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While grading the strength of recommendations and the quality of underlying evidence enhances the usefulness of clinical guidelines, the profusion of guideline grading systems undermines the value of the grading exercise. An American College of Chest Physicians (ACCP) task force formulated the criteria for a grading system to be utilized in all ACCP guidelines that included simplicity and transparency, explicitness of methodology, and consistency with current methodological approaches to the grading process. The working group examined currently available systems, and ultimately modified an approach formulated by the international GRADE group. The grading scheme classifies recommendations as strong (grade 1) or weak (grade 2), according to the balance among benefits, risks, burdens, and possibly cost, and the degree of confidence in estimates of benefits, risks, and burdens. The system classifies quality of evidence as high (grade A), moderate (grade B), or low (grade C) according to factors that include the study design, the consistency of the results, and the directness of the evidence. For all future ACCP guidelines, The College has adopted a simple, transparent approach to grading recommendations that is consistent with current developments in the field. The trend toward uniformity of approaches to grading will enhance the usefulness of practice guidelines for clinicians. (CHEST 2006; 129:174-181)
Key words: grading recommendations; grading system; methodology
Abbreviations: ACCP = American College of Chest Physicians; RCT = randomized controlled trial; RRR = relative risk reduction
Treatment decisions involve a tradeoff between benefits on the one hand, and risks, burdens, and, potentially, costs on the other. Guideline panels provide recommendations for the management of typical patients. To integrate these recommendations with their own clinical judgment, and with individual patient values and preferences, clinicians need to understand the basis for the recommendations that expert guidelines offer. A systematic approach to grading the strength of management recommendations can minimize bias and aid interpretation.3 Indeed, most guideline groups have accepted the necessity for some sort of grading scheme.
While the grading of recommendations represents a positive development for guideline development and interpretation, the proliferation of grading systems has proved to be an unfortunate consequence. Methodologists and guideline developers have given much thought and effort to considering the criteria and approaches to an optimal grading system. The American College of Chest Physicians...