What is GRADE? | BMJ Best Practice (2023)

GRADE (Grading of Recommendations, Assessment, Development and Evaluations) is a transparent framework for developing and presenting summaries of evidence and provides a systematic approach for making clinical practice recommendations.[1-3] It is the most widely adopted tool for grading the quality of evidence and for making recommendations with over 100 organisations worldwide officially endorsing GRADE.

How does it work?

First, the authors decide what the clinical question is, including the population that the question applies to, the two or more alternatives, and the outcomes that matter most to those faced with the decision.[4] A study – ideally a systematic review – provides the best estimate of the effect size for each outcome, in absolute terms (e.g. a risk difference).[3]

The authors then rate the quality of evidence, which is best applied to each outcome, because the quality of evidence often varies between outcomes.[5] An overall GRADE quality rating can be applied to a body of evidence across outcomes, usually by taking the lowest quality of evidence from all of the outcomes that are critical to decision making.[6]

GRADE has four levels of evidence – also known as certainty in evidence or quality of evidence: very low, low, moderate, and high (Table 1). Evidence from randomised controlled trials starts at high quality and, because of residual confounding, evidence that includes observational data starts at low quality. The certainty in the evidence is increased or decreased for several reasons, described in more detail below.

Table 1. GRADE certainty ratings

CertaintyWhat it means
Very lowThe true effect is probably markedly different from the estimated effect
LowThe true effect might be markedly different from the estimated effect
ModerateThe authors believe that the true effect is probably close to the estimated effect
HighThe authors have a lot of confidence that the true effect is similar to the estimated effect

GRADE is subjective

GRADE cannot be implemented mechanically – there is by necessity a considerable amount of subjectivity in each decision. Two persons evaluating the same body of evidence might reasonably come to different conclusions about its certainty. What GRADE does provide is a reproducible and transparent framework for grading certainty in evidence.[7]

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What makes evidence less certain?

For each of risk of bias, imprecision, inconsistency, indirectness, and publication bias, authors have the option of decreasing their level of certainty one or two levels (e.g., from high to moderate).

The GRADE Domains for rating down:

1. Risk of bias

Bias occurs when the results of a study do not represent the truth because of inherent limitations in design or conduct of a study.[8] In practice, it is difficult to know to what degree potential biases influence the results and therefore certainty is lower in the estimated effect if the studies informing the estimated effect could be biased.

There are several tools available to rate the risk of bias in individual randomised trials[9] and observational studies.[10, 11]

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GRADE is used to rate the body of evidence at the outcome level rather than the study level. Authors must, therefore, make a judgement about whether the risk of bias in the individual studies is sufficiently large that their confidence in the estimated treatment effect is lower. Key considerations for risk of bias and a detailed description of the process for moving from risk of bias at the study level to risk of bias for a body of evidence is described in detail in the GRADE guidelines series #4: Rating the quality of evidence – study limitations (risk of bias).[8]

2. Imprecision

The GRADE approach to rating imprecision focuses on the 95% confidence interval around the best estimate of the absolute effect.[12] Certainty is lower if the clinical decision is likely to be different if the true effect was at the upper versus the lower end of the confidence interval. Authors may also choose to rate down for imprecision if the effect estimate comes from only one or two small studies or if there were few events.[13] A detailed description of imprecision is described in the GRADE guidelines series #6: Rating the quality of evidence – imprecision.[12]

3. Inconsistency

Certainty in a body of evidence is highest when there are several studies that show consistent effects. When considering whether or not certainty should be rated down for inconsistency, authors should inspect the similarity of point estimates and the overlap of their confidence intervals, as well as statistical criteria for heterogeneity (e.g., the I2 and chi-squared test).[14] A full discussion of inconsistency is available in the GRADE guidelines series #7: rating the quality of evidence – inconsistency.[14]

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4. Indirectness

Evidence is most certain when studies directly compare the interventions of interest in the population of interest, and report the outcome(s) critical for decision-making. Certainty can be rated down if the patients studied are different from those for whom the recommendation applies. Indirectness can also occur when the interventions studied are different than the real outcomes (for example, a study of a new surgical procedure in a highly specialized centre only indirectly applies to centres with less experience). Indirectness also occurs when the outcome studied is a surrogate for a different outcome – typically one that is more important to patients. A full discussion of indirectness is available in the GRADE guidelines series #8: rating the quality of evidence – indirectness.[15]

5. Publication bias

Publication bias is perhaps the most vexing of the GRADE domains, because it requires making inferences about missing evidence. Several statistical and visual methods are helpful in detecting publication bias, despite having serious limitations. Publication bias is more common with observational data and when most of the published studies are funded by industry. A full discussion of publication bias is available in the GRADE guidelines series #5: rating the quality of evidence – publication bias.[16]

What increases confidence in the evidence?

In rare circumstances, certainty in the evidence can be rated up (see table 2). First, when there is a very large magnitude of effect, we might be more certain that there is at least a small effect. Second, when there is a clear dose-response gradient. Third, when residual confounding is likely to decrease rather than increase the magnitude of effect (in situations with an effect). A more complete discussion of reasons to rate up for confidence is available at in the GRADE guidelines series #9: Rating up the quality of evidence.[17]

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Table 2. Reasons rate certainty in evidence up or down
Certainty can be rated down for:Certainty can be rated up for:
  • Risk of bias
  • Imprecision
  • Inconsistency
  • Indirectness
  • Publication bias
  • Large magnitude of effect
  • Dose-response gradient
  • All residual confounding would decrease magnitude of effect (in situations with an effect)

Moving from quality of evidence to recommendations

In GRADE, recommendations can be strong or weak, in favour or against an intervention. Strong recommendations suggest that all or almost all persons would choose that intervention. Weak recommendations imply that there is likely to be an important variation in the decision that informed persons are likely to make. The strength of recommendations are actionable: a weak recommendation indicates that engaging in a shared decision making process is essential, while a strong recommendation suggests that it is not usually necessary to present both options.

Recommendations are more likely to be weak rather than strong when the certainty in evidence is low, when there is a close balance between desirable and undesirable consequences, when there is substantial variation or uncertainty in patient values and preferences, and when interventions require considerable resources. A full discussion is available in the BMJ series on the GRADE Evidence to Decision framework[18, 19] and in the original series[2, 20].

Authors:Reed Siemieniuk and Gordon Guyatt

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  1. Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schunemann HJ. What is "quality of evidence" and why is it important to clinicians? BMJ (Clinical research ed). 2008;336(7651):995-8.
  2. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ (Clinical research ed). 2008;336(7650):924-6.
  3. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. Journal of clinical epidemiology. 2011;64(4):383-94.
  4. Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, et al. GRADE guidelines: 2. Framing the question and deciding on important outcomes. Journal of clinical epidemiology. 2011;64(4):395-400.
  5. Balshem H, Helfand M, Schunemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines: 3. Rating the quality of evidence. Journal of clinical epidemiology. 2011;64(4):401-6.
  6. Guyatt G, Oxman AD, Sultan S, Brozek J, Glasziou P, Alonso-Coello P, et al. GRADE guidelines: 11. Making an overall rating of confidence in effect estimates for a single outcome and for all outcomes. Journal of clinical epidemiology. 2013;66(2):151-7.
  7. Mustafa RA, Santesso N, Brozek J, Akl EA, Walter SD, Norman G, et al. The GRADE approach is reproducible in assessing the quality of evidence of quantitative evidence syntheses. Journal of clinical epidemiology. 2013;66(7):736-42; quiz 42.e1-5.
  8. Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, et al. GRADE guidelines: 4. Rating the quality of evidence--study limitations (risk of bias). Journal of clinical epidemiology. 2011;64(4):407-15.
  9. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ (Clinical research ed). 2011;343:d5928.
  10. Wells G, Shea B, O’connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa: Ottawa Hospital Research Institute; 2011. oxford. asp; 2011.
  11. Sterne JA, Hernan MA, Reeves BC, Savovic J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ (Clinical research ed). 2016;355:i4919.
  12. Guyatt GH, Oxman AD, Kunz R, Brozek J, Alonso-Coello P, Rind D, et al. GRADE guidelines 6. Rating the quality of evidence--imprecision. Journal of clinical epidemiology. 2011;64(12):1283-93.
  13. Walsh M, Srinathan SK, McAuley DF, Mrkobrada M, Levine O, Ribic C, et al. The statistical significance of randomized controlled trial results is frequently fragile: a case for a Fragility Index. Journal of clinical epidemiology. 2014;67(6):622-8.
  14. Guyatt GH, Oxman AD, Kunz R, Woodcock J, Brozek J, Helfand M, et al. GRADE guidelines: 7. Rating the quality of evidence--inconsistency. Journal of clinical epidemiology. 2011;64(12):1294-302.
  15. Guyatt GH, Oxman AD, Kunz R, Woodcock J, Brozek J, Helfand M, et al. GRADE guidelines: 8. Rating the quality of evidence--indirectness. Journal of clinical epidemiology. 2011;64(12):1303-10.
  16. Guyatt GH, Oxman AD, Montori V, Vist G, Kunz R, Brozek J, et al. GRADE guidelines: 5. Rating the quality of evidence--publication bias. Journal of clinical epidemiology. 2011;64(12):1277-82.
  17. Guyatt GH, Oxman AD, Sultan S, Glasziou P, Akl EA, Alonso-Coello P, et al. GRADE guidelines: 9. Rating up the quality of evidence. Journal of clinical epidemiology. 2011;64(12):1311-6.
  18. Alonso-Coello P, Schunemann HJ, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, et al. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction. BMJ (Clinical research ed). 2016;353:i2016.
  19. Alonso-Coello P, Oxman AD, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, et al. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines. BMJ (Clinical research ed). 2016;353:i2089.
  20. Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, et al. Going from evidence to recommendations. BMJ (Clinical research ed). 2008;336(7652):1049-51.


What is the GRADE system in healthcare? ›

GRADE is used to rate the certainty of evidence for a treatment efficacy from high to very low. The GRADE system takes in two types of studies: randomized controlled trials (RCTs) and observational studies (also including non-randomized trials).

What is the grade approach in research? ›

GRADE is a systematic approach to rating the certainty of evidence in systematic reviews and other evidence syntheses.

What does GRADE stand for in systematic reviews? ›

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach is a systematic and transparent approach for rating the certainty of evidence in systematic reviews and clinical practice guidelines, and for developing and determining the strength of clinical practice recommendations.

What are the five GRADE considerations? ›

The GRADE approach specifies four levels of the certainty for a body of evidence for a given outcome: high, moderate, low and very low. GRADE assessments of certainty are determined through consideration of five domains: risk of bias, inconsistency, indirectness, imprecision and publication bias.

What is grade in clinical practice guideline? ›

GRADE (Grading of Recommendations, Assessment, Development and Evaluations) is a transparent framework for developing and presenting summaries of evidence and provides a systematic approach for making clinical practice recommendations.

What is the purpose of GRADE approach? ›

The GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) is a method of assessing the certainty in evidence (also known as quality of evidence or confidence in effect estimates) and the strength of recommendations in health care.

What are the 3 components of grades? ›

Learners from Grades 1 to 12 are graded on Written Work, Performance Tasks, and Quarterly Assessment every quarter. These three are given specific percentage weights that vary according to the nature of the learning area.

What are the 4 types of research approaches? ›

Types of research approaches
  • The descriptive study. This approach attempts to identify the characteristics of a problem through description. ...
  • The explanatory study. This approach attempts to find the answer to an enigmatic question. ...
  • The remedial study. ...
  • The methodological study. ...
  • The historical study. ...
  • A suggested essay format.

What are the three 3 basic research approaches? ›

The three common approaches to conducting research are quantitative, qualitative, and mixed methods. The researcher anticipates the type of data needed to respond to the research question.

What does a 70% grade mean? ›

C - this is a grade that rests right in the middle. C is anywhere between 70% and 79% D - this is still a passing grade, and it's between 59% and 69% F - this is a failing grade.

Is grade used for meta analysis? ›

The GRADE approach is used to assess the quality of evidence for a specific outcome across studies. It applies most directly to a meta-analysis undertaken in the context of a systematic review but can be applied also to individual studies or non-quantitative syntheses when meta-analyses are not available.

What is the grade scaling? ›

Common examples of grade conversion are: A+ (97–100), A (93–96), A- (90–92), B+ (87–89), B (83–86), B- (80–82), C+ (77–79), C (73–76), C- (70–72), D+ (67–69), D (65–66), D- (below 65).

What are the four steps of the grading process? ›

There are four major roles of the grading process – evaluation, communication, motivation and organization.

What are some of the guidelines for grading? ›

9.12 Guidelines for Creating an Effective Grading System
  • Keep your eyes on the prize. ...
  • An effective grading system fosters communication. ...
  • Grades should reflect a nonjudgmental posture. ...
  • Intentional imprecision. ...
  • Use points only when necessary. ...
  • No surprises. ...
  • Find a balance that works for you. ...
  • Valuing the learning process.

What is the grade assessment tool? ›

GRADE (Grading of Recommendations, Assessment, Development and Evaluations) is a transparent framework for developing and presenting summaries of evidence and provides a systematic approach for making clinical practice recommendations.

What is quality and grade? ›

Quality is the degree to which the product meets the customer or end-user requirements whereas grade is a category assigned to products that have the same functional use but different technical characteristics. High grade does not imply high quality.

What is a grade measurement? ›

'angle'), grad, or grade, is a unit of measurement of an angle, defined as one hundredth of the right angle; in other words, there are 100 gradians in 90 degrees. It is equivalent to 1400 of a turn, 910 of a degree, or π200 of a radian.

What clinical grade means? ›

Clinical Grade is used to describe products or materials that are suitable for direct therapeutic use, such as, injectable grade. Such materials are required to show to safety and efficacy for human use through appropriate clinical trials and regulatory approvals.

What are the four purposes of grading? ›

Align rubric scores to proficiency scales. Clearly define and communicate expectations in relation to standards. Establish common grade or course grading practices. Collaborate to calibrate scoring tools to ensure reliable interpretation of student work as related to the standards.

Why is GRADE so important? ›

Grading is used to evaluate and provide feedback on student work. In this way, instructors communicate to students how they are performing in the course and where they need more help to achieve the course's goals.

What are the characteristics of graded approach? ›

A graded approach is a structured method determining: The characteristics of a facility or activity and operational procedures according to the safety significance and complexity. The potential impacts of the facility or activity on human life and health and the environment.

What factors affect grades? ›

Factors that Affect Student Achievement
  • Instruction quality and delivery style. It shouldn't come as a surprise that the quality of instruction in the classroom is an important factor in student achievement. ...
  • Class size. ...
  • Parent involvement. ...
  • Relationships with peers. ...
  • Assessment. ...
  • School facilities.

What is the latest grading system? ›

Unlike the KPUP, the new k to 12 grading system has 60 as minimum grade but will have a converted rating of 75 in the report card. The lowest grade a student can get is rather 60 for the quarterly and final grades.

What are the three C's in a school? ›

The Three C's: How Project-Based Learning Improves Collaboration, Creativity and Critical Thinking.

What are the 5 qualitative approaches? ›

Five Qualitative Approaches to Inquiry
  • Narrative research.
  • Phenomenology research.
  • Grounded theory research.
  • Ethnographic research.
  • Case study research.

What are the two main approaches to research? ›

There are two main categories of research methods: qualitative research methods and quantitative research methods. Quantitative research methods involve using numbers to measure data.

What are the six main research methods? ›

In conducting research, sociologists choose between six research methods: (1) survey, (2) participant observation, (3), secondary analysis, (4) documents, (5) unobtrusive measures, and (6) experiments.

What are the 3 methodologies? ›

The three types of methodology used by researchers are qualitative, quantitative, and mixed methods.

Which method is best for research? ›

Most frequently used methods include:
  • Observation / Participant Observation.
  • Surveys.
  • Interviews.
  • Focus Groups.
  • Experiments.
  • Secondary Data Analysis / Archival Study.
  • Mixed Methods (combination of some of the above)
Sep 21, 2018

What are the 3 qualitative research methods? ›

The three most common qualitative methods, explained in detail in their respective modules, are participant observation, in-depth interviews, and focus groups. Each method is particularly suited for obtaining a specific type of data.

Is C a failing grade? ›

A grade of C or better is required to earn a Passed; a C- or below will earn a Not Passed grade. A grade of C- may satisfy many requirements (e.g., General Education, elective) but a Not Passed grade will not earn any credit or satisfy requirements.

Is D considered failing? ›

A letter grade of a D is technically considered passing because it not a failure. A D is any percentage between 60-69%, whereas a failure occurs below 60%. Even though a D is a passing grade, it's barely passing.

Is 63 an F? ›

Traditionally, the grades are A+, A, A−, B+, B, B−, C+, C, C−, D+, D, D− and F, with A+ being the highest and F being lowest. In some cases, grades can also be numerical.
Grade conversion.
Letter GradePercentageGPA
10 more rows

What is the difference between GRADE and scale? ›

Letter grades of the first type are assigned based on the percentage of the points earned. So, you may have A- = 90-92%. Scale grades have equal steps between each item in a scale. So, if you have 13 letter grades in your scale, an A- would computationally 12/13.

Can GRADE be used without meta-analysis? ›

GRADE is used to assess the overall quality of synthetic evidence from a systematic review. That is, it is inappropriate to use GRADE to judge the results from the systematic review without meta-analysis, thought it can be applied.

Is GRADE A qualitative or quantitative? ›

Grade level are categories even though they appear as numbers. Also, mathematical operation do not make sense when applied with grade levels. Grade 1 + Grade 2 ≠ \neq = Grade 3. Therefore, grade levels are qualitative data.

What is the most common grading scale? ›

The most commonly used grading system in the U.S. uses discrete evaluation in the form of letter grades. Many schools use a GPA (grade-point average) system in combination with letter grades. There are also many other systems in place. Some schools use a numerical scale of 100 instead of letter grades.

How do teachers scale grades? ›

A common method: Find the difference between the highest grade in the class and the highest possible score and add that many points. If the highest percentage grade in the class was 88%, the difference is 12%. You can add 12 percentage points to each student's test score.

What is grade normalization? ›

If you assume that scores should fit a normal curve, then it makes sense to "normalize" them so they fit under a normal curve. Normalization also requires that overly high scores be adjusted downward for conformity.

How would you make grading efficient and effective? ›

Do not comment on every problem or point. Focus on a couple of major points. This not only helps you to grade more efficiently, it also avoids overwhelming the students. It enables them to focus more effectively on the areas of their work that most need improvement.

What are the two types of grading systems use? ›

The two most common types of grading systems used at the university level are norm-referenced and criterion-referenced.

How many methods of grading are there? ›

There are 4 grading methods: Learning objects - The number of completed/passed learning objects. Highest grade - The highest score obtained in all passed learning objects. Average grade - The mean of all the scores.

What are fair grading practices? ›

This means that all work should be assessed based on defined criteria and that students should be treated equally regardless of whether you looked at their work first, last, or after a long day.

What practices must be maintained to make grading and reporting meaningful? ›

To maintain fairness and consistency, consider using the following best practices:
  • Establish clear grading criteria for assignments and exams. ...
  • Discuss grading criteria with all graders to align perspectives. ...
  • Grade one question at a time rather than one student at a time. ...
  • Beware of conflicts of interest.
Jul 14, 2016

What are the 5 assessment tools? ›

Assessment Tools: Introduction
  • Rubrics. For assessing qualitative student work such as essays, projects, reports, or presentations, we recommend the use of rubrics. ...
  • Curriculum Mapping. ...
  • Focus Groups. ...
  • Portfolios. ...
  • Structured Interviews. ...
  • Surveys.

What are the four types of assessment tools? ›

A Guide to Types of Assessment: Diagnostic, Formative, Interim, and Summative.

What is meant by grade system? ›

May 2021) Grading in education is the process of applying standardized measurements for varying levels of achievements in a course. Grades can be assigned as letters (usually A through F), as a range (for example, 1 to 6), as a percentage, or as a number out of a possible total (often out of 100).

What are the 4 levels of health care? ›

Primary care is when you consult with your primary care provider. Secondary care is when you see a specialist such as an oncologist or endocrinologist. Tertiary care refers to specialized care in a hospital setting such as dialysis or heart surgery. Quaternary care is an advanced level of specialized care.

What are the 3 levels of healthcare? ›

In the medical industry, there are three levels of care called primary, secondary and tertiary care and the terms help patients and healthcare professionals navigate the medical system more easily.

What are the different methods of grading? ›

There are 4 grading methods:
  • Learning objects - The number of completed/passed learning objects.
  • Highest grade - The highest score obtained in all passed learning objects.
  • Average grade - The mean of all the scores.
  • Sum grade - The sum of all the scores.

What is the rule of grade? ›

Grade rules are the difference in measurements between each point of measure on a garment. For example, below is a page from an example tech pack + the grade rules column is highlighted. So point of measure ('POM') 'A' measures 38.5cm with a grade rule of 2.5cm.

What are the 4 A's in healthcare? ›

Perhaps a more reliable measure of the goodness of fit between provider and client is whether someone has a regular physician and a regular site of care, since it can be seen as reflecting availability, accessibility, accommodation, and acceptability.

What are the 6 levels of health care? ›

Levels of care
  • Acute Care. ...
  • Long Term Acute Care Hospitals(LTAC)-Long-term care hospitals (LTCHs) ...
  • Sub-Acute Care/Transitional Care. ...
  • Inpatient Rehabilitation. ...
  • Skilled Nursing Facility (SNF) ...
  • Intermediate Care. ...
  • Home Health Care. ...
  • Hospice Care.

What are the 5 domains of health care? ›

The six domains of healthcare quality outlined by the Institute of Medicine are patient safety, effectiveness, patient-centred, timeliness, efficiency, and equity. Each of these is important for ensuring that patients receive high-quality care.

What are the 8 types of healthcare? ›

They cover emergency, preventative, rehabilitative, long-term, hospital, diagnostic, primary, palliative, and home care.

What does type of practice mean? ›

Related Definitions

Type of practice means the category in which the registered principal of the practice can practise architecture.


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