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GRADE I Guyatt2008
GRADE I Guyatt2008
widely: the World Health Organization, the American Factors that affect the strength of a recommendation
College of Physicians, the American Thoracic Society,
Examples of weak
UpToDate (an electronic resource widely used in North Factor Examples of strong recommendations recommendations
America, www.uptodate.com), and the Cochrane Col-
Quality of evidence Many high quality randomised trials have Only case series have
laboration are among the more than 25 organisations shown the benefit of inhaled steroids in examined the utility of
that have adopted GRADE. This widespread adoption asthma pleurodesis in pneumothorax
of GRADE reflects GRADE’s success as a methodo- Uncertainty about the balance Aspirin in myocardial infarction Warfarin in low risk patients
logically rigorous, user friendly grading system. between desirable and undesirable reduces mortality with minimal toxicity, with atrial fibrillation results
effects inconvenience, and cost in small stroke reduction but
increased bleeding risk and
How does the GRADE system classify quality of substantial inconvenience
evidence? Uncertainty or variability in values Young patients with lymphoma will Older patients with lymphoma
To achieve transparency and simplicity, the GRADE and preferences invariably place a higher value on the life may not place a higher value
system classifies the quality of evidence in one of four prolonging effects of chemotherapy than on the life prolonging effects
on treatment toxicity of chemotherapy than on
levels—high, moderate, low, and very low (box 2). Some treatment toxicity
of the organisations using the GRADE system have cho-
Uncertainty about whether the The low cost of aspirin as prophylaxis The high cost of clopidogrel
sen to combine the low and very low categories. Evi- intervention represents a wise use against stroke in patients with transient and of combination
dence based on randomised controlled trials begins as of resources ischemic attacks dipyridamole and aspirin as
high quality evidence, but our confidence in the evidence prophylaxis against stroke
in patients with transient
may be decreased for several reasons, including: ischaemic attacks
• Study limitations
• Inconsistency of results
• Indirectness of evidence Summary points
• Imprecision Failure to consider the quality of evidence can lead to misguided recommendations;
• Reporting bias. 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
Although observational studies (for example, cohort undesirable effects, or are clearly not, warrants a strong recommendation
and case-control studies) start with a “low quality” Uncertainty about the trade-offs (because of low quality evidence or because the desirable
rating, grading upwards may be warranted if the and undesirable effects are closely balanced) warrants a weak recommendation
magnitude of the treatment effect is very large (such Guidelines should inform clinicians what the quality of the underlying evidence is and
as severe hip osteoarthritis and hip replacement), if whether recommendations are strong or weak
there is evidence of a dose-response relation or if all The Grading of Recommendations Assessment, Development and Evaluation (GRADE )
approach provides a system for rating quality of evidence and strength of recommendations
plausible biases would decrease the magnitude of an
that is explicit, comprehensive, transparent, and pragmatic and is increasingly being
apparent treatment effect. adopted by organisations worldwide