• Monica Hultcrantz, David Rind, Elie A Akl, Shaun Treweek, Reem A Mustafa, Alfonso Iorio, Brian S Alper, Joerg J Meerpohl, M Hassan Murad, Mohammed T Ansari, KatikireddiSrinivasa VittalSVMRC/CSO Social & Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3QB, UK., Pernilla Östlund, Sofia Tranæus, Robin Christensen, Gerald Gartlehner, Jan Brozek, Ariel Izcovich, Holger Schünemann, and Gordon Guyatt.
• Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), S:t Eriksgatan 117, SE-102 33, Stockholm, Sweden; Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodav. 18 A, SE-171 77, Stockholm, Sweden. Electronic address: monica.hultcrantz@sbu.se.
• J Clin Epidemiol. 2017 Jul 1; 87: 4-13.

ObjectiveTo clarify the grading of recommendations assessment, development and evaluation (GRADE) definition of certainty of evidence and suggest possible approaches to rating certainty of the evidence for systematic reviews, health technology assessments, and guidelines.Study Design And SettingThis work was carried out by a project group within the GRADE Working Group, through brainstorming and iterative refinement of ideas, using input from workshops, presentations, and discussions at GRADE Working Group meetings to produce this document, which constitutes official GRADE guidance.ResultsCertainty of evidence is best considered as the certainty that a true effect lies on one side of a specified threshold or within a chosen range. We define possible approaches for choosing threshold or range. For guidelines, what we call a fully contextualized approach requires simultaneously considering all critical outcomes and their relative value. Less-contextualized approaches, more appropriate for systematic reviews and health technology assessments, include using specified ranges of magnitude of effect, for example, ranges of what we might consider no effect, trivial, small, moderate, or large effects.ConclusionIt is desirable for systematic review authors, guideline panelists, and health technology assessors to specify the threshold or ranges they are using when rating the certainty in evidence.Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

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