From: Introducing GRADE (Dijkers, 2013) from KT Update, V1, N5.

Figure 1: Overview of the GRADE process (modified from Guyatt et al. (2011)

Figure 1 presents a schematic view of GRADE's process for developing recommendations; the top half describes steps in the process common to systematic reviews and to guideline development, and the lower half describe steps that are specific to guideline creation.

On the left side of the figure, the top half is indicated by a box on its side with the words, "Systematic reviewing steps." A bracket between that box and several boxes on the top half of the image indicate they relate to the Systematic reviewing steps. On the left side, the bottom half is indicated by a box on its side with the words, "Guideline development steps." A bracket between that box and two boxes on the lower half of the image indicate they relate to the Guideline development steps.

At the top of the image is a box with the words: Question (clinical, public health, health system, etc.)
From the bottom of the Question box, five lines connect that box to five smaller boxes with the words Study 1, Study 2, Study 3, Study 4, and Study 5.

Below that row of five boxes are three boxes side by side, labeled Outcome 1, Outcome 2, and Outcome 3.

Lines from the bottom of Study 1 and Study 2 connect to Outcome 1 on the left and Outcome 2 in the center.
A box with a dashed border is below Outcomes 1 and 2; it is labeled Important outcomes.

Lines from Study 3 connect to Outcome 2 and to Outcome 3.

Lines from Study 4 and Study 5 connect to Outcome 3 on the right.
A box with a dashed border is below Outcome 3; it is labeled Critical outcome.

A box with a solid border below Important and Critical outcomes contains the sentence: Generate an estimate of effect for each outcome.

Under that box, a thick arrow points to a box below it that contains four sentences:

  1. Rate the quality of the evidence for each outcome across studies.
  2. Reduce the rating as needed (study limitations, imprecision, inconsistency of results, indirectness of evidence, likelihood of publication bias).
  3. Increase the rating as warranted (large effect size, dose-response curve, confounders are likely to minimize the effect).
  4. Final rating of evidence quality for each outcome: high, moderate, low or very low.

The next two boxes in the bottom half of the figure relate to Guideline development steps. Below the box on rating quality of the evidence for each outcome, a thick arrow points to a box below it that contains the words in bold: Rate the overall quality of the evidence (lowest quality among critical outcomes)

Below that box, a thick arrow points to a box below it that contains two sentences:

  1. (Decide on the direction (for/against) and grade strength (strong/weak) of the recommendation, considering:
  2. Decide if any revision of direction or strength is necessary considering: resource use.

Source: Modified from Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):383-394. doi: 10.1016/j.jclinepi.2010.04.026

Copyright © 2011 by Elsevier Inc. All rights reserved. SEDL adapted with permission from author Gordon Guyatt and used with fee-based permission from Copyright Clearance Center's Rightlinks service.