BMJ  2004;328:1490 (19 June), doi:10.1136/bmj.328.7454.1490

Education and debate

Grading quality of evidence and strength of recommendations

Clinical guidelines are only as good as the evidence and judgments they are based on. The GRADE approach aims to make it easier for users to assess the judgments behind recommendations

Users of clinical practice guidelines and other recommendations need to know how much confidence they can place in the recommendations. Systematic and explicit methods of making judgments can reduce errors and improve communication. We have developed a system for grading the quality of evidence and the strength of recommendations that can be applied across a wide range of interventions and contexts. In this article we present a summary of our approach from the perspective of a guideline user. Judgments about the strength of a recommendation require consideration of the balance between benefits and harms, the quality of the evidence, translation of the evidence into specific circumstances, and the certainty of the baseline risk. It is also important to consider costs (resource utilisation) before making a recommendation. Inconsistencies among systems for grading the quality of evidence and the strength of recommendations reduce their potential to facilitate critical appraisal and improve communication of these judgments. Our system for guiding these complex judgments balances the need for simplicity with the need for full and transparent consideration of all important issues.

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• Poolman, R. W., Abouali, J. A.K., Conter, H. J., Bhandari, M. (2007). Overlapping Systematic Reviews of Anterior Cruciate Ligament Reconstruction Comparing Hamstring Autograft with Bone-Patellar Tendon-Bone Autograft: Why Are They Different?. JBJS 89: 1542-1552 [Abstract] [Full text]  
• Langhorne, P. (2007). Explicit Priority Setting in Clinical Guidelines: The Next Frontier?. Stroke 38: 2037-2037 [Full text]  
• Vanholder, R. (2007). Approach for guideline development. Nephrol Dial Transplant 22: ii1-ii4 [Full text]  
• Goldsmith, M. R, Bankhead, C. R, Austoker, J. (2007). Synthesising quantitative and qualitative research in evidence-based patient information. J. Epidemiol. Community Health 61: 262-270 [Abstract] [Full text]  
• Himmelfarb, J., Henrich, W., DuBose, T. (2007). Anemia of Kidney Disease and Clinical Practice Guidelines: Quo Vadis?. CJASN 2: 213-214 [Full text]  
• Boulware, L. E., Marinopoulos, S., Phillips, K. A., Hwang, C. W., Maynor, K., Merenstein, D., Wilson, R. F., Barnes, G. J., Bass, E. B., Powe, N. R., Daumit, G. L. (2007). Systematic Review: The Value of the Periodic Health Evaluation. ANN INTERN MED 146: 289-300 [Abstract] [Full text]  
• Glasziou, P., Chalmers, I., Rawlins, M., McCulloch, P. (2007). When are randomised trials unnecessary? Picking signal from noise. BMJ 334: 349-351 [Abstract] [Full text]  
• Taylor, B. J., Dempster, M., Donnelly, M. (2007). Grading Gems: Appraising the Quality of Research for Social Work and Social Care. Br J Soc Work 37: 335-354 [Abstract] [Full text]  
• Corman, S. L., Skledar, S. J., Culley, C. M. (2007). Evaluation of conflicting literature and application to formulary decisions. Am J Health Syst Pharm 64: 182-185 [Abstract] [Full text]  
• Lyles, C. M., Kay, L. S., Crepaz, N., Herbst, J. H., Passin, W. F., Kim, A. S., Rama, S. M., Thadiparthi, S., DeLuca, J. B., Mullins, M. M., for the Hiv/aids Prevention Research Synthesis Tea, (2007). Best-Evidence Interventions: Findings From a Systematic Review of HIV Behavioral Interventions for US Populations at High Risk, 2000-2004. AJPH 97: 133-143 [Abstract] [Full text]  

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