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 use to reach their judgments are unclear.5 6 7 8 They may omit important criteria, give undue weight to some criteria, or not use the best available evidence. Systematic and transparent systems for decision making can help to ensure that all important criteria are considered and that the best available research evidence informs decisions.

Clinicians depend on clinical practice guidelines. Rigorously developed guidelines synthesise the available relevant research, facilitating the translation of evidence into recommendations for clinical practice.9 However, the quality of guidelines is often suboptimal.10 11 If guidelines are not developed systematically and transparently, clinicians are not able to decide whether to rely on them or to explore disagreements when faced with conflicting recommendations.12

The GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group has previously developed and refined a system to assess the certainty of evidence of effects and strength of recommendations.13 14 15 More than 100 organisations globally, including the World Health Organization, the Cochrane Collaboration, and the National Institute for Health and Care Excellence (NICE) now use or have adopted the principles of the GRADE system. Recently, through the DECIDE (Developing and Evaluating Communication Strategies to Support Informed Decisions and Practice Based on Evidence) project (,16 funded by the European Union, the GRADE Working Group has developed the Evidence to Decision (EtD) frameworks to support the process of moving from evidence to decisions. We have developed EtD frameworks for making clinical recommendations, coverage decisions, and health system or public health recommendations and decisions. The frameworks build on the GRADE approach to assessing the strength of recommendations.17 18 19

We developed EtD frameworks using an iterative process that is described in the project protocol.16 The starting point for EtD frameworks was the GRADE Working Group’s approach for moving from evidence to clinical recommendations.17 18 19 We iteratively developed the frameworks based on reviews of relevant literature,1 2 3 4 brainstorming, feedback from stakeholders,20 application of EtD frameworks to a variety of recommendations and decisions, and user testing. We strove for consistency across EtD frameworks for different types of decisions, but, because of differences in the nature of the decisions, there are some differences in the frameworks. In appendix 1, we have provided a glossary of terms used in EtD frameworks, including certainty of the evidence, decisions, recommendations, and strength of recommendations.

This series of two articles describing the EtD frameworks is targeted at guideline developers and users of guidelines. This first article introduces the frameworks. It describes their purpose, development, and structure. It also describes how different organisations can adapt the frameworks to their own contexts and decision-making processes. The second article presents the framework for clinical recommendations.21

Purpose of the frameworks

The main purpose of the EtD frameworks is to help groups of people (panels) 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:

    • Facilitate adaptation of recommendations and decisions to specific contexts

    • Inform panels about the relative pros and cons of the interventions or options being considered

    • Ensure that panels consider important criteria for making a decision

    • Provide panels with a concise summary of the best available evidence to inform their judgments about each criterion

    • Help panels structure discussion and identify reasons for disagreements, making the process and the basis for decisions structured and transparent.

  • EtD frameworks assist users of recommendations by

    • Enabling them to understand the judgments made by the panel and the evidence supporting those judgments

    • Helping them to decide whether recommendations can and should be implemented in their own settings.

Structure of the frameworks

EtD frameworks include three main sections that reflect the main steps in going from evidence to a decision: formulating the question, making an assessment of the evidence, and drawing conclusions. In this article, we illustrate the use of an EtD framework applied to a recommendation about the use of a new drug (bedaquiline) for the treatment of multidrug-resistant tuberculosis (MDR-TB) (box 1, appendix 2).22 We have used an adapted version of a WHO recommendation as an example.

Box 1: Example for application of Evidence to Decision (EtD) framework

Use of bedaquiline to treat multidrug-resistant tuberculosis

“WHO estimates that up to half a million new cases of multidrug-resistant tuberculosis (MDR-TB) occur worldwide each year. Current treatment regimens for MDR-TB present many challenges: treatment lasts 20 months or more, requiring daily administration of drugs that are more toxic, less effective, and far more expensive than those used to treat drug-susceptible TB. Globally, less than half of all patients who start MDR-TB therapy are treated successfully. For the first time in over 40 years, a new TB drug with a novel mechanism of action—bedaquiline—is available, and was granted accelerated approval by the United States Food and Drug Administration in December 2012. There is considerable interest in the potential of this drug to treat MDR-TB. However, information about this new drug remains limited.”22

Formulating the question

The first step in going from evidence to a recommendation or decision is to clearly formulate the question. The question section of an EtD framework includes details of the question in a structured PICO (problem, intervention, comparison, outcomes) format 23—the perspective from which the options to address the question are considered—relevant subgroups, key background information for understanding the question, and why a recommendation or decision is needed. In the scenario in box 1, the question formulated by the panel was: “In multiple drug-resistant tuberculosis (MDR-TB) patients, should bedaquiline be added to a background regimen based on WHO recommendations?” The panel specified the question details, including the population, intervention, comparison, and outcomes (PICO),23 and the setting (MDR-TB clinics globally) (box 2). In this example, an adaptation of a WHO recommendation,22 the panel took a health system perspective, taking into consideration costs (and savings) to the health system and outcomes that might not directly affect the patients being treated.

Box 2: Evidence to Decision (EtD) framework, question section*

In multidrug-resistant tuberculosis (MDR-TB) patients, should bedaquiline be added to a background regimen based on WHO-recommendations?†
  • Population: Multidrug-resistant tuberculosis (MDR-TB) patients

  • Intervention: Bedaquiline plus background MDR-TB treatment

  • Comparison: Background MDR-TB treatment alone

  • Main outcomes: Cure by 120 weeks, adverse drug reactions (clinical and biological serious adverse events), mortality, time to culture conversion, culture conversion at 24 weeks, acquired resistance to fluoroquinolone and injectable drugs

  • Setting: Global, MDR-TB clinics

  • Perspective: Population perspective (health system)

  • Subgroups: Patients with extensively drug-resistant (XDR) or pre-XDR tuberculosis or those with resistance or contraindication to fluoroquinolones or injectables

  • Background:

    • The emergence of drug resistance is a major threat to global tuberculosis care and control. WHO estimates that around 310 000 MDR-TB cases (resistant to at least rifampicin and isoniazid) occurred among notified tuberculosis patients in 2011.

    • Current treatment regimens for drug-resistant tuberculosis are far from satisfactory: overall duration is ≥20 months, and it requires the daily administration of drugs that are more toxic and less effective than those used to treat drug-susceptible tuberculosis.

    • A new drug with a novel mechanism of action—bedaquiline—is available, and was granted accelerated approval by the US Food and Drug Administration in December 2012. However, information about this new drug remains limited

The perspective that a panel takes will determine which economic consequences of an intervention are considered when making a recommendation or decision. Panels should be explicit about this. It may also affect which outcomes they consider (such as availability and access to health services when considering a health system perspective) and whether they look at equity, acceptability, and feasibility (such as when considering a public health or a health system perspective).

Decisions or recommendations can differ across different subgroups of people. Panels should be explicit about which subgroups they considered, if any, ideally in advance. In the bedaquiline example, the panel paid particular attention to the subgroup of patients with extensive drug resistance and patients with resistance to or contraindications for fluoroquinolones or injectable medications. The rationale was that treatment options for these patients are limited and they may be more likely to accept the risks of a new drug than patients with uncomplicated MDR-TB.

Conflicts of interest

Intellectual and financial conflicts of interest are common and can affect judgments and recommendations or decisions.24 25 26 Guideline developers and organisations responsible for healthcare decisions should consider conflicts of interest when a panel is established.27 In addition, because potential conflicts of interest can vary across questions, panels should consider and report them when formulating each question. They should also specify actions to address these, which can range from simply declaring a conflict of interest to excluding panel members from discussions of specific questions or an entire guideline.25 27 28 In the bedaquiline example, the panel reported that all panellists declared either minor or no conflicts of interest (appendix 2).

Making an assessment

EtD frameworks make explicit the criteria that are used to assess interventions or options, the judgments made by the panel for each criterion, and the research evidence and additional considerations used to inform each judgment. Research evidence refers to facts (actual or asserted) used to inform the panel’s judgments that are derived from studies that used systematic and explicit methods. Additional considerations include other evidence, such as routinely collected data, assumptions, and logic used to make a judgment. Panels may make different judgments for one or more subgroups (such as patients who are older or who have more severe disease) in relation to some or all of the criteria. When relevant, they may also report additional details, such as dissenting views of panel members or the results of voting on judgments where there was disagreement. The assessment of the different criteria made by the panel in the bedaquiline example are available in appendix 2 (an interactive version is available at and at

Different types of decisions and different perspectives require different considerations. Consequently, we suggest specific sets of criteria for clinical recommendations from an individual patient perspective, clinical recommendations from a population perspective, coverage decisions, recommendations and decisions about tests, and health system or public health recommendations and decisions (table 1).

Table 1

Criteria for EtD frameworks for five different types of decisions

View this table:

Although there are differences in the operationalisation of the criteria for different types of decisions, most of the criteria are similar, as can be seen in table 1, which shows the criteria for five types of decisions. All five sets of criteria include questions about whether the problem is a priority, the magnitude of the desirable and undesirable effects, the certainty of the evidence, consideration of how patients (or others affected, such as carers) value the main outcomes, the balance between desirable and undesirable effects, resource use, acceptability, and feasibility. All of the frameworks that take a population perspective also include consideration of impacts on equity.

For questions regarding tests, when there is no direct evidence from randomised trials or observational studies of the impact of alternative testing strategies on important outcomes, additional criteria are required.29 This includes consideration of test accuracy and the certainty of the different types of evidence used to inform judgments about the desirable and undesirable effects of a test (including direct effects, such as adverse effects from invasive tests, and indirect effects, resulting from management decisions based on the test results).

Organisations may want to tailor the criteria that they use. For example, guideline developers may have assessed the priority of problems before making recommendations and therefore might elect not to include the priority of the problem as a criterion. Conversely, some organisations, due to their mandate, might elect to consider a factor separately as an additional criterion rather than as a detailed judgment for a broader criterion. For example, autonomy and other ethical considerations are included as detailed judgments under acceptability in EtD frameworks. However, an organisation might elect to consider autonomy as a separate criterion, rather than as a detailed judgment under acceptability. Table 2 shows other criteria that we have incorporated as detailed judgments, which some organisations might want to consider as separate criteria.

Table 2

Detailed judgments in Evidence to Decision (EtD) frameworks

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A key feature of the EtD frameworks, like other GRADE-DECIDE presentations,32 is that they are layered; that is, they present key messages in the top layer with links to more detailed information. For example, the frameworks include concise summaries of the most important research evidence for each criterion (appendix 2). Typically, this is summarised in a table or a paragraph of text. From the framework, it is possible to link to information that is more detailed - for example, an evidence profile 15 or an interactive Summary of Findings table ( and from there to even more detailed information, such as a systematic review. This helps to structure discussions, ensure that there is a shared understanding of the key findings of the research that informs each judgment, and avoids problems that sometimes arise when panel members receive large piles of documents without concise summaries. It also makes it easier for panel members and users of recommendations, when needed, to dig deeper into the supporting evidence.

Drawing conclusions

Drawing conclusions begins with the panel reviewing the judgments they have made for all of the criteria in their assessment and considering the implications of those judgments for the recommendation or decision. Based on their assessment, the panel draws conclusions about the strength of recommendation or type of decision; for example, a strong or weak (sometimes called conditional, discretionary, or qualified) recommendation for or against an intervention or option. In addition, the panel states the recommendation or decision in a concise, clear and actionable manner,18 and provides the justification for their recommendation or decision. The conclusions also include relevant considerations about subgroups, implementation, monitoring and evaluation, and research priorities (see box 3 for the conclusions reached in the bedaquiline example).

Box 3: Evidence to Decision (EtD) framework—Drawing conclusions section

In multidrug-resistant tuberculosis (MDR-TB) patients, should bedaquiline be added to a background regimen based on WHO-recommendations?*
  1. The Expert Group Panel suggests that bedaquiline may be added to a WHO recommended regimen in MDR-TB adult patients under the following conditions [interim conditional recommendation, very low confidence in estimates of effect]:

    • An effective treatment regimen containing four recommended second line drugs from the different classes of drugs according to WHO-recommendations cannot be designed

    • There is documented evidence of resistance to any fluoroquinolone in addition to multiple drug resistance

    • Bedaquiline should be used for a maximum duration of six months and at suggested dosing (400 mg daily for the first 2 weeks, followed by 200 mg three times per week for the remaining 22 weeks)

    • Bedaquiline should be used with caution in people with HIV infection, as well as in patients with comorbidities (such as diabetes) or people with drug or alcohol misuse, because of limited or no information

    • Bedaquiline must not be added alone to a failing regimen.

  • The panel formulated a conditional recommendation for a specific subpopulation that can be implemented only under very specific circumstances. The recommendation is also provisional as the panel decided to revise it in 2015 or earlier if substantial data become available increasing the knowledge on safety, toxicity, and efficacy (such as post-marketing studies, ongoing trials and studies). The panel thought that, given the uncertainty about the benefits and harms, only patients with extensive drug resistance tuberculosis would be willing to accept a treatment such as bedaquiline.

  • The panel judged that the impact on culture conversion was large enough to outweigh the harms for most patients. However, the panel had a low level of confidence in using the available data for global decision making and could not reach consensus on the overall balance of harms and benefits. It proceeded to a vote (observers and technical resources consultants were excluded). The results were as follows: 10 votes that benefits outweighed harms; 4 votes that harms outweighed the benefits; and 2 abstentions (including the chair).

Detailed justification
  • Undesirable effects—In patients taking bedaquiline, compared with background treatment for MDR-TB, death and serious adverse effects were more common (10 more per 100 patients (from 0 to 89 more) and 5 more per 100 patients (from 0 to 25 more)).

  • Values—Treatment success, serious adverse events, and mortality were considered important to patients whereas time to conversion, culture conversion, and resistance were less so. Patients with newly diagnosed and proven MDR-TB are unlikely to accept the risk of taking a new drug with potential increase in mortality. The likelihood that patients would accept an effective treatment regimen would depend on the presence of MDR-TB—such as extensively drug-resistant (XDR) or pre-XDR tuberculosis. For this subpopulation there is possibly important uncertainty or variability.

  • Certainty of the evidence—The overall certainty was low given that the available evidence was limited. There were concerns about imprecision and indirectness due to small sample size, the use of modified intention-to-treat (that is, not intention-to-treat) analysis, and the low quality of evidence for the background MDR-TB treatment regimens used in the trial.

Subgroup considerations
  • The likelihood that patients would accept an effective treatment regimen would depend on subgroups of the MDR-TB population: for example, pre-XDR or XDR patient groups may be more likely to accept the risk of taking a new drug with potential increase in mortality than patients with newly diagnosed and proven MDR-TB.

Implementation considerations
  • A duly informed decision-making-process by patients should be followed.

  • Clinical monitoring and management of comorbidities (especially cardiac and liver disease) should be in place.

  • Spontaneous reporting of adverse drug reactions is reinforced at country level, and active pharmacovigilance is established among patient groups treated with the drug.

Monitoring and evaluation considerations
  • Resistance to other anti-TB drugs should be monitored following WHO recommendations

  • In the absence of a specific bedaquiline drug susceptibility test (DST) assay, resistance to bedaquiline should be monitored through assessment of Minimum Inhibitory Concentrations (MICs).

  • Baseline testing and monitoring for QT prolongation and development of arrhythmia is imperative.

  • Monitor resistance to bedaquiline through assessment of MIC in the absence of a specific bedaquiline DST assay.

  • Concerns on scale-up due to costs and/or local regulatory constraints.

Research priorities
  • Phase 3 clinical trial(s) of safety and efficacy of bedaquiline, with particular attention to mortality (including causes of death), in the treatment of MDR-TB should be accelerated

  • Development of a reliable test for bedaquiline resistance.

  • Pharmacokinetics, safety, and efficacy studies in specific populations (children, HIV patients, alcohol and drug misusers, elderly, pregnant women, diabetics, and people with extrapulmonary TB).

  • Well designed safety studies events (short and long term), including type, frequency, and severity of adverse events.

  • Drug-drug interactions, including with existing and other newly developed anti-TB drugs and antiretroviral drugs.

  • Mortality (including cause of death).

  • Acquisition of resistance to bedaquiline and to other anti-TB drugs.

  • Duration and dosing of treatment.

  • Patient acceptability.

  • Further research on the validity of culture conversion as a surrogate marker of treatment outcome.

Guideline panels may be reluctant to make a recommendation for or against an intervention or option. Panels should not fail to make a recommendation simply because different people would make different choices. Indeed, that is a defining feature when making a weak recommendation. However, one reason for not recommending for or against an intervention or option is that the pros and cons of the intervention or option and the comparison are so closely balanced that the panel is not prepared to make a weak recommendation in one direction or the other. Another possible reason is that there is so much uncertainty that the panel concludes that a recommendation either for or against the intervention or option would be speculative.17 18 19

The types of recommendations or decisions that are appropriate vary. For example, strong and weak recommendations are appropriate for clinical recommendations and these different types of recommendations have clear implications for clinicians and patients.17 18 19 The WHO panel, for example, developed an interim recommendation regarding bedaquiline that was conditional because the certainty of the evidence was very low and because it is recommended only under specific conditions (box 3).

It is not, however, possible to make a strong or weak coverage, health system, or public health decision. For example, an intervention is either covered or it is not, although there can be caveats to coverage. Types of coverage decisions that are possible include not covering an intervention, coverage only in the context of research,33 covering it with price negotiation, restricted coverage, and full coverage.

The justification for a recommendation or decision should flow from the judgments that the panel made in relation to the criteria used in the assessment. A detailed justification can elaborate on the panel’s thinking for the key criteria that drove their recommendation or decision, as illustrated with the bedaquiline example (an adapted version of a WHO recommendation) in box 3. The panel’s conclusions about subgroup considerations should specify which subgroups the panel considered and how those considerations affected their recommendation. If the panel’s judgments (and the research evidence or additional considerations that informed those judgments) and their conclusions for a subgroup are very different from the overall assessment, the panel can elect to present a separate EtD framework for the subgroup.

Conclusions about implementation considerations should specify key concerns about the feasibility and acceptability of the intervention and strategies to address those concerns, as well as any important information about how to implement the intervention, particularly for complex interventions. Conclusions about monitoring and evaluation should include suggestions for which, if any, indicators should be monitored and any evaluation that is needed in connection with implementing the recommendation or decision. This is particularly relevant for health system and public health decisions and recommendations. Finally, having reviewed and assessed the evidence, panels should identify research priorities to address any important uncertainties or gaps in the research evidence that informed their judgments.

How are EtD frameworks prepared and used by panels and users of recommendations

Technical teams or others with relevant expertise should generally prepare EtD frameworks. Expertise should typically include an understanding of appropriate systematic review methods,34 the GRADE system,13 14 and the clinical, health system, or public health topic. The GRADEPro Guideline Development Tool (GRADEPro GDT) (, the interactive EtD (, and the interactive Summary of Findings (iSoF; are free, web based software solutions for preparing and using interactive EtD frameworks. The iEtD and iSoF are also integrated in other alternative authoring and publication tools such as MAGIC (Making GRADE the Irresistible Choice; These tools facilitate collaborative preparation and management of EtD frameworks by technical teams and the use of EtD frameworks by panels. They also support the dissemination of information derived from the frameworks to target audiences, including preparation of presentations tailored to clinicians, patients and the public, or policy makers in different formats. GRADEpro also has an all-in-one web solution for managing, summarising, and presenting information for healthcare decision making and developing guidelines. As part of this functionality, GRADEPro GDT supports creating evidence profiles and Summary of Findings (SoF) tables,15 and it facilitates the development of clinical practice guidelines. GRADEpro also contains a growing database of evidence profiles and evidence to decision frameworks (

EtD frameworks can also be used by guideline developers to adapt recommendations to specific contexts or can be used by decision makers deciding whether to implement a recommendation in their setting. “Recommendation to decision (RtD)” presentations can facilitate this process, as illustrated for the bedaquiline example in appendix 3 (an adapted version of a WHO recommendation). These presentations can be generated by the iEtD. Clinicians and other users of recommendations can use the frameworks to systematically review recommendations and decide whether they are applicable to their setting or to particular patients.

Final remarks and future developments

Over the past 15 years the GRADE Working Group has established criteria for moving from evidence to recommendations. These criteria have been applied in numerous clinical and public health guidelines, and their use has increased transparency in guidelines and provided a structured approach for determining the direction and strength of a recommendation. EtD frameworks are an evolution of this approach to making recommendations.

Advantages of EtD frameworks compared with less structured approaches used in guideline development and decision making include:

  • Rigorous development by a wide international multidisciplinary group

  • Transparent process for moving from evidence to recommendations or decisions

  • Explicit consideration of how much outcomes are valued by those affected by a decision

  • Use of a layered approach by panels and in disseminating recommendations or decisions.

The EtD frameworks differ from the earlier versions of GRADE Evidence to Recommendation tables17 18 19 in several ways. They incorporate new criteria and require more explicit and structured summaries of evidence to address each criterion, beyond summaries of findings for the effects of interventions.14 They address coverage, health system, and public health decisions, as well as recommendations, and they facilitate decision making based on recommendations. They require panels to specify the perspective they are taking and differences in their judgments for specific criteria for relevant subgroups. They provide a more detailed structure that can help to facilitate panel discussions, make discussions more efficient, and clarify the research evidence used to inform discussions; and they help ensure that recommendations and decisions flow from judgments about relevant criteria and make the basis for recommendations more transparent.

A potential limitation of EtD frameworks is their increased complexity compared with the previous GRADE Evidence to Recommendation tables. Because healthcare decisions are complex, any system for moving from evidence to decisions requires a balance between simplicity and full transparent consideration of all the important factors. Although EtD frameworks are more complex than the previous approach suggested by the GRADE Working Group for making judgments about the strength of recommendations,17 18 19 they add clarity and make the judgments underlying a decision more explicit. Moreover, we have found that, once the question has been formulated and evidence searched for and summarised, the process of reaching decisions using EtD frameworks does not add substantial amounts of time to the decision making process. Nevertheless, as with the use of other methods, mastering the use of EtD frameworks requires familiarisation and practice.

Ideally, research evidence should be used to inform judgments about each criterion in EtD frameworks. However, often research evidence will be lacking or organisations will have limited resources to find and systematically review all of the relevant evidence. EtD frameworks explicitly show what, if any, research evidence was used to inform each judgment and, if no research evidence was available, what considerations were made. Organisations can tailor the criteria that they use and might elect not to use some criteria. However, all of the criteria included in the EtD frameworks can sometimes be critical for a decision. Therefore, we suggest that organisations wanting to reduce the number of criteria, should first consider the implications of doing so. For example, if a guideline developer elects not to include criteria related to resource use, it is then either making implicit judgments about resource use or leaving it up to users of their guidelines to consider resource use when deciding whether to adhere to their recommendations.

We have put substantial effort into both identifying a comprehensive set of criteria and making the frameworks as simple as possible. As with all aspects of the GRADE system, we will continue to monitor and evaluate the use of EtD frameworks in practice and, if needed, refine the criteria that are included in each of the frameworks or other aspects of the frameworks.

The use of multiple criteria in making healthcare recommendations or decisions, and the use of evidence that goes beyond evidence of effectiveness and cost effectiveness are not new.1 2 3 4 35 36 37 38 Some have argued for the use of multiple criteria decision analysis (MCDA) (using mathematical models) in health technology assessment and coverage decisions.37 38 39 However, these models have rarely been used. The advantages and disadvantages of using MCDA compared with EtD frameworks are similar to the advantages and disadvantages of using a balance sheet approach compared with an economic evaluation.39 It might sometimes be desirable to use both, but few organisations are likely to have the resources to undertake MCDA, and there are many uncertainties regarding MCDA models and their role in informing these types of decisions.

EtD frameworks provide an approach to structured reflection that can help those making recommendations or decisions to be more systematic and explicit about the judgments that they make, the evidence used to inform each of those judgments, additional considerations, and the basis for their recommendations or decisions. For users of recommendations and those affected by decisions, EtD frameworks can help to ensure the trustworthiness of those recommendations or decisions, enable them to appraise the basis for recommendations or decisions, and facilitate adaptation of recommendations or decisions to their own contexts.


  • Members of the GRADE Working Group who contributed to writing this paper include: Pablo Alonso, Holger J Schünemann, Jenny Moberg, Romina Brignardello-Petersen, Elie Akl, Marina Davoli, Shaun Treweek, Reem Mustafa, Gabriel Rada, Sarah Rosenbaum, Angela Morelli, Gordon H Guyatt, Andrew D Oxman, Signes Flottorp, Gerald Gartlehner, Claire Glenton, Joerg Meerpohl, Elena Parmelli, Roger Stanev, Per Vandvik, Ilse Verstijnen, and Erik Von Elm Bjorn. We thank Roman Jaeschke for his comments and suggestions.

    We have obtained permission from the WHO to adapt the bedaquiline recommendation used as an example in this article.

  • Author contributions: PAC and ADO wrote the first draft of this manuscript and PAC, HS, JM, EA, RBP, MD, ST, RM, PV, JM, GHG, ADO, SF, GG, CG, JM, EP, RS, PV, IV, EVE contributed to the writing. All authors have read and commented on the results and conclusions in the manuscript, and have given written agreement of their authorship.

  • Funding: Work on this article has been partially funded by the European Commission FP7 Program (grant agreement 258583) as part of the DECIDE project. Sole responsibility lies with the authors; the European Commission is not responsible for any use that may be made of the information contained therein.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: support from the European Commission FP7 Program (grant agreement 258583); no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work. Authors are members of the GRADE Working Group and the DECIDE project. PAC is supported by a Miguel Servet investigator contract from the Instituto de Salud Carlos III (CPII15/0034).

  • Transparency: ADO affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.


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