GRADE Series
GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations

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Abstract

This article describes the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to classifying the direction and strength of recommendations. The strength of a recommendation, separated into strong and weak, is defined as the extent to which one can be confident that the desirable effects of an intervention outweigh its undesirable effects. Alternative terms for a weak recommendation include conditional, discretionary, or qualified. The strength of a recommendation has specific implications for patients, the public, clinicians, and policy makers. Occasionally, guideline developers may choose to make “only-in-research” recommendations. Although panels may choose not to make recommendations, this choice leaves those looking for answers from guidelines without the guidance they are seeking. GRADE therefore encourages panels to, wherever possible, offer recommendations.

Introduction

What is new?

Key points

  1. The strength of a recommendation is defined as the extent to which one can be confident that the desirable consequences of an intervention outweigh its undesirable consequences.

  2. Grading of Recommendations Assessment, Development, and Evaluation GRADE has chosen a simple four-category classification of recommendations, a binary classification of recommendations as strong or weak (also known as conditional, discretionary, or qualified) recommendations for or against a management approach.

  3. The strength of a recommendation has specific implications for patients, the public, clinicians, and policy -makers.

In prior papers in this series devoted to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to systematic reviews and practice guidelines, we have dealt with the process before developing recommendations: framing the question [1], choosing critical and important outcomes [2], rating the confidence in effect estimates for each outcome [3], [4], [5], [6], [7], [8], [9], rating the confidence in effect estimates across outcomes [10], dealing with resource use [11], creating an evidence profile and a Summary of Findings (SoF) table [12], [13], and GRADE's approach to diagnostic test recommendations. This article addresses GRADE's approach to categorizing, labeling, and wording health care recommendations. As we did in the initial article in this series, we will define strong or weak recommendations for or against a particular management approach, and discuss the interpretation and presentation of these recommendations. In the next article in the series, we will focus on the process of going from the evidence to the recommendations. Throughout this article, we will refer to guideline developers as “the panel.”

Section snippets

Direction of recommendations

Panels make recommendations either for (when the desirable consequences outweigh the undesirable consequences) or against (when the opposite is true) a particular strategy, in relation to a comparator. With the GRADE approach, the desirable and undesirable consequences are the outcomes classified as “critical” and “important but not critical.” These outcomes are selected at the outset, confirmed when the results are reviewed, and presented in the evidence profile and SoF table.

In almost all

What GRADE means by strong and weak recommendations—for clinicians and patients

Using the GRADE approach, guideline authors make a strong recommendation when they believe that all or almost all informed people would make the recommended choice for or against an intervention. Consider, for example, the recommendation to take supplemental folate before and during the pregnancy. High-quality evidence suggests folate prevents neural tube defects, a catastrophic outcome of pregnancy [19], [20]. Folate is inexpensive and has no proven adverse effects. Because the desirable

Transparent values and preferences

In this section, we deal with the explicit and transparent presentation of the values and preferences underlying recommendations (Box 2). In the next article in the series, we deal with the sources of the values and preferences and how to use them in the process of making recommendations.

Ideally, guidelines will state foundational assumptions about the values and preferences that underlie their recommendations for the target population. For instance, a guideline addressing issues of thrombosis

Recommendations to use interventions only in research may be appropriate

Panels may face decisions about promising interventions associated with appreciable harms or costs and with insufficient evidence of benefit to support their use. They may be reluctant, on one hand, to recommend against such interventions out of fear that they will stifle further investigation. At the same time, they may worry about encouraging the rapid diffusion of potentially ineffective or harmful interventions, and preventing recruitment to research already under way, by providing

Conclusion

Guideline developers have used widely varying presentations of recommendations, and generally fail to specify the implications of recommendations for patients, clinicians, and policy makers. For instance, Hussain et al. [36] observed important variation in formulations of recommendations within and across guidelines. GRADE's approach to standardized terminology and presentation, and clear specification of the implications of strong and weak recommendations, addresses these shortcomings.

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The GRADE system has been developed by the GRADE Working Group. The named authors drafted and revised this article. A complete list of contributors to this series can be found on the JCE Web site.

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