Dana Best

Users of clinical practice guidelines and other recommendations need to know how much confidence they can place in the recommendations. Systematic and explicit methods of making judgments can reduce errors and improve communication. We have developed a system for grading the quality of evidence and the strength of recommendations that can be applied across a wide range of interventions and contexts. In this article we present a summary of our approach from the perspective of a guideline user. Judgments about the strength of a recommendation require consideration of the balance between benefits and harms, the quality of the evidence, translation of the evidence into specific circumstances, and the certainty of the baseline risk. It is also important to consider costs (resource utilisation) before making a recommendation. Inconsistencies among systems for grading the quality of evidence and the strength of recommendations reduce their potential to facilitate critical appraisal and improve communication of these judgments. Our system for guiding these complex judgments balances the need for simplicity with the need for full and transparent consideration of all important issues.

The GRADE Working Group is developing and evaluating a common, sensible approach to grading quality of evidence and strength of recommendations in health care. In this article, we discuss the advantages and disadvantages of using letters, numbers, symbols or words to represent grades of evidence and recommendations. Using multiple strategies, we searched for comparative studies of alternative ways of representing ordered categories in any context. In addition, we contacted experts and reviewed theoretical work and qualitative research on how best to communicate grades of any kind quickly and clearly. We were unable to identify health care research that addressed, either directly or indirectly, the best way to present grades of evidence and recommendations. 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. Although a number of grading systems are used in health care and other fields, there is little or no evidence of how well various presentations are understood. Before promoting the use of specific symbols, numbers, letters or words, the extent to which the intended message is comprehended should be evaluated.

Incidence of EBL (blood lead > or =10 microg/dL) for children aged < or = 1.3 years in Washington, DC increased more than 4 times comparing 2001-2003 when lead in water was high versus 2000 when lead in water was low. The incidence of EBL was highly correlated (R2 = 0.81) to 90th percentile lead in water lead levels (WLLs) from 2000 to 2007 for children aged < or = 1.3 years. The risk of exposure to high water lead levels varied markedly in different neighborhoods of the city. For children aged < or =30 months there were not strong correlations between WLLs and EBL, when analyzed for the city as a whole. However, the incidence of EBL increased 2.4 times in high-risk neighborhoods, increased 1.12 times in moderate-risk neighborhoods, and decreased in low-risk neighborhoods comparing 2003 to 2000. The incidence of EBL for children aged < or =30 months also deviated from national trends in a manner that was highly correlated with 90th percentile lead in water levels from 2000 to 2007 (R2 = 0.83) in the high-risk neighborhoods. These effects are consistent with predictions based on biokinetic models and prior research.

Secondhand tobacco smoke (SHS) exposure of children and their families causes significant morbidity and mortality. In their personal and professional roles, pediatricians have many opportunities to advocate for elimination of SHS exposure of children, to counsel tobacco users to quit, and to counsel children never to start. This report discusses the harms of tobacco use and SHS exposure, the extent and costs of tobacco use and SHS exposure, and the evidence that supports counseling and other clinical interventions in the cycle of tobacco use. Recommendations for future research, policy, and clinical practice change are discussed. To improve understanding and provide support for these activities, the harms of SHS exposure are discussed, effective ways to eliminate or reduce SHS exposure are presented, and policies that support a smoke-free environment are outlined.