Grading quality of evidence and strength of recommendations in clinical practice guidelines

Part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions


Holger J. Schünemann MD PhD
Department of Clinical Epidemiology & Biostatistics
McMaster University Health Sciences Centre, Room 2C10B
1200 Main Street West Hamilton
ON L8N 3Z5


The GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach provides guidance to grading the quality of underlying evidence and the strength of recommendations in health care. The GRADE system’s conceptual underpinnings allow for a detailed stepwise process that defines what role the quality of the available evidence plays in the development of health care recommendations. The merit of GRADE is not that it eliminates judgments or disagreements about evidence and recommendations, but rather that it makes them transparent. This first article in a three-part series describes the GRADE framework in relation to grading the quality of evidence about interventions based on examples from the field of allergy and asthma. In the GRADE system, the quality of evidence reflects the extent to which a guideline panel’s confidence in an estimate of the effect is adequate to support a particular recommendation. The system classifies quality of evidence as high, moderate, low, or very low according to factors that include the study methodology, consistency and precision of the results, and directness of the evidence.