Core GRADE 7: principles for moving from evidence to recommendations and decisions

Guyatt, Gordon and Vandvik, Per Olav and Iorio, Alfonso and Agarwal, Arnav and Yao, Liang and Eachempati, Prashanti and Zeng, Linan and Chu, Derek K and D'Souza, Rohan and Agoritsas, Thomas and Murad, M Hassan and Schandelmaier, Stefan and Rylance, Jamie and Djulbegovic, Benjamin and Montori, Victor M and Hultcrantz, Monica and Brignardello-Petersen, Romina (2025) Core GRADE 7: principles for moving from evidence to recommendations and decisions. BMJ (Clinical research ed.), 389. No. e083867. ISSN 1756-1833

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Abstract

This seventh article in a seven part series presents the Core GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for moving from evidence to recommendations or policy decisions. Core GRADE users make strong recommendations for an intervention versus a comparator when the desirable consequences clearly outweigh the undesirable consequences, and a conditional (weak) recommendation when the balance is less clear. Primary considerations in deciding on recommendations considering an individual patient perspective include balance of benefits, harms, and burdens; the certainty of evidence; and values and preferences. Secondary considerations, most important from a population perspective, include costs, feasibility, acceptability, and equity. Moving from evidence to recommendations begins with considering evidence regarding patients’ values and preferences and choosing the smallest difference in each outcome that patients perceive as important (the minimal important difference). Core GRADE users construct statements that make clear the values and preferences underlying their recommendations. In general, Core GRADE users make strong recommendations only when certainty of evidence is high or moderate. When evidence certainty is low, recommendations will be conditional under all but special circumstances.

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