Intended for healthcare professionals

Education And Debate

Grading quality of evidence and strength of recommendations

BMJ 2004; 328 doi: (Published 17 June 2004) Cite this as: BMJ 2004;328:1490
  1. GRADE Working Group (oxman{at}
  1. Informed Choice Research Department, Norwegian Health Services Research Centre, PO Box 7004, St Olavs Plass, 0130 Oslo, Norway
  1. Correspondence to: Andrew D Oxman,
  • Accepted 5 March 2004


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.

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


  • Contributors All of the members of the GRADE Working Group listed above have contributed to the preparation of this manuscript and the development of the ideas contained in it, participated in at least one meeting, and read and commented on drafts of this article. GHG and ADO led the process. GEV has had primary responsibility for preparing the evidence profiles used in the pilot study and coordinating the process.

  • Competing interests Most of the members of the GRADE Working Group have a vested interest in another system of grading the quality of evidence and the strength of recommendations.

  • Accepted 5 March 2004
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