GRADE guidelines: 15. Going from evidence to recommendation—determinants of a recommendation's direction and strength

      Abstract

      In the GRADE approach, the strength of a recommendation reflects the extent to which we can be confident that the composite desirable effects of a management strategy outweigh the composite undesirable effects.
      This article addresses GRADE's approach to determining the direction and strength of a recommendation. The GRADE describes the balance of desirable and undesirable outcomes of interest among alternative management strategies depending on four domains, namely estimates of effect for desirable and undesirable outcomes of interest, confidence in the estimates of effect, estimates of values and preferences, and resource use. Ultimately, guideline panels must use judgment in integrating these factors to make a strong or weak recommendation for or against an intervention.

      Keywords

      To read this article in full you will need to make a payment

      References

        • Guyatt G.
        • Oxman A.
        • Kunz R.
        • Atkins D.
        • Brozek J.
        • Vist G.
        • et al.
        GRADE guidelines: 2. Framing the question and deciding on important outcomes.
        J Clin Epidemiol. 2011; 64: 395-400
        • Balshem H.
        • Helfand M.
        • Schunemann H.J.
        • Oxman A.D.
        • Kunz R.
        • Brozek J.
        • et al.
        GRADE guidelines: 3. Rating the quality of evidence.
        J Clin Epidemiol. 2011; 64: 401-406
        • Guyatt G.H.
        • Oxman A.D.
        • Vist G.
        • Kunz R.
        • Brozek J.
        • Alonso-Coello P.
        • et al.
        GRADE guidelines: 4. Rating the quality of evidence—study limitations (risk of bias).
        J Clin Epidemiol. 2011; 64: 407-415
        • Guyatt G.H.
        • Oxman A.D.
        • Montori V.
        • Vist G.
        • Kunz R.
        • Brozek J.
        • et al.
        GRADE guidelines: 5. Rating the quality of evidence-publication bias.
        J Clin Epidemiol. 2011; 64: 1277-1282
        • Guyatt G.
        • Oxman A.D.
        • Kunz R.
        • Brozek J.
        • Alonso-Coello P.
        • Rind D.
        • et al.
        GRADE guidelines 6. Rating the quality of evidence—imprecision.
        J Clin Epidemiol. 2011; 64: 1283-1293
        • Guyatt G.H.
        • Oxman A.D.
        • Kunz R.
        • Woodcock J.
        • Brozek J.
        • Helfand M.
        • et al.
        GRADE guidelines: 7. Rating the quality of evidence-inconsistency.
        J Clin Epidemiol. 2011; 64: 1294-1302
        • Guyatt G.H.
        • Oxman A.D.
        • Kunz R.
        • Woodcock J.
        • Brozek J.
        • Helfand M.
        • et al.
        GRADE guidelines: 8. Rating the quality of evidence-indirectness.
        J Clin Epidemiol. 2011; 64: 1303-1310
        • Guyatt G.H.
        • Oxman A.D.
        • Sultan S.
        • Glasziou P.
        • Akl E.A.
        • Alonso-Coello P.
        • et al.
        GRADE guidelines: 9. Rating up the quality of evidence.
        J Clin Epidemiol. 2011; 64: 1311-1316
        • Brunetti M.
        • Shemilt I.
        • Pregno S.
        • Vale L.
        • Oxman A.
        • Lord J.
        • et al.
        GRADE guidelines: 10. Considering resource use and rating the quality of economic evidence.
        J Clin Epidemiol. 2013; 66: 140-150
        • Guyatt G.H.
        • Oxman A.D.
        • Sultan S.
        • Brozek J.
        • Glasziou P.
        • Alonso-Coello P.
        • et al.
        GRADE guidelines: 11. Making an overall rating of confidence in effect estimates for a single outcome and for all outcomes.
        J Clin Epidemiol. 2013; 64: 151-157
        • Guyatt G.H.
        • Oxman A.D.
        • Santesso N.
        • Helfand M.
        • Vist G.
        • Kunz R.
        • et al.
        GRADE guidelines: 12. Preparing summary of findings tables: binary outcomes.
        J Clin Epidemiol. 2013; 66: 158-172
        • Guyatt G.H.
        • Thorlund K.
        • Oxman A.D.
        • Walter S.
        • Patrick D.
        • Furukawa T.A.
        • et al.
        GRADE guidelines: 13. Preparing summary of findings tables: continuous outcomes.
        J Clin Epidemiol. 2013; 66: 173-183
        • Guyatt G.
        • Oxman A.
        • Akl E.
        • Kunz R.
        • Vist G.
        • Brozek J.
        • et al.
        GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables.
        J Clin Epidemiol. 2011; 64: 383-394
        • Andrews J.
        • Guyatt G.
        • Oxman A.D.
        • Alderson P.
        • Dahm P.
        • Falck-Ytter Y.
        • et al.
        GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations.
        J Clin Epidemiol. 2013; 66: 719-725
        • Eisenberg J.M.
        Globalize the evidence, localize the decision: evidence-based medicine and international diversity.
        Health Aff (Millwood). 2002; 21: 166-168
        • Schunemann H.J.
        • Woodhead M.
        • Anzueto A.
        • Buist S.
        • Macnee W.
        • Rabe K.F.
        • et al.
        A vision statement on guideline development for respiratory disease: the example of COPD.
        Lancet. 2009; 373: 774-779
        • Montori V.
        • Devereaux P.
        • Straus S.
        • Haynes B.
        • Guyatt G.
        Decision making and the patient.
        in: Guyatt G. The users' guides to the medical literature: a manual for evidence-based clinical practice. 2nd ed. McGraw-Hill, New York, NY2008
        • McLean S.
        • Mulla S.
        • Akl E.A.
        • Jankowski M.
        • Vandvik P.
        • Ibrahim S.
        • et al.
        Patient values and preferences in decision making for antithrombotic therapy: a systematic review. Antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest physicians Evidence-Based Clinical Practice Guidelines.
        Chest. 2012; 141: e1S-e23S
        • Pottie K.
        • Greenaway C.
        • Feightner J.
        • Welch V.
        • Swinkels H.
        • Rashid M.
        • et al.
        Evidence-based clinical guidelines for immigrants and refugees.
        CMAJ. 2011; 183: E824-E925
        • Bates S.
        • Greer I.
        • Middeldorp S.
        • Veenstra D.
        • Prabulos A.
        • Vandvik P.
        • et al.
        VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest physicians Evidence-Based Clinical Practice Guidelines.
        Chest. 2012; 141: e691S-e736S
        • Goodman S.G.
        • Menon V.
        • Cannon C.P.
        • Steg G.
        • Ohman E.M.
        • Harrington R.A.
        Acute ST-segment elevation myocardial infarction: American College of Chest physicians evidence-based clinical practice guidelines (8th Edition).
        Chest. 2008; 133: 708S-775S
        • Webster A.
        • Woodroffe R.
        • Taylor R.
        • Chapman J.
        • Craig J.
        Tacrolimus versus cyclosporin as primary immunosuppression for kidney transplant recipients.
        Cochrane Database Syst Rev. 2006; 4: CD003961
        • Devereaux P.J.
        • Anderson D.R.
        • Gardner M.J.
        • Putnam W.
        • Flowerdew G.J.
        • Brownell B.F.
        • et al.
        Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study.
        BMJ. 2001; 323: 1218-1222
      1. Guidelines for counseling postmenopausal women about preventive hormone therapy. American College of Physicians.
        Ann Intern Med. 1992; 117: 1038-1041
        • Hulley S.
        • Grady D.
        • Bush T.
        • Furberg C.
        • Herrington D.
        • Riggs B.
        • et al.
        Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group.
        JAMA. 1998; 280: 605-613
        • Rossouw J.E.
        • Anderson G.L.
        • Prentice R.L.
        • LaCroix A.Z.
        • Kooperberg C.
        • Stefanick M.L.
        • et al.
        Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial.
        JAMA. 2002; 288: 321-333
        • Chapman S.W.
        • Dismukes W.E.
        • Proia L.A.
        • Bradsher R.W.
        • Pappas P.G.
        • Threlkeld M.G.
        • et al.
        Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America.
        Clin Infect Dis. 2008; 46: 1801-1812
        • Lauenstein T.C.
        • Semelka R.C.
        Emerging techniques: whole-body screening and staging with MRI.
        J Magn Reson Imaging. 2006; 24: 489-498
        • Malfertheiner P.
        • Megraud F.
        • O'Morain C.
        • Bazzoli F.
        • El-Omar E.
        • Graham D.
        • et al.
        Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report.
        Gut. 2007; 56: 772-781
        • Magee L.A.
        • Helewa M.
        • Moutquin J.M.
        • van Dadelszen P.
        • for the Hypertension Guideline Committee
        Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. SOGC Clinical Practice Guideline, No. 206, March 2008.
        J Obstet Gynaecol Can. 2008; 30: S1-S48
        • Bhasin S.
        • Cunningham G.
        • Hayes F.
        • Matsumoto A.
        • Snyder P.
        • Swerdloff R.
        • et al.
        Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline.
        J Clin Endocrinol Metab. 2010; 95: 2536-2559
        • Schunemann H.J.
        • Hill S.R.
        • Kakad M.
        • Bellamy R.
        • Uyeki T.M.
        • Hayden F.G.
        • et al.
        WHO Rapid Advice Guidelines for pharmacological management of sporadic human infection with avian influenza A (H5N1) virus.
        Lancet Infect Dis. 2007; 7: 21-31
        • Kearon C.
        • Akl E.A.
        • Comerota A.J.
        • Prandoni P.
        • Bounameaux H.
        • Goldhaber S.Z.
        • et al.
        Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest physicians Evidence-Based Clinical Practice Guidelines.
        Chest. 2012; 141: e419S-e494S
      2. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2008; 149: 627-637
        • Levin B.
        • Lieberman D.A.
        • McFarland B.
        • Andrews K.S.
        • Brooks D.
        • Bond J.
        • et al.
        Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology.
        Gastroenterology. 2008; 134: 1570-1595
      3. Guidance on surveillance for people at increased risk of colorectal cancer. New Zealand Guidelines Group, Wellington, New Zealand2012
        • Tugwell P.
        • Pottie K.
        • Welch V.
        • Ueffing E.
        • Chambers A.
        • Feightner J.
        Evaluation of evidence-based literature and formulation of recommendations for the clinical preventive guidelines for immigrants and refugees in Canada.
        CMAJ. 2011; 183: E933-E938
        • Schunemann H.J.
        • Hill S.R.
        • Kakad M.
        • Vist G.E.
        • Bellamy R.
        • Stockman L.
        • et al.
        Transparent development of the WHO rapid advice guidelines.
        PLoS Med. 2007; 4: e119
        • Oxman A.D.
        • Glasziou P.
        • Williams Jr., J.W.
        What should clinicians do when faced with conflicting recommendations?.
        BMJ. 2008; 337: a2530
        • Georg G.
        • Colombet I.
        • Durieux P.
        • Menard J.
        • Meneton P.
        A comparative analysis of four clinical guidelines for hypertension management.
        J Hum Hypertens. 2008; 22: 829-837
        • Matthys J.
        • De Meyere M.
        • van Driel M.L.
        • De Sutter A.
        Differences among international pharyngitis guidelines: not just academic.
        Ann Fam Med. 2007; 5: 436-443
        • Kaafarani H.M.
        • Atluri P.V.
        • Thornby J.
        • Itani K.M.
        beta-Blockade in noncardiac surgery: outcome at all levels of cardiac risk.
        Arch Surg. 2008; 143 (discussion 944): 940-944
        • van Lier F.
        • Schouten O.
        • van Domburg R.T.
        • van der Geest P.J.
        • Boersma E.
        • Fleisher L.A.
        • et al.
        Effect of chronic beta-blocker use on stroke after noncardiac surgery.
        Am J Cardiol. 2009; 104: 429-433
        • Bangalore S.
        • Wetterslev J.
        • Pranesh S.
        • Sawhney S.
        • Gluud C.
        • Messerli F.H.
        Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis.
        Lancet. 2008; 372: 1962-1976