HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:
Guest Access | Sign In via User Name/Password

This Article Full Text Free Full Text (PDF) Free Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Article Archive Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (46) Citing Articles via Google Scholar Google Scholar Articles by Guyatt, G. Articles by Schünemann, H. Search for Related Content PubMed PubMed Citation Articles by Guyatt, G. Articles by Schünemann, H.

Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines^*

Report From an American College of Chest Physicians Task Force

^* From the Departments of Medicine, and Clinical Epidemiology and Biostatistics (Dr. Guyatt), McMaster University, Hamilton, ON, Canada; the Department of Medicine (Dr. Gutterman), Medical College of Wisconsin, Milwaukee, WI; the University of Mississippi Medical Center (Dr. Baumann), Jackson, MS; New York University School of Medicine (Dr. Addrizzo-Harris), New York, NY; the Department of Medicine (Dr. Hylek), Research Unit-Section of General Internal Medicine, Boston University School of Medicine, Boston, MA; the University of Kentucky College of Medicine (Dr. Phillips), Lexington, KY; College of Public Health (Dr. Raskob), University of Oklahoma Health Sciences Center, Oklahoma City, OK; the American College of Chest Physicians (Dr. Lewis), Northbrook, IL; and the Department of Clinical Epidemiology, Italian National Cancer Institute (Dr. Schünemann), Rome, Italy.

Correspondence to: Gordon Guyatt, MD, MSc, FCCP, Department of Clinical Epidemiology and Biostatistics, HSC-2C12, McMaster University, 1200 Main St West, Hamilton, ON, Canada L8N 3Z5; e-mail: guyatt{at}mcmaster.ca

Abstract

While grading the strength of recommendations and the quality of underlying evidence enhances the usefulness of clinical guidelines, the profusion of guideline grading systems undermines the value of the grading exercise. An American College of Chest Physicians (ACCP) task force formulated the criteria for a grading system to be utilized in all ACCP guidelines that included simplicity and transparency, explicitness of methodology, and consistency with current methodological approaches to the grading process. The working group examined currently available systems, and ultimately modified an approach formulated by the international GRADE group. The grading scheme classifies recommendations as strong (grade 1) or weak (grade 2), according to the balance among benefits, risks, burdens, and possibly cost, and the degree of confidence in estimates of benefits, risks, and burdens. The system classifies quality of evidence as high (grade A), moderate (grade B), or low (grade C) according to factors that include the study design, the consistency of the results, and the directness of the evidence. For all future ACCP guidelines, The College has adopted a simple, transparent approach to grading recommendations that is consistent with current developments in the field. The trend toward uniformity of approaches to grading will enhance the usefulness of practice guidelines for clinicians.

Key Words: grading recommendations • grading system • methodology

This article has been cited by other articles:

				P. J. Karanicolas, R. Kunz, and G. H. Guyatt Point: Evidence-Based Medicine Has a Sound Scientific Base Chest, May 1, 2008; 133(5): 1067 - 1071. [Full Text] [PDF]

				G. H. Guyatt, P. J. Karanicolas, and R. Kunz Rebuttal From Dr. Guyatt et al Chest, May 1, 2008; 133(5): 1074 - 1075. [Full Text] [PDF]

				D. Langer, T. Troosters, M. Decramer, and R. Gosselink Grading Recommendations: A Matter of Interpretation Chest, March 1, 2008; 133(3): 830 - 830. [Full Text] [PDF]

				K. E. Donahue, G. Gartlehner, D. E. Jonas, L. J. Lux, P. Thieda, B. L. Jonas, R. A. Hansen, L. C. Morgan, and K. N. Lohr Systematic Review: Comparative Effectiveness and Harms of Disease-Modifying Medications for Rheumatoid Arthritis Ann Intern Med, November 19, 2007; (2007) 0000605-200801150-00192. [Abstract] [Full Text] [PDF]

				R. Milroy New American College of Chest Physicians Lung Cancer Guidelines*: An Important Addition to the Lung Cancer Guidelines Armamentarium Chest, September 1, 2007; 132(3): 744 - 746. [Full Text] [PDF]

				M. H. Baumann, S. Z. Lewis, and D. Gutterman ACCP Evidence-Based Guideline Development: A Successful and Transparent Approach Addressing Conflict of Interest, Funding, and Patient-Centered Recommendations Chest, September 1, 2007; 132(3): 1015 - 1024. [Abstract] [Full Text] [PDF]

				A. L. Ries, G. S. Bauldoff, B. W. Carlin, R. Casaburi, C. F. Emery, D. A. Mahler, B. Make, C. L. Rochester, R. ZuWallack, and C. Herrerias Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines Chest, May 1, 2007; 131(5_suppl): 4S - 42S. [Abstract] [Full Text] [PDF]

				K. Verkerk, H. Van Veenendaal, J. L. Severens, E. J. M. Hendriks, and J. S. Burgers Considered judgement in evidence-based guideline development Int. J. Qual. Health Care, October 1, 2006; 18(5): 365 - 369. [Abstract] [Full Text] [PDF]

				R. S. Irwin The New "Face" of CHEST Heralds a New Era Chest, January 1, 2006; 129(1): 1 - 3. [Full Text] [PDF]

				R. Kunz "What's in the Black Box?" Chest, January 1, 2006; 129(1): 7 - 10. [Full Text] [PDF]

				M. H. Baumann and D. D. Gutterman American College of Chest Physicians Evidence-Based Guidelines-the Next Generation: Considering Resource Use and Evolution to a Single Grading System Chest, January 1, 2006; 129(1): 10 - 12. [Full Text] [PDF]

				G. Guyatt, M. Baumann, S. Pauker, J. Halperin, J. Maurer, D. K. Owens, A. N.A. Tosteson, B. Carlin, D. Gutterman, M. Prins, et al. Addressing Resource Allocation Issues in Recommendations From Clinical Practice Guideline Panels: Suggestions From an American College of Chest Physicians Task Force Chest, January 1, 2006; 129(1): 182 - 187. [Abstract] [Full Text] [PDF]