BMJ  2008;336:924-926 (26 April), doi:10.1136/bmj.39489.470347.AD

Analysis

Rating quality of evidence and strength of recommendations

GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

¹ Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada L8N 3Z5, ² Norwegian Knowledge Centre for the Health Services, PO Box 7004, St Olavs Plass, 0130 Oslo, Norway, ³ Basel Institute of Clinical Epidemiology, University Hospital Basel, Hebelstrasse 10, 4031 Basel, Switzerland, ⁴ Division of Gastroenterology, Case Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA, ⁵ Iberoamerican Cochrane Center, Servicio de Epidemiología Clínica y Salud Pública (Universidad Autónoma de Barcelona), Hospital de Sant Pau, Barcelona 08041, Spain , ⁶ Department of Epidemiology, Italian National Cancer Institute Regina Elena, Rome, Italy

Guidelines are inconsistent in how they rate the quality of evidence and the strength of recommendations. This article explores the advantages of the GRADE system, which is increasingly being adopted by organisations worldwide

The first 150 words of the full text of this article appear below.

Summary points Failure to consider the quality of evidence can lead to misguided recommendations; hormone replacement therapy for post-menopausal women provides an instructive example High quality evidence that an intervention’s desirable effects are clearly greater than its undesirable effects, or are clearly not, warrants a strong recommendation Uncertainty about the trade-offs (because of low quality evidence or because the desirable and undesirable effects are closely balanced) warrants a weak recommendation Guidelines should inform clinicians what the quality of the underlying evidence is and whether recommendations are strong or weak The Grading of Recommendations Assessment, Development and Evaluation (GRADE ) approach provides a system for rating quality of evidence and strength of recommendations that is explicit, comprehensive, transparent, and pragmatic and is increasingly being adopted by organisations worldwide

Guideline developers around the world are inconsistent in how they rate quality of evidence and grade strength of recommendations. As a result, guideline users face . . . [Full text of this article]

Box 1 Advantages of GRADE over other systems

What is "quality of evidence" and why is it important?

How should guideline developers alert clinicians to quality of evidence?

What is "strength of recommendation" and why is it important?

What makes a good grading system?

How does the GRADE system classify quality of evidence?

Box 2 Quality of evidence and definitions

How does the GRADE system consider strength of recommendation?

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