Intended for healthcare professionals

Rapid response to:

Analysis Rating quality of evidence and strength of recommendations

Going from evidence to recommendations

BMJ 2008; 336 doi: (Published 08 May 2008) Cite this as: BMJ 2008;336:1049

Rapid Response:

Is this 12 years old BMJ article outdated?

Dear Editor

Maybe this 12 years old BMJ article [1] is not outdated because it is still one of the first downloadable from the website ( of the inventors of GRADE (Grading of Recommendations Assessment, Development and Evaluation) who authored this BMJ article. It is also obvious that these definitions copied below from this article are quite clever: “GRADE classifies recommendations as strong or weak:
1.Strong recommendations mean that most informed patients would choose the recommended management and that clinicians can structure their interactions with patients accordingly,
2.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”.
In more recent articles, GRADE tended to replace the adjective “weak” by “conditional”, which is also clever in my view.
On the other hand, maybe this 12 years old BMJ article [1] is outdated because in GRADE leading members' recent real life, the words “most informed patients” may apparently not mean (as I have always believed they meant, because I tended to believe in the wisdom of the inventors of GRADE) “more than 95% of the informed patients at the very least”. For example, in quite recent guidelines endorsed by GRADE, it is stated: “for asymptomatic women aged 50 to 69 with an average risk of breast cancer, mammography screening is recommended in the context of an organised screening programme (strong recommendation, moderate certainty in the evidence)” [2, 3]. The authors of this recommendation also report “possibly important uncertainty about or variability in how much people value the main outcomes” [2, 3]. In patients' real life, this uncertainty or variability is shown by the fact that participation rates among women who are invited to take part in organized screening programs rarely (and barely) exceed 70%.

More recently leading members of GRADE insisted, again, that these recent breast-cancer guidelines strictly stick to the GRADE principles and methods [3]. Therefore maybe it is now time for the inventors of GRADE to update their 12 years old BMJ article, and clarify that “most informed patients” means in fact something like “more than 50% of the informed patients” [1]? (wich would be quite hazardous in my view)

[1] Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, Schünemann HJ, GRADE working group. Going from evidence to recommendations. BMJ 2008;336:1049.
[2] Schünemann HJ, Lerda D, Dimitrova N, et al; European Commission Initiative on Breast Cancer Contributor Group. Methods for development of the European Commission Initiative on Breast Cancer guidelines: recommendations in the era of guideline transparency. Ann Intern Med 2019;171:273-80.
[3] Schünemann HJ, Alonso-Coello P, Gräwingholt A, Quinn C, Follmann M, Langendam M, Saz-Parkinson Z. Development of the European Commission Initiative on Breast Cancer Guidelines. Ann Intern Med 2020; 172: 72-73.

Competing interests: No competing interests

19 September 2020
Joseph Watine
consultant, laboratory medicine
hôpital de Villefranche-de-Rouergue
Avenue Caylet, F-12200 Villefranche-de-Rouergue