Intended for healthcare professionals

Research Methods & Reporting

GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction

BMJ 2016; 353 doi: (Published 28 June 2016) Cite this as: BMJ 2016;353:i2016
  1. Pablo Alonso-Coello, researcher1 2,
  2. Holger J Schünemann, professor2 3,
  3. Jenny Moberg, researcher4,
  4. Romina Brignardello-Petersen, postdoctoral fellow and lecturer2 5,
  5. Elie A Akl, associate professor and director2 6,
  6. Marina Davoli, director7,
  7. Shaun Treweek, professor8,
  8. Reem A Mustafa, assistant professor2 9,
  9. Gabriel Rada, director, associate profesor, chairman and CEO10 11 12,
  10. Sarah Rosenbaum, designer/researcher4,
  11. Angela Morelli, information designer4,
  12. Gordon H Guyatt, distinguished professor2 3,
  13. Andrew D Oxman, senior researcher4,
  14. the GRADE Working Group
  1. 1Iberoamerican Cochrane Centre, CIBERESP-IIB Sant Pau, Barcelona, Spain
  2. 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
  3. 3Department of Medicine, McMaster University, Hamilton, Canada
  4. 4Norwegian Institute of Public Health, Oslo, Norway
  5. 5Evidence Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago, Chile
  6. 6Department of Internal Medicine, Clinical Epidemiology Unit, American University of Beirut Medical Center, Beirut 1107, 2020, Lebanon
  7. 7Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
  8. 8Health Services Research Unit, University of Aberdeen, Aberdeen, UK
  9. 9Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA, 64110
  10. 10Evidence Based Health Care Program, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
  11. 11Department of Internal Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
  12. 12Epistemonikos Foundation, Santiago, Chile
  1. Correspondence to: A D Oxman oxman{at}

Summary points

  • Clinicians, guideline developers, and policymakers sometimes neglect important criteria, give undue weight to criteria, and do not use the best available evidence to inform their judgments

  • Explicit and transparent systems for decision making can help to ensure that all important criteria are considered and that decisions are informed by the best available research evidence

  • The purpose of Evidence to Decision (EtD) frameworks is to help people use evidence in a structured and transparent way to inform decisions in the context of clinical recommendations, coverage decisions, and health system or public health recommendations and decisions

  • EtD frameworks have a common structure that includes formulation of the question, an assessment of the evidence, and drawing conclusions, though there are some differences between frameworks for each type of decision

  • EtD frameworks inform users about the judgments that were made and the evidence supporting those judgments by making the basis for decisions transparent to target audiences

  • EtD frameworks also facilitate dissemination of recommendations and enable decision makers in other jurisdictions to adopt recommendations or decisions, or adapt them to their context


Healthcare decision making is complex. Decision-making processes and the factors (criteria) that decision makers should consider vary for different types of decisions, including clinical recommendations, coverage decisions, and health system or public health recommendations or decisions.1 2 3 4 However, some criteria are relevant for all of these decisions, including the anticipated effects of the options being considered, the certainty of the evidence for those effects (also referred to as quality of evidence or confidence in effect estimates), and the costs and feasibility of the options. Decision makers must make judgments about each relevant factor, informed by the best evidence that is available to them.

Often, the processes that decision makers use, the criteria that they consider and the evidence that they …

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