidence according to quality of evidence rather than to study design

In order to obtain reliable and evidence-based guidelines in geriatric surgery, the GRADE system for grading evidence should be used as consolidated standard.