Grading of Recommendations Assessment, Development, and Evaluation (GRADE) offers a worldwide approach to guideline development for clinical practice. For the clinical practice of acupuncture therapy, 18 evidence-based guidelines have been developed in China using GRADE. In this study, we review the advantages and limitations of the GRADE approach in the guideline development for acupuncture and moxibustion and propose some solutions to these limitations. Scientific advantages of rating the quality of evidence, outcome-centric direction, overall progression to develop recommendations, and strength of recommendations providing specific clinical guidance are the advantages of GRADE. The limitations of GRADE in the development of guidelines for acupuncture and moxibustion include rating the quality of evidence for ancient literature and literature on famous traditional Chinese medicine experts’ experiences and specific guidelines for formulating recommendations from evidence. In the guideline development for clinical practice with acupuncture and moxibustion, we suggest that a specific method should be explored based on the GRADE approach and the characteristics of acupuncture therapy.
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Guyatt GH, Oxman AD, Schünemann HJ, Tugwell P, Knottnerus A. GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol 2011; 64(4): 380–382
Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, Norris S, Falck-Ytter Y, Glasziou P, DeBeer H, Jaeschke R, Rind D, Meerpohl J, Dahm P, Schünemann HJ. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 2011; 64(4): 383–394
Zhao H, Sun YX, Luo HC, Guo X, Zi MJ, Liu J, Zhu Y, Li SN, Liu BY. Clinical practice guidelines for using acupuncture to treat depression. Chin J Integr Med 2015 Nov 23. [Epub ahead of print] doi:10.1007/s11655-015-2294-z
Liu ZS, Peng WN, Liu BY, Wang J, Wang Y, Mao M, Deng YH, Yu JN, Liaw Y, Mu Y, Luo Y, Xiao XL, Wu XD, Zi MJ. Clinical practice guideline of acupuncture for herpes zoster. Chin J Integr Med 2013; 19(1): 58–67
Wang JJ, Wu ZC, Hu J, Jiao Y, Yang JH. Development and clinical application of guideline of clinical practice with acupuncture and moxibustion: migraine. Chin Acupunct Mox (Zhongguo Zhen Jiu) 2010; 30(4): 325–328 (in Chinese)
Zhao JP, Wang J, Wang P, Zi MJ. Explanation of guideline of clinical practice with acupuncture and moxibustion: poststroke pseudobulbar paralysis. J Beijing Univ Tradit Chin Med (Beijing Zhong Yi Yao Da Xue Xue Bao) 2012; 19(3): 34–36 (in Chinese)
Zhao H, Liu Z, Xie L, Zhu Y, Li S. Interpretation of clinical practice guideline for low back pain treated with acupuncture and moxibustion. Chin Acupunct Mox (Zhongguo Zhen Jiu) 2015; 35(10): 1065–1068 (in Chinese)
Jiao Y, Wu Z, Zhou W, Si X, Wang J, Zhou J, Chen Z, Li R, Zhao X, Xiao L. Explanation of evidence-based guidelines of clinical practice with acupuncture and moxibustion: adult bronchial asthma. Chin Acupunct Mox (Zhongguo Zhen Jiu) 2016; 36(5): 529–531 (in Chinese)
Wang YT, Jiang R, Guo Y, Li GL. Methodological exploration of guideline of clinical practice with acupuncture and moxibustion: chronic atrophic gastritis. Henan Tradit Chin Med (Henan Zhong Yi) 2013; 33(9): 1398–1400 (in Chinese)
Liu ZS, Peng WN, Mao M, Deng YH, Wang J, Liu BY. Assessment on literature quality in guideline of clinical practice with acupuncture and moxibustion. Chin Acupunct Mox (Zhongguo Zhen Jiu) 2009; 29(1): 81–83 (in Chinese)
Fang YG, Bai Y, Liu BY, Wang F, Wu X. Quality assessment of AGREEIII in guideline of clinical practice with acupuncture and moxibustion. Chin Acupunct Mox (Zhongguo Zhen Jiu) 2014; 34(6): 599–601 (in Chinese)
Hong Z, Zhishun L. Analysis on clinical research of depression treated with acupuncture and moxibustion. Chin Acupunct Mox (Zhongguo Zhen Jiu) 2009; S1: 98–100 (in Chinese)
Goyatá SL, Avelino CC, Santos SV, Souza Junior DI, Gurgel MD, Terra F de S. Effects from acupuncture in treating anxiety: integrative review. Rev Bras Enferm 2016; 69(3): 602–609 (in Portuguese)
Brożek JL, Akl EA, Compalati E, Kreis J, Terracciano L, Fiocchi A, Ueffing E, Andrews J, Alonso-Coello P, Meerpohl JJ, Lang DM, Jaeschke R, Williams JW Jr, Phillips B, Lethaby A, Bossuyt P, Glasziou P, Helfand M, Watine J, Afilalo M, Welch V, Montedori A, Abraha I, Horvath AR, Bousquet J, Guyatt GH, Schünemann HJ; GRADE Working Group. Grading quality of evidence and strength of recommendations in clinical practice guidelines part 3 of 3. The GRADE approach to developing recommendations. Allergy 2011; 66(5): 588–595
Andrews JC, Schünemann HJ, Oxman AD, Pottie K, Meerpohl JJ, Coello PA, Rind D, Montori VM, Brito JP, Norris S, Elbarbary M, Post P, Nasser M, Shukla V, Jaeschke R, Brozek J, Djulbegovic B, Guyatt G. GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation’s direction and strength. J Clin Epidemiol 2013; 66(7): 726–735
Guyatt GH, Prasad K, Schunemann HJ, Jaeschke R, Cook DJ. Users’ Guides to the Medical Literature: a Manual for Evidencebased Clinical Practice. New York: McGraw-Hill Professional, 2008: 597–618
Kaminski-Hartenthaler A, Meerpohl JJ, Gartlehner G, Kien C, Langer G, Wipplinger J, Schünemann HJ. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. Z Evid Fortbild Qual Gesundhwes 2014; 108(7): 413–420 (in German)
Liu JP. The composition of evidence body of traditional medicine and recommendations for its evidence grading. Chin J Integr Med (Zhongguo Zhong Xi Yi Jie He Za Zhi) 2007; 27(12): 1061–1065(in Chinese)
Bai Y, Fang YG, Liu BY, Wu X. Discussion of methodology and promotion of guideline of clinical practice with acupuncture and moxibustion. J Tradit Chin Med (Zhong Yi Za Zhi) 2014; 55(13): 1103–1105 (in Chinese)
Zi MJ, Wu X, Liu BY, Zhao H, Liu ZS, Zhao JP, Liang FR. Characteristics of guideline of clinical practice with acupuncture and moxibustion. Chin Acupunct Mox (Zhongguo Zhen Jiu) 2010; 30(12): 1038–1040 (in Chinese)
Wang YJ, Liu YL, Yang KH, Guo Y. Based on evidence to establish reporting guidelines for TCM-featured acupuncture systematic reviews/meta-analysis: a methodology discussion. Chin Acupunct Mox (Zhongguo Zhen Jiu) 2014; 34(12): 1231–1234 (in Chinese)
This study was supported by the Standardization Project of State Administration of Traditional Chinese Medicine (No. ZYYS-2009-0009-3).
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Zhao, H., Liang, F., Fang, Y. et al. Application of Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to the guideline development for clinical practice with acupuncture and moxibustion. Front. Med. 11, 590–594 (2017). https://doi.org/10.1007/s11684-017-0537-4