The Grade Working Group: Grading the Graders

Welcome to the  Grade Working Group: From evidence to recommendations – transparent and sensible

The Grading of Recommendations Assessment, Development and Evaluation (short GRADE) working group began in the year 2000 as an informal collaboration of people with an interest in addressing the shortcomings of grading systems in health care. 

The working group has developed a common, sensible and transparent approach to grading quality (or certainty) of evidence and strength of recommendations.

So this is a group that’s grading the graders? 

Considering the increasing conflicts of interest in so-called “scientific” research, we’re on our own. We ourselves have to review the study methods, validate the assumptions used, find the distortions of bias, and fact-check every statement because even peer review isn’t catching the problems (possibly because “peers” know that the authors they are reviewing may at some time end up reviewing their own work).

A selected list of GRADE publications to get you started or to provide a deep-dive.


Want to quickly find out what GRADE is all about? We suggest reading our BMJ series. Please note that the online text is the longer, full version of the submitted manuscript. The pdf’s on BMJ’s website are abbreviated print issues.

You can also learn more about how diagnostic tests and strategies or resource use are considered in GRADE.


The JCE series and the GRADE handbook in GRADEproprovide a guide for systematic review and health technology assessment authors, guideline panelists and methodologists on how to apply the GRADE methodology framework in more detail: 

GRADE evidence profiles,

Summary of Findings tables (binary) and (continues), presentation of recommendations, and recommendation’s direction and strength.

There’s even an online book about these issues:

Clinical Practice Guidelines We Can Trust | The National Academies Press – 2011

Advances in medical, biomedical and health services research have reduced the level of uncertainty in clinical practice.


The more we learn, the more other variables/factors we find and our original inquiry becomes ever more complicated. Our original questions are multiplied by countless other factors besides the ones we’re looking at. We are more uncertain than ever.

Clinical Practice Guidelines We Can Trust examines the current state of clinical practice guidelines and how they can be improved to enhance healthcare quality and patient outcomes.

Clinical practice guidelines now are ubiquitous in our healthcare system.

The Guidelines International Network (GIN) database currently lists more than 3,700 guidelines from 39 countries.

Clinical Practice Guidelines We Can Trust explores questions surrounding the quality of CPG development processes and the establishment of standards.

It proposes eight standards for developing trustworthy clinical practice guidelines emphasizing

  1. transparency;
  2. management of conflict of interest;
  3. systematic review–guideline development intersection;
  4. establishing evidence foundations for and
  5. rating strength of guideline recommendations;
  6. articulation of recommendations;
  7. external review; and
  8. updating.

Clinical Practice Guidelines We Can Trust shows how clinical practice guidelines can enhance clinician and patient decision-making by translating complex scientific research findings into recommendations for clinical practice that are

relevant to the individual patient encounter, instead of implementing a one size fits all approach to patient care.

How can any standard *not* be one size fits all?

Isn’t that the whole point of standards: that we treat everyone according to the same standard rules?

I can’t imagine how a guideline or standard can be relevant to all patients to whom such standards apply (or are applied, regardless).

You can access the full book in two ways:

Other thoughts?

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