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Modifying the GRADE framework could benefit public health
  1. D N Durrheim1,
  2. A Reingold2
  1. 1School of Public Health and Medical Practice, University of Newcastle, Newcastle, New South Wales, Australia
  2. 2School of Public Health, University of California, Berkeley, California, USA
  1. Correspondence to David N Durrheim, Private Bag X10, Wallsend, 2287 NSW, Australia; david.durrheim{at}

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The commitment in recent years to ensuring that rigorous evidence is available to guide medical practice and health policy making is commendable. To guide the assessment of evidence, various approaches have emerged in recent years. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework has enjoyed particular popularity, providing a systematic and intelligible approach to ranking available research outcomes.1

The merits and limitations of the GRADE framework for systematically evaluating the quality of evidence for guiding clinical practice guidelines have recently been eloquently debated.2 3 We will not dwell on the methodological allegations that GRADE suffers from external and internal inconsistency, potential for bias and lack of validation, nor the possibility that these apparent flaws are a result of maladroit operators rather than framework deficiencies. Our concern is that the GRADE framework may have some unforeseen detrimental public health impacts unless modified.

The large-scale vigorous adoption of the framework across the global public health …

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  • Competing interests None.

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