Compare indirectness judgments outcome by outcome against the same population and setting criteria, then harmonize the ratings and document each change. GRADE rates certainty at the outcome level, so an indirectness downgrade belongs to a specific outcome rather than to the review as a whole; that is where the inconsistency sits and where the fix begins.
- Build an outcome-by-criterion table. List every outcome in the Summary of Findings table and, for each, record the population, intervention, comparator, and setting the included evidence actually addresses. Mark where each departs from the review's question. The result is a side-by-side view that shows which outcomes received a downgrade and which did not.
- Reapply one explicit indirectness rule across all outcomes. Decide in advance what counts as a serious departure (for example, evidence drawn from a different population or setting than the review question) and apply that same threshold to every row. GRADE's explicit criteria support this consistent, transparent application. The result is a set of ratings that can be defended row by row.
- Harmonize the ratings and record the change. Where the reapplication changes a judgment, update the certainty rating for that outcome and note the reason, the criterion applied, and the effect on the overall certainty. Documenting the harmonization keeps the audit trail visible to readers and reviewers.
Cochrane's guidance on applicability and indirectness in interpreting results supports tying these judgments to the review question and to the evidence actually available for each outcome. Keep the harmonized judgments in the Summary of Findings table so the certainty for each outcome is transparent.