11
GRADE Classification of Guideline Recommendations
Certainty
of Evidence
Interpretation
High
⊕⊕⊕⊕
We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate
⊕⊕⊕
We are moderately confident in the effect estimate. The true effect is likely to be close to
the estimate of the effect, but there is a possibility that it is substantially different.
Low
⊕⊕
Our confidence in the effect estimate is limited. The true effect may be substantially
different from the estimate of the effect.
Very Low
⊕
We have very little confidence in the effect estimate. The true effect is likely to be
substantially different from the estimate of effect.
Source: Reprinted with permission from Schünemann HJ, Brożek J, Guyatt GH, Oxman
AD. GRADE Handbook. Handbook for grading the quality of evidence and the strength of
recommendations using the GRADE approach. Updated October 2013.
GRADE Strength of Recommendation Classifications and
Interpretation
Strength of
recommendation Criteria
Interpretation by
patients
Interpretation by
health care providers
Interpretation by
policy makers
1 – Strong
recommendation
for or against
Desirable
consequences
CLEARLY
OUTWEIGH
the undesirable
consequences
in most settings
(or vice versa).
Most individuals
in this situation
would want the
recommended
course of action,
and only a small
proportion would
not.
Most individuals
should receive the
recommended
course of action.
Formal decision
aids are not likely to
be needed to help
individuals make
decisions consistent
with their values and
preferences.
The
recommendation
can be adopted
as policy in
most situations.
Adherence to this
recommendation
according to the
guideline could
be used as a
quality criterion
or performance
indicator.
2 – Conditional
recommendation
for or against
Desirable
consequences
PROBABLY
OUTWEIGH
undesirable
consequences
in most settings
(or vice versa).
The majority of
individuals in this
situation would
want the suggested
course of action, but
many would not.
Clinicians should
recognize that
different choices
will be appropriate
for each individual
and that clinicians
must help each
individual arrive
at a management
decision consistent
with the individual's
values and
preferences. Decision
aids may be useful
in helping patients
make decisions
consistent with
their individual
risks, values and
preferences.
Policy-making
will require
substantial debate
and involvement of
various stakeholders.
Performance
measures should
assess whether
decision making is
appropriate.
Source: Data from Schünemann HJ, et al. Blood Adv, 2018, Nov 27; 2(22):3198–3225 ©
