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Grading recommendations in clinical practice guidelines: randomised experimental evaluation of four different systems
  1. Carlos A Cuello García1,2,
  2. Karla P Pacheco Alvarado1,2,
  3. Giordano Pérez Gaxiola3
  1. 1Centre for Evidence-Based Practice, Tecnológico de Monterrey, School of Medicine, Monterrey, Mexico
  2. 2Quality in Healthcare and Patient Safety Residency Programme, Tecnológico de Monterrey, School of Medicine, Monterrey, Mexico
  3. 3Department of Evidence-Based Medicine, Hospital Pediátrico de Sinaloa ‘Dr. Rigoberto Aguilar Pico’, Culiacán, Mexico
  1. Correspondence to Carlos A Cuello Garcia, Avda. Morones Prieto 3000 pte, CITES piso 3, Col. Los Doctores, 64710, Monterrey NL, Mexico; carlos.cuello{at}


Objective To evaluate the effect of presenting a recommendation in a clinical practice guideline using different grading systems to determine to what extent the system used changes the clinician's eventual response to a particular clinical question.

Design Randomised experimental study.

Setting Clinician offices and academic settings.

Participants Paediatricians and paediatric residents in private and public practice in Mexico.

Intervention Case notes of a child with diarrhoea and a question about clinician preference for using racecadotril. The same evidence was provided in a clinical recommendation but with different presentations according to the following grading systems: NICE (National Institute for Health and Clinical Excellence), SIGN (Scottish Intercollegiate Guideline Network), GRADE (Grading of Recommendations Assessment, Development and Evaluation) and CEBM (Centre for Evidence-Based Medicine, Oxford).

Main outcome measure Mean change in direction from baseline response (measured on a 10 cm visual scale and a Likert scale) and among groups.

Results 216 subjects agreed to participate. Most participants changed their decision after reading the clinical recommendations (mean difference 0.7 cm, 95% CI 0.29 to 1.0; p<0.001). By groups, mean change (95% CI) from baseline was 0.04 (−0.68 to 0.77) for NICE, 0.31 (−0.41 to 1.05) for SIGN, 2.18 (1.48 to 2.88) for GRADE and 0.08 (−0.52 to 0.69) for CEBM (p=0.007 between groups). In a final survey, a small difference was noted regarding the clarity of the results presented with the GRADE system.

Conclusion The clinician's decision to use a therapy was influenced most by the GRADE system.

Trial registration number NCT00940290.

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  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Institutional Review Board of the Tecnólogico de Monterrey School of Medicine.

  • Provenance and peer review Not commissioned; externally peer reviewed.