Grading recommendations in clinical practice guidelines: randomised experimental evaluation of four different systems

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Abstract
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; pConclusion The clinician's decision to use a therapy was influenced most by the GRADE system. Trial registration number NCT00940290.

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