Grading quality of evidence and strength of recommendations: a perspective

Systematic reviews are considered the best available evidence and are often used in the development of CPGs [1],[2]. Since guideline development involves an assessment of the overall quality of evidence and complex balancing of trade-offs between the important benefits and harms of any given intervention, arbitrariness, value judgements, and subjectivity ultimately come into play in the guideline development process and associated recommendations [3]. In a new Policy Forum published in this issue of PLoS Medicine, Kavanagh [9] questions the external consistency of the GRADE framework by comparing the Surviving Sepsis Campaign (SSC) guideline recommendations developed in 2004 and updated in 2008. [...]Kavanagh expresses his concerns on the processes of the GRADE development and its formal validation.