Grades of Recommendation, Assessment, Development, and Evaluation
|Target Audience||Strong Recommendation||Conditional* Recommendation|
|For patients/ public||We believe most people in this situation would want the recommended course of action and only a small number would not.||We believe that most people in this situation would want the recommended course of action, but many would not. Different choices are acceptable for each person, and clinicians should support patients and discuss their values and preferences to reach a decision. Decision aids may support people in reaching these decisions.|
|For clinicians||The recommendation would apply to most individuals. Formal discussion aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.||We recognize that different choices may be appropriate for individual patients. Clinicians should support each patient in reaching a management decision consistent with his or her values and preferences. Decision aids may support individuals in reaching such decisions.|
|For policy makers and developers of quality measures||The recommendation can be adapted as policy in most situations. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator.||Policy-making will require substantial debate and involvement of various stakeholders. An appropriately documented decision making process could be used as quality indicator.|
*The task force previously used the term “weak recommendation,” but has replaced this with the term “conditional recommendation,” to improve understanding and facilitate implementation of guidance, based on feedback from clinician knowledge users. One reason for this change was the value that the task force places on shared decision making, together with a need to clarify better when implementation of a recommendation depends on circumstances such as patient values, resource availability or other contextual considerations. Conditional recommendations based on patient values and preferences require clinicians to recognize that different choices will be appropriate for different patients and those decisions must be consistent with each patient’s values and preferences. Knowledge translation tools are available on the task force website to facilitate decisions that are evidence informed and aligned with an individual’s priorities.
Quality of evidence
Recommendations in the guidelines prepared by the Canadian Task Force on Preventive Health Care (CTFPHC) are graded as either strong or weak according to the Grading of Recommendations Assessment, Development and Evaluation system (GRADE). The CTFPHC’s judgments about the quality of evidence are summarized by the degree of confidence that available evidence correctly reflects the theoretical true effect of the intervention or service.
We judge evidence as high quality when we are highly confident that the true effect lies close to that of the estimate of the effect. For example, evidence is judged as high quality if all of the following apply: there is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We judge evidence as moderate quality when we consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. For example, evidence might be judged as moderate quality if any of the following applies: there are only a few studies and some have limitations but not major flaws, there is some variation between studies, or the confidence interval of the summary estimate is wide.
We judge evidence to be low or very low quality when the true effect may be substantially different from the estimate of the effect. For example, evidence might be judged as low quality if any of the following applies: the studies have major flaws, there is important variation between studies, or the confidence interval of the summary estimate is very wide.
Strength of recommendations
In addition to the quality of supporting evidence, the strength of our recommendations is influenced by,
- The balance between desirable and undesirable effects;
- The variability or uncertainty in values and preferences of citizens; and
- Whether or not the intervention represents a wise use of resources.
Strong recommendations are those for which we are confident that the desirable effects of an intervention outweigh its undesirable effects (strong recommendation for an intervention) or that the undesirable effects of an intervention outweigh its desirable effects (strong recommendation against an intervention). A strong recommendation implies that most individuals will be best served by the recommended course of action.
Conditional* recommendations are those for which the desirable effects probably outweigh the undesirable effects (conditional recommendation for an intervention) or undesirable effects probably outweigh the desirable effects (conditional recommendation against an intervention) but uncertainty exists. Conditional recommendations result when the balance between desirable and undesirable effects is small, the quality of evidence is lower, and there is more variability in the values and preferences of individuals. A conditional recommendation implies that we believe most people would want the recommended course of action but that many would not. Clinicians must recognize that different choices will be appropriate for different individuals, and they must support each person in reaching a management decision consistent with his/her values and preferences. Policy-making will require substantial debate and involvement of various stakeholders.
Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group, 2011.