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Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines*: Report From an American College of Chest Physicians Task Force

Gordon Guyatt, MD, MSc, FCCP; David Gutterman, MD, FCCP; Michael H. Baumann, MD, MSc, FCCP; Doreen Addrizzo-Harris, MD, FCCP; Elaine M. Hylek, MD, MPH; Barbara Phillips, MD, FCCP; Gary Raskob, PhD; Sandra Zelman Lewis, PhD; Holger Schünemann, MD, PhD, FCCP
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*From the Departments of Medicine, and Clinical Epidemiology and Biostatistics (Dr. Guyatt), McMaster University, Hamilton, ON, Canada; the Department of Medicine (Dr. Gutterman), Medical College of Wisconsin, Milwaukee, WI; the University of Mississippi Medical Center (Dr. Baumann), Jackson, MS; New York University School of Medicine (Dr. Addrizzo-Harris), New York, NY; the Department of Medicine (Dr. Hylek), Research Unit-Section of General Internal Medicine, Boston University School of Medicine, Boston, MA; the University of Kentucky College of Medicine (Dr. Phillips), Lexington, KY; College of Public Health (Dr. Raskob), University of Oklahoma Health Sciences Center, Oklahoma City, OK; the American College of Chest Physicians (Dr. Lewis), Northbrook, IL; and the Department of Clinical Epidemiology, Italian National Cancer Institute (Dr. Schünemann), Rome, Italy.

Correspondence to: Gordon Guyatt, MD, MSc, FCCP, Department of Clinical Epidemiology and Biostatistics, HSC-2C12, McMaster University, 1200 Main St West, Hamilton, ON, Canada L8N 3Z5; e-mail: guyatt@mcmaster.ca



Chest. 2006;129(1):174-181. doi:10.1378/chest.129.1.174
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While grading the strength of recommendations and the quality of underlying evidence enhances the usefulness of clinical guidelines, the profusion of guideline grading systems undermines the value of the grading exercise. An American College of Chest Physicians (ACCP) task force formulated the criteria for a grading system to be utilized in all ACCP guidelines that included simplicity and transparency, explicitness of methodology, and consistency with current methodological approaches to the grading process. The working group examined currently available systems, and ultimately modified an approach formulated by the international GRADE group. The grading scheme classifies recommendations as strong (grade 1) or weak (grade 2), according to the balance among benefits, risks, burdens, and possibly cost, and the degree of confidence in estimates of benefits, risks, and burdens. The system classifies quality of evidence as high (grade A), moderate (grade B), or low (grade C) according to factors that include the study design, the consistency of the results, and the directness of the evidence. For all future ACCP guidelines, The College has adopted a simple, transparent approach to grading recommendations that is consistent with current developments in the field. The trend toward uniformity of approaches to grading will enhance the usefulness of practice guidelines for clinicians.


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