BMJ  2008;336:1049-1051 (10 May), doi:10.1136/bmj.39493.646875.AE

Analysis

Rating quality of evidence and strength of recommendations

Going from evidence to recommendations

¹ CLARITY Research Group, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada L8N 3Z5, ² Norwegian Knowledge Centre for the Health Services, Oslo, Norway, ³ Basel Institute of Clinical Epidemiology, University Hospital Basel, Basel, Switzerland, ⁴ Division of Gastroenterology, Case Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA, ⁵ University of Modena and Reggio Emilia and Agenzia Sanitaria Regionale, Bologna, Italy, ⁶ Department of Epidemiology, CLARITY Research Group, Italian National Cancer Institute Regina Elena, Rome, Italy

Analysis, doi: 10.1136/bmj.39490.551019.BEAnalysis, doi: 10.1136/bmj.39489.470347.AD

The GRADE system classifies recommendations made in guidelines as either strong or weak. This article explores the meaning of these descriptions and their implications for patients, clinicians, and policy makers

The first 150 words of the full text of this article appear below.

Summary points The strength of a recommendation reflects the extent to which we can be confident that desirable effects of an intervention outweigh undesirable effects GRADE classifies recommendations as strong or weak Strong recommendations mean that most informed patients would choose the recommended management and that clinicians can structure their interactions with patients accordingly Weak recommendations mean that patients’ choices will vary according to their values and preferences, and clinicians must ensure that patients’ care is in keeping with their values and preferences Strength of recommendation is determined by the balance between desirable and undesirable consequences of alternative management strategies, quality of evidence, variability in values and preferences, and resource use

This is the third of a series of five articles describing the GRADE approach to developing and presenting recommendations for management of patients. In it, we deal with how GRADE suggests clinicians should interpret the strength of a recommendation.

What do we mean by strength of recommendation?

The strength . . . [Full text of this article]

Strong and weak recommendations provide specific guidance

Four key factors determine the strength of a recommendation

Balance between desirable and undesirable effects
Quality of evidence
Values and preferences
Costs

Strong recommendations may not be important from all perspectives

Recommendations to use interventions in research context may be appropriate

Various presentations of quality of evidence and strength of recommendations may be appropriate

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This article has been cited by other articles:

• Guyatt, G. H, Oxman, A. D, Kunz, R., Jaeschke, R., Helfand, M., Liberati, A., Vist, G. E, Schunemann, H. J, for the GRADE working group, (2008). Incorporating considerations of resources use into grading recommendations. BMJ 336: 1170-1173 [Full text]  

Rapid Responses:

Read all Rapid Responses

Grading is possible only for simple (non-compound) and unambiguous recommendations

Michael Power
bmj.com, 13 May 2008 [Full text]