The GRADE handbook

You can find the GRADE handbook here: GRADE handbook

Or go directly to one of the chapters: 

1. Overview of the GRADE Approach

1.1 Purpose and advantages of the GRADE approach

1.2 Separation of confidence in effect estimates from strength of recommendations

1.3 Special challenges in applying the the GRADE approach

1.4 Modifications to the GRADE approach

2. Framing the health care question

2.1 Defining the patient population and intervention

2.2 Dealing with multiple comparators

2.3 Other considerations

2.4 Format of health care questions using the GRADE approach

3. Selecting and rating the importance of outcomes

3.1 Steps for considering the relative importance of outcomes

3.2 Influence of perspective

3.3 Using evidence in rating the importance of outcomes

3.4 Surrogate (substitute) outcomes

4. Summarizing the evidence

4.1 Evidence Tables

4.2 GRADE Evidence Profile

4.3 Summary of Findings table

5. Quality of evidence

5.1 Factors determining the quality of evidence

5.1.1 Study design

5.2 Factors that can reduce the quality of the evidence

5.2.1 Study limitations (Risk of Bias)

5.2.2 Inconsistency of results

5.2.2.1 Deciding whether to use estimates from a subgroup analysis

5.2.3 Indirectness of evidence

5.2.4 Imprecision

5.2.4.1 Imprecision in guidelines

5.2.4.2 Imprecision in in systematic reviews

5.2.4.3 Rating down two levels for imprecision

5.2.5 Publication bias

5.3. Factors that can increase the quality of the evidence

5.3.1 Large magnitude of an effect

5.3.2. Dose-response gradient

5.3.3. Effect of plausible residual confounding

5.4 Overall quality of evidence

6. Going from evidence to recommendations

6.1 Recommendations and their strength

6.1.1 Strong recommendation

6.1.2 Weak recommendation

6.1.3 Recommendations to use interventions only in research

6.1.4 No recommendation

6.2 Factors determining direction and strength of recommendations

6.2.1 Balance of desirable and undesirable consequences

6.2.1.1 Estimates of the magnitude of the desirable and undesirable effects

6.2.1.2 Best estimates of values and preferences

6.3.2 Confidence in best estimates of magnitude of effects (quality of evidence)

6.3.3 Confidence in values and preferences

6.3.4 Resource use (cost)

6.3.4.1 Differences between costs and other outcomes

6.3.4.2 Perspective

6.3.4.3 Resource implications considered

6.3.4.4 Confidence in the estimates of resource use (quality of the evidence about cost)

6.3.4.5 Presentation of resource use

6.3.4.6 Economic model

6.3.4.7 Consideration of resource use in recommendations

6.4 Presentation of recommendations

6.4.1 Wording of recommandations

6.3.2 Symbolic representation

6.4.3 Providing transparent statements about assumed values and preferences

6.5 The Evidence-to-Decision framework

7. The GRADE approach for diagnostic tests and strategies

7.1. Questions about diagnostic tests

7.1.1. Establishing the purpose of a test

7.1.2. Establishing the role of a test

7.1.3. Clear clinical questions

7.2. Gold standard and reference test

7.3. Estimating impact on patients

7.4. Indirect evidence and impact on patient-important outcomes

7.5. Judgment about the quality of the underlying evidence

7.5.1. Initial study design

7.5.2. Factors that determine and can decrease the quality of evidence

7.5.2.1. Risk of bias

7.5.2.2. Indirectness of the evidence

7.5.2.3. Inconsistency, imprecision, publication bias and upgrading for dose effect, large estimates of accuracy and residual plausible confounding

7.5.3. Overall confidence in estimates of effects

8. Criteria for determining whether the GRADE approach was used

9. Glossary of terms and concepts

10. Articles about GRADE

11. Additional resources

12. The GRADE Working Group


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