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Disseminating quality controlled scientific knowledge

Systems for grading the quality of evidence and the strength of recommendations I: Critical appraisal of existing approaches The GRADE Working Group

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Author(s): Atkins David | Eccles Martin | Flottorp Signe | Guyatt Gordon | Henry David | Hill Suzanne | Liberati Alessandro | O'Connell Dianne | Oxman Andrew | Phillips Bob | Sch√ľnemann Holger | Edejer Tessa | Vist Gunn | Williams John

Journal: BMC Health Services Research
ISSN 1472-6963

Volume: 4;
Issue: 1;
Start page: 38;
Date: 2004;
Original page

Keywords: evidence-based health care | levels of evidence | practice guidelines | strength of recommendation | systematic reviews

ABSTRACT
Abstract Background A number of approaches have been used to grade levels of evidence and the strength of recommendations. The use of many different approaches detracts from one of the main reasons for having explicit approaches: to concisely characterise and communicate this information so that it can easily be understood and thereby help people make well-informed decisions. Our objective was to critically appraise six prominent systems for grading levels of evidence and the strength of recommendations as a basis for agreeing on characteristics of a common, sensible approach to grading levels of evidence and the strength of recommendations. Methods Six prominent systems for grading levels of evidence and strength of recommendations were selected and someone familiar with each system prepared a description of each of these. Twelve assessors independently evaluated each system based on twelve criteria to assess the sensibility of the different approaches. Systems used by 51 organisations were compared with these six approaches. Results There was poor agreement about the sensibility of the six systems. Only one of the systems was suitable for all four types of questions we considered (effectiveness, harm, diagnosis and prognosis). None of the systems was considered usable for all of the target groups we considered (professionals, patients and policy makers). The raters found low reproducibility of judgements made using all six systems. Systems used by 51 organisations that sponsor clinical practice guidelines included a number of minor variations of the six systems that we critically appraised. Conclusions All of the currently used approaches to grading levels of evidence and the strength of recommendations have important shortcomings.
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