Intended for healthcare professionals


Use of GRADE grid to reach decisions on clinical practice guidelines when consensus is elusive

BMJ 2008; 337 doi: (Published 31 July 2008) Cite this as: BMJ 2008;337:a744
  1. Roman Jaeschke, clinical professor1,
  2. Gordon H Guyatt, professor12,
  3. Phil Dellinger, professor3,
  4. Holger Schünemann, professor4,
  5. Mitchell M Levy, professor5,
  6. Regina Kunz, associate professor6,
  7. Susan Norris, assistant professor7,
  8. Julian Bion, professor of intensive care medicine8
  9. for the GRADE working group
  1. 1Department of Medicine, McMaster University, Hamilton, ON, Canada L8P 3B6
  2. 2Department of Clinical Epidemiology and Biostatistics, McMaster University
  3. 3Division of Critical Care, Cooper University Hospital and Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Camden, NJ, USA
  4. 4Department of Epidemiology, Italian National Cancer Institute Rome, Rome 00144, Italy
  5. 5Division of Pulmonary and Critical Care Medicine, Brown University School of Medicine, Providence, RI, USA
  6. 6Basle Institute of Clinical Epidemiology, University Hospital Basle, 4031 Basle, Switzerland
  7. 7Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR 97239, USA
  8. 8University of Birmingham, Queen Elizabeth Hospital, Birmingham B15 2TH
  1. Correspondence to: J Bion J.F.Bion{at}
  • Accepted 19 May 2008

The large and diverse nature of guideline committees can make consensus difficult. Roman Jaeschke and colleagues describe a simple technique for clarifying opinion

Guidelines have become an important vehicle for influencing clinical practice. Many local, national, and international societies now go through the process of identifying relevant clinical areas, formulating specific clinical questions, reviewing the applicable evidence, and formulating recommendations that they believe clinicians and their patients should follow.

Over the years, in recognition of the diversity of individuals required to produce optimal recommendations (content experts, methodologists, front line clinicians, patients’ representatives), guideline panels have grown in size. The resulting large and diverse panels present challenges for decision making, such as ensuring that all participants have a voice and can influence the results of the debate, ensuring transparency, dealing with disagreement, achieving consensus, and resolving situations in which consensus is not possible.

Guideline panels often use only informal processes to deal with these challenges. Informal processes are, however, vulnerable to the idiosyncrasies of small or moderate sized group interaction. Factors including time pressure; fatigue; lack of expertise in content, methods, or group leadership; and, most importantly, dominance by individuals with powerful personalities and intimidating reputations threaten the integrity of the process.

Those interested in the science of guideline development have developed two strategies to deal with these problems. The first uses structured approaches to collect, analyse, and summarise the relevant evidence and to use that evidence to produce and grade recommendations. These approaches are epitomised by the method suggested by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group, which has developed an increasingly widely adopted structure for developing guidelines.1 2 3 4 5 6 The second relies on somewhat formalised processes to encourage a consensus to which all panellists can contribute more or less equally.7 …

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