Grading Tutorial

Grade of Recommendation Clarity of risk/benefit Quality of supporting evidence Implications

1A.

Strong recommendation. High quality evidence

Benefits clearly outweigh risk and burdens, or vice versa Consistent evidence from well performed randomized, controlled trials or overwhelming evidence of some other form. Further research is unlikely to change our confidence in the estimate of benefit and risk. Strong recommendation, can apply to most patients in most circumstances without reservation

1B.

Strong recommendation. Moderate quality evidence

Benefits clearly outweigh risk and burdens, or vice versa Evidence from randomized, controlled trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise), or very strong evidence of some other form. Further research (if performed) is likely to have an impact on our confidence in the estimate of benefit and risk and may change the estimate. Strong recommendation, likely to apply to most patients

1C.

Strong recommendation. Low quality evidence

Benefits appear to outweigh risk and burdens, or vice versa Evidence from observational studies, unsystematic clinical experience, or from randomized, controlled trials with serious flaws. Any estimate of effect is uncertain. Relatively strong recommendation; might change when higher quality evidence becomes available

2A.

Weak recommendation. High quality evidence

Benefits closely balanced with risks and burdens Consistent evidence from well performed randomized, controlled trials or overwhelming evidence of some other form. Further research is unlikely to change our confidence in the estimate of benefit and risk. Weak recommendation, best action may differ depending on circumstances or patients or societal values

2B.

Weak recommendation. Moderate quality evidence

Benefits closely balanced with risks and burdens, some uncertainly in the estimates of benefits, risks and burdens Evidence from randomized, controlled trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise), or very strong evidence of some other form. Further research (if performed) is likely to have an impact on our confidence in the estimate of benefit and risk and may change the estimate. Weak recommendation, alternative approaches likely to be better for some patients under some circumstances

2C.

Weak recommendation. Low quality evidence

Uncertainty in the estimates of benefits, risks, and burdens; benefits may be closely balanced with risks and burdens Evidence from observational studies, unsystematic clinical experience, or from randomized, controlled trials with serious flaws. Any estimate of effect is uncertain. Very weak recommendation; other alternatives may be equally reasonable.

Grading Recommendations in UpToDate®

This tutorial was created for UpToDate authors, section editors, and peer reviewers, but it is available for anyone who wants to learn about GRADE. We expect it will take you about 30 minutes to complete.

Before you start, we suggest you print this Grading Table.

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