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We found examples of symbols used by government, commercial and consumer organizations to communicate quality of evidence or strength of recommendations, but no comparative studies. We were unable to identify health care research that addressed, either directly or indirectly, the best way to present grades of evidence and recommendations. In addition, we contacted experts and reviewed theoretical work and qualitative research on how best to communicate grades of any kind quickly and clearly. Using multiple strategies, we searched for comparative studies of alternative ways of representing ordered categories in any context.
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In this article, we discuss the advantages and disadvantages of using letters, numbers, symbols or words to represent grades of evidence and recommendations.
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THE GRADE WORKING GROUP IS DEVELOPING and evaluating a common, sensible approach to grading quality of evidence and strength of recommendations in health care. Williams Jr., Associate Professor, The Center for Health Services Research in Primary Care, Health Services Research and Development, Department of Veterans Affairs Medical Center and Duke University Medical Center, USA Stephanie Zaza, Acting Associate Director for Science, Epidemiology Program Office, Centers for Disease Control and Prevention, USA Haugh, Methodologist, Fédération Nationale des Centres de Lutte Contre le Cancer, France David Henry, Professor and Suzanne Hill, Senior Lecturer, Department of Clinical Pharmacology, Faculty of Medicine and Health Sciences, University of Newcastle, Australia Gillian Leng, Guidelines Programme Director, National Institute for Clinical Excellence, United Kingdom Alessandro Liberati, Professor, Università di Modena e Reggio Emilia and Centro per la Valutazione della Efficacia della Assistenza Sanitaria, Italy Nicola Magrini, Director, Centro per la Valutazione della Efficacia della Assistenza Sanitaria, Italy Philippa Middleton, Honorary Research Fellow, Australasian Cochrane Centre, Australia Jacek Mrukowicz, Executive Director, Polish Institute for Evidence Based Medicine, Poland Dianne O'Connell, Senior Epidemiologist, Cancer Epidemiology Research Unit, Cancer Research and Registers Division, The Cancer Council, Australia Bob Phillips, Associate Fellow, Centre for Evidence-based Medicine, University Department of Psychiatry, Warneford Hospital, United Kingdom Holger J Schünemann, Assistant Professor, Departments of Medicine and of Social & Preventive Medicine, University of Buffalo, USA Tessa Tan-Torres Edejer, Medical Officer/Scientist, Global Programme on Evidence for Health Policy, World Health Organisation, Switzerland Helena Varonen, Associate Editor, Finnish Medical Society Duodecim, Finland John W. Harbour, Quality and Information Director, Scottish Intercollegiate Guidelines Network, United Kingdom Margaret C. Guyatt, Professor, and Roman Jaeschke, Associate Clinical Professor, Departments of Clinical Epidemiology and Biostatistics and Medicine, McMaster University, Canada Robin T. Oxman, Director, Department of Health Services Research, Norwegian Directorate for Health and Social Welfare, Norway Gordon H. Vist, Researcher, Signe Flottorp, Researcher, and Andrew D. Yngve Falck-Ytter, Associate Director, German Cochrane Centre, Institute for Medical Biometry and Medical Informatics, University Hospital Freiburg, Germany Gunn E. Members of the GRADE Working Group: David Atkins, Chief Medical Officer, Center for Practice and Technology Assessment, Agency for Healthcare Research and Quality, USA Dana Best, Assistant Professor, Department of General Pediatrics and Adolescent Medicine, George Washington University, Children's National Medical Center, USA Peter A Briss, Acting Chief Community Guide Branch, Centers for Disease Control and Prevention, USA Martin Eccles, Professor, and James Mason, Professor, Centre for Health Services Research, University of Newcastle upon Tyne, U.K. (Schünemann) the Division of General Pediatrics, Children's National Medical Center, Washington, DC (Best) and the Department of Health Services Research, Norwegian Directorate for Health and Social Welfare, Oslo, Norway (Vist, Oxman) From the Departments of Medicine and of Social and Preventive Medicine, University of Buffalo, Buffalo, NY (Schünemann) the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.