Boston University School of Medicine, Boston, MA
Correspondence to: Kevin C. Wilson, MD, FCCP, UpToDate, 95 Sawyer Rd, Waltham, MA 02453; e-mail: firstname.lastname@example.org
My wife has an investment account that is independently managed and may include stock in health-care-related companies at any given time (not a mutual fund). I am a Deputy Editor for Pulmonary, Critical Care, and Sleep Medicine at UpToDate, which uses the GRADE system to grade recommendations. I have been invited to join the GRADE working group.
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).
The objection of Dr. Tobin to evidence-based medicine in a recent issue of CHEST (May 2008)1,2 seems to focus on the grading of recommendations. As Deputy Editor of a popular clinical resource, I have personally graded > 100 recommendations using the Grading Recommendations Assessment, Development, and Evaluation (GRADE) system and feel well qualified to comment on its benefits.3
Grading improves transparency by conveying the following for each recommendation: (1) the quality of the related evidence; (2) the author's confidence that the benefits of the intervention outweigh the potential harms; and (3) the likelihood that informed patients would choose the intervention. No longer can authors make recommendations that fail to reveal the quality of the related evidence or the strength of the author's belief. The transparency of recommendations is arguably as important as that of potential conflicts of interest, although the latter is more widely accepted.
The same information can be conveyed without grading, of course, but additional text is required. This causes clutter, redundancy, and monotony, which may distract and delay the reader. Ultimately, the quality of the review or guidelines suffers.
An additional benefit of grading is that authors, editors, and peer reviewers focus more on recommendations that are graded. One can argue whether this is appropriate, but the observation is undeniable. The added attention results in clearer recommendations that are easier for readers to apply to clinical practice.
I have heard many arguments against grading. Common among all arguments are misunderstandings of the purpose of grading and the GRADE system. In time, I firmly believe the entire medical community will appreciate the many advantages of grading recommendations.
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