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New Promise for Uniform Evidence-based Guideline Development: The GRADE Approach
By: Ned Calonge, MD, MPH

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system is gaining acceptance and prominence as a uniform and transparent approach to translating research evidence into recommendations (1). As more groups such as the World Health Organization (WHO), the American College of Physicians (ACP), and the British Medical Journal (BMJ) adopt this process, it is important to review the advantages and potential disadvantages of this important approach.

There are a number of different evidence grading and recommendation systems in use across the world (2, 3). In the United States, at least three nationally-vetted systems for reviewing evidence and developing recommendations in the area of preventive services have common origins and elements: the system used by the U.S. Preventive Services Task Force (USPSTF) (4), that used by the Centers for Disease Control and Prevention's Evaluation of Genomic Applications in Practice and Prevention Work Group (EGAPP) (5), and most recently, that adopted by the Department of Health and Human Services (DHHS) Secretary's Advisory Committee on Heritable Disorders of Newborns and Children (ACHDNC).

GRADE has definite advantages over all these. Notably, it is usable over a wider range of topic areas other than just screening and/or genetic testing and other preventive services, it can account for personal preferences and values, and it allows for the explicit consideration of resource use (1, 6-10). By comparison, the USPSTF process and its derivatives largely exclude preferences and values and pay only limited attention to costs and/or resource consumption. These GRADE additions are important enhancements that broaden the utility of the system. In addition, the GRADE process involves reporting on the evaluation of the quality of evidence and the rating of the strength of the recommendation separately, in a transparent fashion based on explicit criteria. While this is not unique to GRADE, the reports and recommendations using this system allow a reader to easily understand how the developers reached their decisions.

GRADE uses two related axes in the evaluation and translation of evidence: the quality of evidence and the strength of the resulting recommendation. The quality of the evidence is rated as high, moderate, low and very low (see Table 1). Explicit criteria are used to up- or down-grade evidence quality after accounting for study design, including consistency of results, directness of evidence, precision, and assessment of the source, direction and magnitude of potential bias.

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NGC - Expert Resources - Expert Commentary