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From the Departments of Medicine and of Social and Preventive Medicine, University of Buffalo, Buffalo, NY (Schünemann); the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. (Schünemann); the Division of General Pediatrics, Children's National Medical Center, Washington, DC (Best); and the Department of Health Services Research, Norwegian Directorate for Health and Social Welfare, Oslo, Norway (Vist, Oxman)Members of the GRADE Working Group : David Atkins, Chief Medical Officer, Center for Practice and Technology Assessment, Agency for Healthcare Research and Quality, USA; Dana Best, Assistant Professor, Department of General Pediatrics and Adolescent Medicine, George Washington University, Children's National Medical Center, USA; Peter A Briss, Acting Chief Community Guide Branch, Centers for Disease Control and Prevention, USA; Martin Eccles, Professor, and James Mason, Professor, Centre for Health Services Research, University of Newcastle upon Tyne, U.K.; Yngve Falck-Ytter, Associate Director, German Cochrane Centre, Institute for Medical Biometry and Medical Informatics, University Hospital Freiburg, Germany; Gunn E. Vist, Researcher, Signe Flottorp, Researcher, and Andrew D. Oxman, Director, Department of Health Services Research, Norwegian Directorate for Health and Social Welfare, Norway; Gordon H. Guyatt, Professor, and Roman Jaeschke, Associate Clinical Professor, Departments of Clinical Epidemiology and Biostatistics and Medicine, McMaster University, Canada; Robin T. Harbour, Quality and Information Director, Scottish Intercollegiate Guidelines Network, United Kingdom; Margaret C. Haugh, Methodologist, Fédération Nationale des Centres de Lutte Contre le Cancer, France; David Henry, Professor and Suzanne Hill, Senior Lecturer, Department of Clinical Pharmacology, Faculty of Medicine and Health Sciences, University of Newcastle, Australia; Gillian Leng, Guidelines Programme Director, National Institute for Clinical Excellence, United Kingdom; Alessandro Liberati, Professor, Università di Modena e Reggio Emilia and Centro per la Valutazione della Efficacia della Assistenza Sanitaria, Italy; Nicola Magrini, Director, Centro per la Valutazione della Efficacia della Assistenza Sanitaria, Italy; Philippa Middleton, Honorary Research Fellow, Australasian Cochrane Centre, Australia; Jacek Mrukowicz, Executive Director, Polish Institute for Evidence Based Medicine, Poland; Dianne O'Connell, Senior Epidemiologist, Cancer Epidemiology Research Unit, Cancer Research and Registers Division, The Cancer Council, Australia; Bob Phillips, Associate Fellow, Centre for Evidence-based Medicine, University Department of Psychiatry, Warneford Hospital, United Kingdom; Holger J Schünemann, Assistant Professor, Departments of Medicine and of Social & Preventive Medicine, University of Buffalo, USA; Tessa Tan-Torres Edejer, Medical Officer/Scientist, Global Programme on Evidence for Health Policy, World Health Organisation, Switzerland; Helena Varonen, Associate Editor, Finnish Medical Society Duodecim, Finland; John W. Williams Jr., Associate Professor, The Center for Health Services Research in Primary Care, Health Services Research and Development, Department of Veterans Affairs Medical Center and Duke University Medical Center, USA; Stephanie Zaza, Acting Associate Director for Science, Epidemiology Program Office, Centers for Disease Control and Prevention, USA
Correspondence to: Dr. Holger J. Schünemann, Departments of Medicine and of Social and Preventive Medicine, University of Buffalo, 270 Farber Hall, 3435 Main St., Buffalo NY 14214, USA; fax 716-898-4493; hjs{at}buffalo.edu
Abstract
THE GRADE WORKING GROUP IS DEVELOPING and evaluating a common, sensible approach to grading quality of evidence and strength of recommendations in health care. In this article, we discuss the advantages and disadvantages of using letters, numbers, symbols or words to represent grades of evidence and recommendations. Using multiple strategies, we searched for comparative studies of alternative ways of representing ordered categories in any context. In addition, we contacted experts and reviewed theoretical work and qualitative research on how best to communicate grades of any kind quickly and clearly. We were unable to identify health care research that addressed, either directly or indirectly, the best way to present grades of evidence and recommendations. We found examples of symbols used by government, commercial and consumer organizations to communicate quality of evidence or strength of recommendations, but no comparative studies. Although a number of grading systems are used in health care and other fields, there is little or no evidence of how well various presentations are understood. Before promoting the use of specific symbols, numbers, letters or words, the extent to which the intended message is comprehended should be evaluated.
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