PRISMA 2020 and GRADE: Distinct Roles of Reporting and Certainty Assessment in Systematic Reviews

PRISMA 2020 is a 27-item checklist and accompanying flow diagram for reporting systematic reviews. GRADE (Grading of Recommendations Assessment, Development and Evaluation) is a separate framework for rating the certainty of a body of evidence and the strength of any recommendation based on it. A review can adhere fully to PRISMA’s reporting structure without ever applying GRADE, or vice versa, because the two address different questions.

Scope of the 27-item PRISMA 2020 checklist

Page and colleagues’ PRISMA 2020 statement organises its 27 items across title, abstract, introduction, methods, results, discussion, and a final “other information” section covering registration, funding, competing interests and data availability1. The methods section carries the most items, including eligibility criteria, information sources, search strategy, the study-selection and data-collection processes, risk-of-bias assessment, effect measures, synthesis methods, reporting-bias assessment, and — specifically relevant here — item 15, which asks the reviewer to state the methods used to assess certainty in the body of evidence. PRISMA governs completeness and transparency of reporting; it does not itself prescribe which certainty-rating method to use.

Contribution of GRADE

GRADE, maintained by the international GRADE Working Group, rates the certainty of evidence for each outcome as high, moderate, low or very low, based on considerations including risk of bias, inconsistency across studies, indirectness of the evidence to the question asked, imprecision, and publication bias, with upgrading factors available for observational evidence showing a large or dose-response effect2. This is the step that turns “the included studies showed X” into “we have moderate confidence that X is true,” and it is the step most often omitted or applied loosely when a review ends at PRISMA-compliant reporting of what was found.

Integration of PRISMA and GRADE within a single review

A well-constructed systematic review uses PRISMA to structure and report the conduct of the review (items 1–14, 16–21, 23–27) and applies GRADE as the specific method referenced in PRISMA item 15, with the resulting certainty ratings reported against PRISMA item 22. Treated in this way, the two frameworks are complementary steps in the same process rather than competing standards: PRISMA’s function is transparency about what was done; GRADE’s function is an explicit statement of how much confidence the result warrants.

Key points

Practical application

Frequently asked questions

@misc{prisma_2020_and_grade_2026,
  author       = {{Pubrica Academy}},
  title        = {PRISMA 2020 and GRADE: Distinct Roles of Reporting and Certainty Assessment in Systematic Reviews},
  howpublished = {Pubrica},
  year         = {2026},
  month        = {oct},
  url          = {https://pubrica.com/academy/concepts-definitions/prisma-2020-and-grade/},
  note         = {Accessed: <span data-cite-acc="iso">2026-10-15</span>}
}

[ ] Certainty-rating method named explicitly (PRISMA item 15)
[ ] GRADE domains assessed per outcome: risk of bias, inconsistency, indirectness, imprecision, publication bias
[ ] Upgrading factors considered for observational evidence where applicable
[ ] Certainty rating (high/moderate/low/very low) reported per outcome (PRISMA item 22)
[ ] Discussion's confidence in its conclusions matches the reported certainty ratings