Portal de Periódicos da CAPES

The GRADE System for Rating Clinical Guidelines

2009; Public Library of Science; Volume: 6; Issue: 9 Linguagem: Inglês

10.1371/journal.pmed.1000094

1549-1676

Brian P. Kavanagh,

Sepsis Diagnosis and Treatment

Professional medical groups commonly issue clinical practice guidelines. Such guidelines are traditionally the result of consensus conferences or expert panels and represent attempts to synthesize—from the best available evidence and expertise—practical guidance on the best possible care. Beyond issuing a guideline, many organizations have felt the need to provide a grading of each guideline's quality, thereby conveying to the reader a sense of the confidence that might be placed in it. This article addresses only the grading of guidelines, not their use or development. The idea that evidence in the medical literature should be graded was initially proposed in publications from McMaster University [1]–[3], with the idea of categorizing individual studies into grades of reliability ranging from randomized controlled trials (most reliable) to case reports with expert opinion (least reliable). Grading of guidelines followed, but this has been besieged with problems. To give one example, a guideline by Ferraris and colleagues gave the use of aprotonin during high-risk cardiac surgery a “high-grade” recommendation [4], but this intervention was subsequently shown to increase mortality [5]. The pursuit of better approaches to grading guidelines has resulted in GRADE (Grades of Recommendation Assessment, Development and Evaluation), introduced in 2004 [6]. GRADE has been adopted “unchanged or with only minor modifications” by national and international professional medical societies, health-related branches of government, health care regulatory bodies, and UpToDate, an on-line medical resource that is accessed by trainees and physicians in most US academic medical centers (Box 1) [7],[8]. Box 1. Organizations That Have Adopted the Grade System Agency for Healthcare Research and Quality (USA) Agenzia Sanitaria Regionale (Italy) American College of Chest Physicians (USA) American College of Physicians (USA) American Thoracic Society (USA) Arztliches Zentrum fur Qualitat in der Medizin (Germany) British Medical Journal (United Kingdom) BMJ Clinical Evidence (United Kingdom) COMPUS at The Canadian Agency for Drugs and Technologies in Health (Canada) The Cochrane Collaboration (International) EMB Guidelines (Finland/International) The Endocrine Society (USA) European Respiratory Society (Europe) European Society of Thoracic Surgeons (International) Evidence-based Nursing Sudtirol (Italy) German Center for Evidence-based Nursing “sapere aude” (Germany) Infectious Diseases Society of America (USA) Japanese Society for Temporomandibular Joint (Japan) Journal of Infection in Developing Countries (International) Kidney Disease: Improving Global Outcome (International) Ministry for Health and Long-Term Care, Ontario (Canada) National Board of Health and Welfare (Sweden) National Institute for Health and Clinical Excellence (United Kingdom) Norwegian Knowledge Centre for the Health Services (Norway) Polish Institute for EBM (Poland) Society for Critical Care Medicine (USA) Society for Vascular Surgery (USA) Spanish Society for Family and Community Medicine (Spain) Surviving Sepsis Campaign (International) University of Pennsylvania Health System Center for Evidence-Based Practice (USA) UpToDate (USA) World Health Organization (International)