Intended for healthcare professionals

Analysis Rating quality of evidence and strength of recommendations

Incorporating considerations of resources use into grading recommendations

BMJ 2008; 336 doi: (Published 22 May 2008) Cite this as: BMJ 2008;336:1170

This article has a correction. Please see:

  1. Gordon H Guyatt, professor1,
  2. Andrew D Oxman, researcher2,
  3. Regina Kunz, associate professor3,
  4. Roman Jaeschke, clinical professor4,
  5. Mark Helfand, professor of medicine5,
  6. Alessandro Liberati, professor6,
  7. Gunn E Vist, researcher2,
  8. Holger J Schünemann, associate professor7
  9. 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, 0130 Oslo, Norway
  3. 3Basel Institute of Clinical Epidemiology, University Hospital Basel, 4031 Basel, Switzerland
  4. 4Department of Medicine, McMaster University, Hamilton, ON, Canada L8N 3Z5
  5. 5Portland VA Medical Center and OHSU Department of Medicine, Portland, Oregon 97201
  6. 6Università di Modena e Reggio Emilia and Agenzia Sanitaria Regionale, Regione Emilia Romagna, 40127 Bologna, Italy
  7. 7Department of Epidemiology, Italian National Cancer Institute Regina Elena, Rome, Italy
  1. Correspondence to: G H Guyatt guyatt{at}

    Guideline panellists have differing opinions on whether resource use should influence decisions on individual patients. As medical care costs rise, resource use considerations become more compelling, but panellists may find dealing with such considerations challenging

    In this last part of a series describing the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to making recommendations we will look at how guideline panellists and clinicians can incorporate matters related to the use of resources into recommendations and practice. Clinical recommendations inevitably involve judgments about the allocation of resources, judgments commonly referred to as costs. We will deal with some of the challenges of considering costs, explain reasons for focusing on resource use rather than costs, and discuss how to incorporate considerations of resource use into recommendations.

    Cost as an outcome presents special challenges

    In one sense, cost is just another potentially important outcome—like mortality, morbidity, and quality of life—associated with alternative ways of managing patients. In addition to these clinical outcomes, an intervention may increase costs or decrease costs. However, costs differ from other outcomes in several ways (box).1

    In what way do costs differ from other health outcomes?

    • Patients receive health benefits and bear the burden of adverse health outcomes, but healthcare costs are typically shared by society as a whole (as represented by the government), employers, and patients

    • Attitudes differ as to whether costs should influence a doctor’s decision about treating individual patients

    • Healthcare costs may vary widely among and even within jurisdictions and quickly change over time

    • What societies can purchase if they forego use of healthcare resources (opportunity cost) varies widely between countries. A year’s supply of an expensive drug may pay a nurse’s salary in the US and 30 nurses’ salaries in China

    • When healthcare expenditures demand foregoing expenditures elsewhere, attitudes differ as to whether the health system, public expenditures, or society as a whole should bear the burden

    • Matters relating …

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