---
title: "GRADE approach"
chunk: 2/2
source: "https://en.wikipedia.org/wiki/GRADE_approach"
category: "reference"
tags: "science, encyclopedia"
date_saved: "2026-05-05T04:25:54.489651+00:00"
instance: "kb-cron"
---

=== Certainty of evidence ===
GRADE rates the certainty of evidence as follows:

The GRADE working group has developed a software application that facilitates the use of the approach, allows the development of summary tables and contains the GRADE handbook. The software is free for non-profit organizations and is available online.
The GRADE approach to assess the certainty in evidence is widely applicable, including to questions about diagnosis, prognosis, network meta-analysis and public health.

=== Strength of recommendation ===
Factors and criteria that determine the direction and strength of a recommendation:

Factors for which overlap is described are often not shown separately in a decision table.

== Usage ==
Over 100 organizations (including the World Health Organization, the UK National Institute for Health and Care Excellence (NICE), the Canadian Task Force for Preventive Health Care, the Colombian Ministry of Health and Social Protection, and the Saudi Arabian Ministry of Health) have endorsed and/or are using GRADE to evaluate the quality of evidence and strength of health care recommendations.

== Criticism ==
When used to summarize evidence from nutritional science, dietary, lifestyle, and environmental exposure, the use of the GRADE approach has been criticized. Critics argue that the GRADE system had focused on randomized controlled trials (RCT) to be rated as high evidence and rates all observational studies as low evidence because of their potential for confounding, but this is incorrect and observational studies can yield high certainty evidence which is made explicit in GRADE guidance Number 18. Such an approach could have dismissed the strength of observational studies when it comes to long-term effects of dietary and lifestyle factors while not reflecting the key limitations that RCTs have when it comes to long-term effects. One example of a slowly progressing disease that should, according to critics, preferably be studied with observational studies but not RCTs is atherosclerosis. Indeed, non-randomized studies may be rated as high certainty when using GRADE if they take measures to control for confounding. Furthermore, the GRADE Working Group has published other guidance that lays out how observational studies can be utilized in the context of long-term effects which does not dismiss the value of observational studies.

== References ==