GRADE guidelines: 9. Rating up the quality of evidence

Gordon H. Guyatt*, Andrew D. Oxman, Shahnaz Sultan, Paul Glasziou, Elie A. Akl, Pablo Alonso-Coello, David Atkins, Regina Kunz, Jan Brozek, Victor Montori, Roman Jaeschke, David Rind, Philipp Dahm, Joerg Meerpohl, Gunn Vist, Elise Berliner, Susan Norris, Yngve Falck-Ytter, M. Hassan Murad, Holger J. Schünemann

*Corresponding author for this work

Research output: Contribution to journalArticleResearchpeer-review

934 Citations (Scopus)


The most common reason for rating up the quality of evidence is a large effect. GRADE suggests considering rating up quality of evidence one level when methodologically rigorous observational studies show at least a two-fold reduction or increase in risk, and rating up two levels for at least a five-fold reduction or increase in risk. Systematic review authors and guideline developers may also consider rating up quality of evidence when a dose-response gradient is present, and when all plausible confounders or biases would decrease an apparent treatment effect, or would create a spurious effect when results suggest no effect. Other considerations include the rapidity of the response, the underlying trajectory of the condition, and indirect evidence.

Original languageEnglish
Pages (from-to)1311-1316
Number of pages6
JournalJournal of Clinical Epidemiology
Issue number12
Publication statusPublished - Dec 2011


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