title: A guide for health professionals to interpret and use recommendations in guidelines developed with the GRADE approach.
abstract: An increasing number of organizations worldwide are using new and improved standards for developing trustworthy clinical guidelines. One of such approaches, developed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group, offers systematic and transparent guidance in moving from evidence to recommendations. The GRADE strategy concentrates on four factors: the balance between benefits and harms, the certainty of the evidence, values and preferences, and resource considerations. However, it also considers issues around feasibility, equity, and acceptability of recommendations. GRADE distinguishes two types of recommendations: strong and weak. Strong recommendations reflect a clear preference for one alternative and should apply to all or almost all patients, obviating the need for a careful review of the evidence with each patient. Weak recommendations are appropriate when there is a close balance between desirable and undesirable consequences of alternative management strategies, uncertainty regarding the effects of the alternatives, uncertainty or variability in patients' values and preferences, or questionable cost-effectiveness. Weak recommendations usually require accessing the underlying evidence and a shared decision-making approach. Clinicians using GRADE recommendations should understand the meaning of the strength of the recommendation, be able to critically appraise the recommendation, and apply trustworthy recommendations according to their strength.
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Room 2C12, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Internal Medicine, School of Medicine, Pontificia Universidad Catolica de Chile, Alameda 340, Santiago, Chile. Electronic address: ignacio.neumann@gmail.com.
authors.forename: Ignacio
authors.initials: I
authors.lastname: Neumann
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Room 2C12, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
authors.forename: Nancy
authors.initials: N
authors.lastname: Santesso
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Room 2C12, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Internal Medicine, American University of Beirut, American University of Beirut Medical Center, P.O. Box: 11-0236, Riad-El-Solh, Beirut 1107 2020, Lebanon.
authors.forename: Elie A
authors.initials: EA
authors.lastname: Akl
authors.affiliation: Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA; UpToDate, 230 Third Avenue, Waltham, MA 02451, USA.
authors.forename: David M
authors.initials: DM
authors.lastname: Rind
authors.affiliation: Norwegian Knowledge Centre for the Health Services, PO Box 7004 St. Olavs plass, N-0130 Oslo, Norway.
authors.forename: Per Olav
authors.initials: PO
authors.lastname: Vandvik
authors.affiliation: Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau-CIBERESP), Sant Antoni Maria Claret, 167, Pabellón 18, 08025, Barcelona, Spain.
authors.forename: Pablo
authors.initials: P
authors.lastname: Alonso-Coello
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Room 2C12, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Division of Clinical Epidemiology & Division of General Internal Medicine, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland.
authors.forename: Thomas
authors.initials: T
authors.lastname: Agoritsas
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Room 2C12, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Medicine, University of Missouri-Kansas City, Kansas City, 5100 Rockhill Rdm, MO, USA.
authors.forename: Reem A
authors.initials: RA
authors.lastname: Mustafa
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Room 2C12, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
authors.forename: Paul Elias
authors.initials: PE
authors.lastname: Alexander
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Room 2C12, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
authors.forename: Holger
authors.initials: H
authors.lastname: Schünemann
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Room 2C12, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
authors.forename: Gordon H
authors.initials: GH
authors.lastname: Guyatt
mesh_terms: D003657:Decision Making; D004501:Education, Medical / Q000379:methods / Q000592:standards*; D019317:Evidence-Based Medicine / Q000592:standards*; D005260:Female; D006282:Health Personnel / Q000193:education*; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic / Q000592:standards*; D011787:Quality of Health Care
keywords: Clinical practice guidelines; Decision making; Evidence-based practice; GRADE; Medical education; Recommendations