In a systematic review using GRADE methodology, a well-conducted RCT that shows serious risk of bias would be downgraded to:
- A High certainty
- B Moderate certainty ✓
- C Low certainty
- D Very low certainty
Correct answer: B. Moderate certainty
Explanation
In GRADE, evidence from RCTs starts at HIGH certainty. Downgrading occurs for: risk of bias, inconsistency, indirectness, imprecision, and publication bias — each can lower by one or two levels. Serious risk of bias (not very serious) downgrades by one level — from HIGH to MODERATE certainty. Two serious concerns in the same domain would downgrade two levels to LOW.
Reference: Park's Textbook of Preventive and Social Medicine, 27th ed.
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