Takaisin Tulosta

Grading the strength of recommendation

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Editors
17.12.2010

The strength of a recommendation reflects the extent to which we can be confident that desirable effects of an intervention outweigh undesirable effects. GRADE classifies recommendations as strong or weak.

  • Strong recommendations mean that most informed patients would choose the recommended management and that clinicians can structure their interactions with patients accordingly
  • Weak recommendations mean that patients’ choices will vary according to their values and preferences, and clinicians must ensure that patients’ care is in keeping with their values and preferences

Strength of recommendation is determined by the balance between desirable and undesirable consequences of alternative management strategies, quality of evidence, variability in values and preferences, and resource use (see Table)

Table 1. Determinants of strength of recommendation
Factor Comment
Balance between desirable and undesirable effects The larger the difference between the desirable and undesirable effects, the higher the likelihood that a strong recommendation is warranted. The narrower the gradient, the higher the likelihood that a weak recommendation is warranted
Quality of evidence The higher the quality of evidence, the higher the likelihood that a strong recommendation is warranted
Values and preferences The more values and preferences vary, or the greater the uncertainty in values and preferences, the higher the likelihood that a weak recommendation is warranted
Costs (resource allocation) The higher the costs of an intervention — that is, the greater the resources consumed — the lower the likelihood that a strong recommendation is warranted

The implications of a strong recommendation are:

  • For patients — most people in your situation would want the recommended course of action and only a small proportion would not; request discussion if the intervention is not offered
  • For clinicians — most patients should receive the recommended course of action
  • For policy makers — the recommendation can be adopted as a policy in most situations.

The implications of a weak recommendation are:

  • For patients — most people in your situation would want the recommended course of action, but many would not
  • For clinicians — you should recognise that different choices will be appropriate for different patients and that you must help each patient to arrive at a management decision consistent with her or his values and preferences
  • For policy makers — policy making will require substantial debate and involvement of many stakeholders.

Source: Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, Schünemann HJ, GRADE Working Group. Going from evidence to recommendations. BMJ 2008 May 10;336(7652):1049-51 «PMID: 18467413»PubMed.

GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group «http://www.gradeworkinggroup.org»1