How do I repair a GRADE downgrade that reviewers disagree on?

Re-examine the domain evidence against each GRADE criterion to locate the source of the disagreement, then document a consensus judgement with reasons; escalate to a third methodologist if consensus is not reached.

GRADE rates certainty of evidence using explicit criteria and outcome-level judgements, so a disputed downgrade is best resolved by returning to the specific criterion and outcome where reviewers diverge. The GRADE Working Group describes this as a transparent approach to rating certainty and strength of recommendations.

1. Isolate the disputed domain and outcome. List each downgraded domain (risk of bias, inconsistency, indirectness, imprecision, publication bias) and the outcome it applies to. Expected result: you can name the exact criterion and outcome under dispute instead of arguing about the overall rating.
2. Re-read the domain evidence against that criterion. Compare the study data, confidence intervals, and applicability notes for that outcome. Cochrane GRADE resources and the Cochrane Handbook chapter on interpreting results cover confidence intervals, absolute and relative effects, indirectness, and certainty. Expected result: each reviewer states which piece of evidence supports or opposes the downgrade.
3. Separate evidence gaps from judgement differences. Note where reviewers agree on the data and differ only on how severe the limitation is. Expected result: the remaining disagreement is narrow enough to resolve by discussion.
4. Record a consensus judgement with reasons. Write the final domain rating, the evidence cited, and the rationale in the Summary of Findings documentation. Expected result: the rating is traceable to explicit criteria.
5. Escalate unresolved disagreements. If consensus is not reached, refer the specific domain and outcome to a third methodologist and record that adjudication alongside the rating.

A downgrade that survives this process reflects a documented judgement about the evidence for that outcome. Keep the reasoning visible so readers can follow how the certainty rating was reached.