A guide to GRADE guidelines for the readers of JTH


  • Manuscript handled by: F. R. Rosendaal
  • Final decision: F. R. Rosendaal, 10 June 2013

Correspondence: John W. Eikelboom, Department of Medicine, McMaster University, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada.

Tel.: +1905 527 4322 ext 40323; fax: +1905 521 1551.

E-mail: eikelbj@mcmaster.ca


More than 70 organizations worldwide have adopted the GRADE methodology for guideline development. The ninth iteration of the American Collage of Chest Physicians guidelines (AT9) adopted structural and policy changes that resulted in a greater adherence to GRADE guidance than previous iterations. The most important of these changes include minimizing the impact of financial and intellectual conflict of interest, increasing the rigor of evidence evaluation, acknowledging uncertainty in estimates of typical values and preferences, and awareness of the large variability in values and preferences. One of the consequences of the greater adherence to GRADE methodology is an increase in weak vs. strong recommendations in AT9. The result of the GRADE process highlights the desirability of higher-quality evidence both regarding the outcomes of alternative management strategies and regarding the distribution of values and preferences in patients considering those alternatives. It also encourages shared decision making in encounters between physicians and patients. Although some physicians might find the uncertainty underlying medical practice discouraging or unsettling, relative to denying or obscuring the uncertainty, acknowledging and addressing the uncertainty will lead to more credible, realistic, and useful recommendations.