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Analysis Rating quality of evidence and strength of recommendations

GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39489.470347.AD (Published 24 April 2008) Cite this as: BMJ 2008;336:924
  1. Gordon H Guyatt, professor1,
  2. Andrew D Oxman, researcher2,
  3. Gunn E Vist, researcher2,
  4. Regina Kunz, associate professor3,
  5. Yngve Falck-Ytter, assistant professor4,
  6. Pablo Alonso-Coello, researcher5,
  7. Holger J Schünemann, professor6
  8. for the GRADE Working Group
  1. 1Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada L8N 3Z5
  2. 2Norwegian Knowledge Centre for the Health Services, PO Box 7004, St Olavs Plass, 0130 Oslo, Norway
  3. 3Basel Institute of Clinical Epidemiology, University Hospital Basel, Hebelstrasse 10, 4031 Basel, Switzerland
  4. 4Division of Gastroenterology, Case Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA
  5. 5Iberoamerican Cochrane Center, Servicio de Epidemiología Clínica y Salud Pública (Universidad Autónoma de Barcelona), Hospital de Sant Pau, Barcelona 08041, Spain
  6. 6Department of Epidemiology, Italian National Cancer Institute Regina Elena, Rome, Italy
  1. Correspondence to: G H Guyatt, CLARITY Research Group, Department of Clinical Epidemiology and Biostatistics, Room 2C12, 1200 Main Street, West Hamilton, ON, Canada L8N 3Z5 guyatt{at}mcmaster.ca

Guidelines are inconsistent in how they rate the quality of evidence and the strength of recommendations. This article explores the advantages of the GRADE system, which is increasingly being adopted by organisations worldwide

Summary points

  • Failure to consider the quality of evidence can lead to misguided recommendations; hormone replacement therapy for post-menopausal women provides an instructive example

  • High quality evidence that an intervention’s desirable effects are clearly greater than its undesirable effects, or are clearly not, warrants a strong recommendation

  • Uncertainty about the trade-offs (because of low quality evidence or because the desirable and undesirable effects are closely balanced) warrants a weak recommendation

  • Guidelines should inform clinicians what the quality of the underlying evidence is and whether recommendations are strong or weak

  • The Grading of Recommendations Assessment, Development and Evaluation (GRADE ) approach provides a system for rating quality of evidence and strength of recommendations that is explicit, comprehensive, transparent, and pragmatic and is increasingly being adopted by organisations worldwide

Guideline developers around the world are inconsistent in how they rate quality of evidence and grade strength of recommendations. As a result, guideline users face challenges in understanding the messages that grading systems try to communicate. Since 2006 the BMJ has requested in its “Instructions to Authors” on bmj.com that authors should preferably use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for grading evidence when submitting a clinical guidelines article. What was behind this decision?

In this first in a series of five articles we will explain why many organisations use formal systems to grade evidence and recommendations and why this is important for clinicians; we will focus on the GRADE approach to recommendations. In the next two articles we will examine how the GRADE system categorises quality of evidence and strength of recommendations. The final two articles will …

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