What is GRADE?

The Grading of Recommendations Assessment, Development and Evaluation (short GRADE) working group began in the year 2000 as an informal collaboration of people with an interest in addressing the shortcomings of grading systems in health care. The working group has developed a common, sensible and transparent approach to grading quality (or certainty) of evidence and strength of recommendations. Many international organizations have provided input into the development of the GRADE approach which is now considered the standard in guideline development.

Judgments about evidence and recommendations in healthcare are complex. For example, those making recommendations about whether or not to recommend a new generation of blood thinners for patients with irregular heart beat (atrial fibrillation) must agree on which outcomes to consider, which evidence to include for each outcome, how to assess the quality of that evidence, and how to determine if blood thinners do more good than harm. Because resources are always limited and money that is allocated to treating atrial fibrillation cannot be spent on other worthwhile interventions, they may also need to decide whether any incremental health benefits are worth the additional costs.

Systematic reviews of the effects of healthcare provide essential, but not sufficient information for making well informed decisions. Reviewers and people who use reviews draw conclusions about the quality of the evidence, either implicitly or explicitly. Such judgments guide subsequent decisions. For example, clinical actions are likely to differ depending on whether one concludes that the evidence that blood thinners reduces the risk of stroke in patients with atrial fibrillation is convincing (high quality) or that it is unconvincing (low quality).

Similarly, practice guidelines and people who use them draw conclusions about the strength of recommendations, either implicitly or explicitly. Using the same example, a guideline that recommends that patients with atrial fibrillation should be treated may suggest that all patients definitely should be treated or that patients should probably be treated, implying that treatment may not be warranted in all patients. A systematic and explicit approach to making judgments such as these can help to prevent errors, facilitate critical appraisal of these judgments, and can help to improve communication of this information.

One of the aims of the GRADE Working Group was to reduce unnecessary confusion arising from multiple systems for grading evidence and recommendations. To avoid adding to this confusion by having multiple variations of the GRADE system we suggest that the criteria below should be met when stating that the GRADE approach was used to assess evidence or develop recommendations. Also, while users may believe there may be good reasons for modifying the GRADE system, we discourage the use of "modified GRADE approaches" that differ from the approach described by the GRADE Working Group.

On the other hand, we encourage and welcome constructive criticism of the GRADE approach, suggestions for improvements, and involvement in the GRADE Working Group. As most scientific approaches to advancing healthcare, the GRADE approach will continue to evolve in response to new evidence and to meet the needs of systematic review authors, guideline developers and other users.

Suggested criteria for stating that the GRADE system was used (updated 2016-04; full pdf version with document history and references):

  1. The certainty in the evidence (also known as quality of evidence or confidence in the estimates) should be defined consistently with the definitions used by the GRADE Working Group.
  2. Explicit consideration should be given to each of the GRADE domains for assessing the certainty in the evidence (although different terminology may be used).
  3. The overall certainty in the evidence should be assessed for each important outcome using four or three categories (such as high, moderate, low and/or very low) and definitions for each category that are consistent with the definitions used by the GRADE Working Group.
  4. Evidence summaries and evidence to decision criteria should be used as the basis for judgments about the certainty in the evidence and the strength of recommendations. Ideally, evidence profiles should be used to assess the certainty in the evidence and these should be based on systematic reviews. At a minimum, the evidence that was assessed and the methods that were used to identify and appraise that evidence should be clearly described.
  5. Explicit consideration should be given to each of the GRADE criteria for determining the direction and strength of a recommendation or decision. Ideally, GRADE evidence to decision frameworks should be used to document the considered research evidence, additional considerations and judgments transparently.
  6. The strength of recommendations should be assessed using two categories (for or against an option) and definitions for each category such as strong and weak/conditional that are consistent with the definitions used by the GRADE Working Group (although different terminology may be used), such as strong.

Getting started

Browse our publications or learn hands-on. We'll get you started in no time.

Publications

A selected list of GRADE publications to get you started or to provide a deep-dive.

Quick

Want to quickly find out what GRADE is all about? We suggest reading our BMJ series. Please note that the online text is the longer, full version of the submitted manuscript. The pdf's on BMJ's website are abbreviated print issues. Start with GRADE: an emerging consensus on rating quality of evidence and strength of recommendations, followed by What is "quality of evidence" and why is it important to clinicians? and Going from evidence to recommendations. You can also learn more about how diagnostic tests and strategies or resource use are considered in GRADE.

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In-depth

The JCE series and the GRADE handbook in GRADEpro provide a guide for systematic review and health technology assessment authors, guideline panelists and methodologists on how to apply the GRADE methodology framework in more detail: GRADE evidence profiles, framing the question and deciding on important outcomes, rating the quality of evidence, risk of bias, publication bias, imprecision, inconsistency, indirectness, rating up, resource use, overall rating, Summary of Findings tables (binary) and (continues), presentation of recommendations, and recommendation's direction and strength.

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Get involved

A GRADE center or network serves as the primary hub within the region for GRADE related questions and for support and collaboration opportunities. The mission of GRADE centers/networks is to help the GRADE working group in the training, promotion, dissemination and implementation of GRADE. GRADE centers and networks develop effective actions to spread the use of GRADE methodology in health guidelines and systematic reviews through advocacy, training and support of guideline developers and review authors; provide methodological support to national, regional or professional organizations and guideline development programs; and conduct workshops and graduate courses on GRADE application, e.g., for health science students, trainees, and faculty members.

Organizations

More than 100 organizations from 19 countries around the world have endorsed or are using GRADE.

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  • Asia
  • Europe
  • International
  • North America
  • Oceania

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