Improving the contextual use of GRADE (Grading of Recommendations Assessment, Development, and Evaluation) for interventional pain procedures: bridging evidence certainty and clinical reality

Grading of Recommendations Assessment, Development, and Evaluation (GRADE) is a tool designed to assess the certainty of evidence and has been widely applied to evaluate the medical literature. GRADE has several strengths, including transparency, reproducibility, and an explicit linkage between evidence certainty and the strength of the recommendation. It is a robust instrument for evaluating the overall certainty of a body of evidence by appraising risk of bias, precision, inconsistency, indirectness, publication bias, magnitude of effect, and dose–response gradients, thereby improving the credibility of evidence to generate recommendations that serve as a basis of clinical guideline development.1 Given the increasing use of GRADE to inform payer coverage guidelines, it is important to highlight pitfalls of GRADE that must be addressed when applied to procedures used to treat chronic pain to avoid mischaracterizing the evidence and making flawed clinical or policy decisions. Misapplication of GRADE, or interpretation of GRADE without the appropriate clinical context of risks, benefits, and alternatives of a given intervention, has grave consequences. Recent examples include coverage policy changes deeming denervation of the lateral branches of the sacral dorsal rami “investigational”2 and a proposal to end coverage for the majority of peripheral nerve block and denervation procedures for various chronic pain indications.3 In the present article, we discuss the limitations of GRADE given its epistemology and how it might be contextualized appropriately for procedures performed to help patients with chronic pain.