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Evidence Based Practice Tutorial

Applying What You Learned

  1. How does the new information influence your previous knowledge?
  2. What factors now need to be assessed for implementation?
    • Patient values and circumstances
    • Community and cultural practices
    • Best Research Available
    • Information from the practice context (is it feasible?)
    • Clinical Expertise

Moving from Evidence to Recommendations


Grading of Recommendations, Assessment, Development and Evaluations (GRADE) 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 organizations worldwide officially endorsing GRADE.

GRADE provides a way of assessing confidence in research by providing Four Levels of Evidence.

Certainty Level What it Means

Very Low

The true effect is probably markedly different from the estimated effect
Low The true effect might be markedly different from the estimated effect
Moderate The authors believe that the true effect is probably close to the estimated effect
High The authors believe that the true effect is probably close 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.

Factors that influence certainty:

Negative Certainty Influence Positive Certainty Influence
  • Risk of Bias (bad randomization, etc)
  • Imprecision
  • Inconsistency
  • Indirectness
  • Publication Bias
  • Large Magnitude 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 favor of 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 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.