Table 7.

The GRADE Approach

1. Rating the Quality of Evidence
Study design	Initial rating of quality of evidence	Rate down when	Rate up when
RCT	High	Risk of bias	Large effect (e.g., RR: 0.5)
	Moderate	Inconsistency	Very large effect (e.g., RR: 0.2)
		Imprecision	Dose response gradient
Observational	Low	Indirectness	All plausible confounding would increase the association
	Very low	Publication bias
2. Determinants of the Strength of a Recommendation Quality of evidence Balance of benefits and harms Patient values and preferences Resources and costs
3. Implications of the Strength of Recommendation
Strong	Population: Most people in this situation would want the recommended course of action and only a small proportion would not. Health care workers: Most people should receive the recommended course of action. Policy makers: The recommendation can be adapted as a policy in most situations.
Conditional	Population: The majority of people in this situation would want the recommended course of action, but many would not. Health care workers: Be prepared to help patients make a decision that is consistent with their values using decision aids and shared decision making. Policy makers: There is a need for substantial debate and involvement of stakeholders.