A guide and pragmatic considerations for applying GRADE to network meta-analysis

Network meta-analysis (NMA) allows assessing the comparative effectiveness of multiple interventions by combining direct and indirect evidence in one statistical model, resulting in estimates of effect comparing every pair of interventions included in the network—even if they have not been compared directly in trials.1 Assessing the certainty of the evidence (also known as quality of the evidence, and confidence in the estimates of effects) from NMAs is crucial for interpreting those estimates and moving from evidence to decision. The GRADE (grading of recommendations, assessment, development, and evaluations) working group has provided guidance for assessing the certainty of the evidence and drawing conclusions from NMAs.2345678 The approach considers the certainty of all direct, indirect, and network (also known as mixed) estimates between interventions (nodes) included in the network (fig 1). Implementing the GRADE approach for NMA requires an understanding of the methods, and an awareness that the larger the network, the…
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