title: Introducing GRADE across the NICE clinical guideline program.
abstract: OBJECTIVE
  Grading of Recommendations Assessment, Development and Evaluation (GRADE) is a system for rating the confidence in estimates of effect and grading guideline recommendations. It promotes evaluation of the quality of the evidence for each outcome and an assessment of balance between desirable and undesirable outcomes leading to a judgment about the strength of the recommendation. In 2007, the National Institute for Health and Clinical Excellence began introducing GRADE across its clinical guideline program to enable separation of judgments about the evidence quality from judgments about the strength of the recommendation.
  
  
  METHODS
  We describe the process of implementing GRADE across guidelines.
  
  
  RESULTS
  Use of GRADE has been positively received by both technical staff and guideline development group members.
  
  
  CONCLUSIONS
  A shift in thinking about confidence in the evidence was required leading to a more structured and transparent approach to decision making. Practical problems were also encountered; these have largely been resolved, but some areas require further work, including the application of imprecision and presenting results from analyses considering more than two alternative interventions. The use of GRADE for nonrandomized and diagnostic accuracy studies needs to be refined.
authors.affiliation: Centre for Clinical Practice, National Institute for Health and Clinical Excellence, City Tower, Piccadilly Plaza, Manchester M1 4BD, United Kingdom. judith.thornton@nice.org.uk
authors.forename: Judith
authors.initials: J
authors.lastname: Thornton
authors.forename: Philip
authors.initials: P
authors.lastname: Alderson
authors.forename: Toni
authors.initials: T
authors.lastname: Tan
authors.forename: Claire
authors.initials: C
authors.lastname: Turner
authors.forename: Sue
authors.initials: S
authors.lastname: Latchem
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Shaw
authors.forename: Francis
authors.initials: F
authors.lastname: Ruiz
authors.forename: Stefanie
authors.initials: S
authors.lastname: Reken
authors.forename: Moira A
authors.initials: MA
authors.lastname: Mugglestone
authors.forename: Jennifer
authors.initials: J
authors.lastname: Hill
authors.forename: Julie
authors.initials: J
authors.lastname: Neilson
authors.forename: Maggie
authors.initials: M
authors.lastname: Westby
authors.forename: Karen
authors.initials: K
authors.lastname: Francis
authors.forename: Craig
authors.initials: C
authors.lastname: Whittington
authors.forename: Faisal
authors.initials: F
authors.lastname: Siddiqui
authors.forename: Tarang
authors.initials: T
authors.lastname: Sharma
authors.forename: Victoria
authors.initials: V
authors.lastname: Kelly
authors.forename: Lynda
authors.initials: L
authors.lastname: Ayiku
authors.forename: Kathryn
authors.initials: K
authors.lastname: Chamberlain
mesh_terms: D004813:Epidemiology / Q000592:standards*; D055317:Evidence-Based Practice / Q000458:organization & administration*; D019983:Guideline Adherence / Q000592:standards*; D006801:Humans; D017410:Practice Guidelines as Topic; D016730:Program Development; D015397:Program Evaluation; D011785:Quality Assurance, Health Care / Q000592:standards*; D016032:Randomized Controlled Trials as Topic; D014481:United States