Intended for healthcare professionals

Research Methods & Reporting

GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines

BMJ 2016; 353 doi: (Published 30 June 2016) Cite this as: BMJ 2016;353:i2089
  1. Pablo Alonso-Coello, researcher1 2,
  2. Andrew D Oxman, senior researcher3,
  3. Jenny Moberg, researcher3,
  4. Romina Brignardello-Petersen, postdoctoral fellow and lecturer2 4,
  5. Elie A Akl, associate professor and director2 5,
  6. Marina Davoli, director6,
  7. Shaun Treweek, professor7,
  8. Reem A Mustafa, assistant professor2 8,
  9. Per O Vandvik, senior researcher3,
  10. Joerg Meerpohl, co-director9,
  11. Gordon H Guyatt, distinguished professor2 10,
  12. Holger J Schünemann, professor2 10,
  13. 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. 3Global Health Unit, Norwegian Institute of Public Health, Oslo, Norway
  4. 4Evidence Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago, Chile
  5. 5Department of Internal Medicine, Clinical Epidemiology Unit, American University of Beirut Medical Center, Beirut, Lebanon
  6. 6Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
  7. 7Health Services Research Unit, University of Aberdeen, Aberdeen, UK
  8. 8Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
  9. 9Cochrane Germany, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
  10. 10Department of Medicine, McMaster University, Hamilton, Canada
  1. Correspondence to: P Alonso-Coello palonso{at}

Summary points

  • Clinicians do not have the time or resources to consider the underlying evidence for the myriad decisions they must make each day and, as a consequence, rely on recommendations from clinical practice guidelines

  • Guideline panels should consider all the relevant factors (criteria) that influence a decision or recommendation in a structured, explicit, and transparent way and provide clinicians with clear and actionable recommendations

  • The GRADE working group has developed Evidence to Decision (EtD) frameworks for different types of decisions and recommendations.

  • The purpose of the Evidence to Decision (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. In this article we will describe EtD frameworks for clinical practice recommendations

  • The general structure of the EtD framework for clinical recommendations is similar to EtD frameworks for other types of recommendations and decisions, and includes formulation of the question, an assessment of the different criteria, and conclusions

  • Clinical recommendations require considering criteria differently, depending on whether an individual patient or a population perspective is taken. For example, from an individual patient’s perspective, out-of-pocket costs are an important consideration, whereas, from a population perspective, resource use (not only out-of-pocket costs) and cost effectiveness are important

  • From a population perspective, equity, acceptability, and feasibility are also important considerations, whereas the importance of these criteria is often limited from an individual patient perspective

  • Specific subgroups for which different recommendations may be required should be clearly identified and considered in relation to each criterion because judgments might vary across subgroups


Clinicians regularly face situations with two or more alternative actions. Each alternative often has different advantages and disadvantages, including differences in effectiveness, adverse effects, costs and other factors …

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