World Health Organization recommendations are often strong based on low confidence in effect estimates Journal Articles uri icon

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  • OBJECTIVES: Expert guideline panelists are sometimes reluctant to offer weak/conditional/contingent recommendations. Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance warns against strong recommendations when confidence in effect estimates is low or very low, suggesting that such recommendations may seldom be justified. We aim to characterize the classification of strength of recommendations and confidence in estimates in World Health Organization (WHO) guidelines that used the GRADE approach and graded both strength and confidence (GRADEd). STUDY DESIGN AND SETTING: We reviewed all WHO guidelines (January 2007 to December 2012), identified those that were GRADEd, and, in these, examined the classifications of strong and weak and associated confidence in estimates (high, moderate, low, and very low). RESULTS: We identified 116 WHO guidelines in which 43 (37%) were GRADEd and had 456 recommendations, of which 289 (63.4%) were strong and 167 (36.6%) were conditional/weak. Of the 289 strong recommendations, 95 (33.0%) were based on evidence warranting low confidence in estimates and 65 (22.5%) on evidence warranting very low confidence in estimates (55.5% strong recommendations overall based on low or very low confidence in estimates). CONCLUSION: Strong recommendations based on low or very low confidence estimates are very frequently made in WHO guidelines. Further study to determine the reasons for such high uncertainty recommendations is warranted.


  • Alexander, Paul E
  • Bero, Lisa
  • Montori, Victor M
  • Brito, Juan Pablo
  • Stoltzfus, Rebecca
  • Djulbegovic, Benjamin
  • Neumann, Ignacio
  • Rave, Supriya
  • Guyatt, Gordon

publication date

  • June 2014