Evolution of Levels of Evidence and Strength of Recommendations in Medical Research_Chinese Journal of Evidence-Based Medicine

Authors：

CHEN Yaolong ¹ ,  LI Youping ¹ , DU Liang ² , WANG Li ¹ , WEN Jin ¹ , YANG Xiaoyan ¹

1. Clinical Epidemiology and Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu 610041, China2. Editorial Board of the Chinese Journal of Evidence Based Medicine, West China Hospital, Sichuan University, Chengdu 610041, China;

Corresponding author：

LI Youping, Email: yzmylab@hotmail.com

Keywords：

Evidence-based Medicine; Levels of Evidence; Strength of Recommendations

DOI：

10.7507/1672-2531.20080028

Video：

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A systematic literature search and a comparative study were conducted to investigate the evolution of the levels of evidence and strength of recommendations in medical research. Fifty systems were included from 1979 to 2007, and 11 of these, which came from five states or international organizations, were selected and divided into three stages according to their characteristics, sphere of influence and application fields. Ideas about levels of evidence and strength of recommendations are becoming mature in medical research. The challenge for the future is how to introduce evidence-based principles and develop the corresponding levels of evidence and strength of recommendations in the fields of management, education, basic medical sciences, economics, sociology and legal research.

Citation： CHEN Yaolong,LI Youping,DU Liang,WANG Li,WEN Jin,YANG Xiaoyan. Evolution of Levels of Evidence and Strength of Recommendations in Medical Research. Chinese Journal of Evidence-Based Medicine, 2008, 08(2): 127-133. doi: 10.7507/1672-2531.20080028 Copy

1.	McCol l A, Smith H,White P,et al .General practitioner’s perceptions of the route to evidence based medicine: a questionnaire survey. BMJ, 1998, 316(7128): 361-365.
2.	Guyatt G, Meade M,Jaeschke R,et al. Practitioners of evidence based care: not all clinicians need to appraise evidence from scratch but all need some skills. BMJ, 2000, 320(7240): 954-955.
3.	Glasziou P, Vandenbroucke JP, Chalmers I. assessing the qual ity of research. BMJ, 2004, 328(7430): 39-41.
4.	Campbell DT, Stanley JC. Experimental and quasi-experimental designs for Research.Chicago, IL: Rand McNally College, 1963.
5.	Chalmers I, Hedges L, Cooper H. A brief history of research synthesis. Evaluation & the health professions, 2002, 25(1): 12-37.
6.	Canadian Task Force on the Periodic Health Examination: The periodic health examination. CMAJ, 1979, 121(19): 1193-1254.
7.	Schünemann HJ, Best D, Vist G, et al. Letters, numbers, symbols and words: how to communicate grades of evidence and recommendations. CMAJ, 2003, 169(7): 677-680.
8.	Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ, 2004, 328(7454): 1490-1494.
9.	Goldbloom R. Weighing the evidence: the Canadian experience. Am J Clin Nutr, 1997, 65(2 suppl): 584S-586S.
10.	Atkins D, Eccles M, Flottorp S. Systems for grading the quality of evidence and the strength of recommendations I: Critical appraisal of existing approaches. BMC Health Serv Res, 2004, 4(1): 38.
11.	Sackett DL. Rules of evidence and cl inical recommendations on the use of antithrombotic agents. Chest, 1986, 89(2 Suppl): 2S-3S.
12.	Sackett DL. Rules of evidence and cl inical recommendations on the use of antithrombotic agents. Archives Int Med, 1986, 146(3): 464-465.
13.	Guyatt GH,Sackett DL,Sinclair JC,et al .Users’ guides to the medical literature.IX. A method for grading health care recommendations. Evidence-Based Medicine Working Group. JAMA, 1995, 274(22): 1800-1804.
14.	Sackett DL. Rules of evidence and cl inical recommendations on the use of antithrombotic agents. Chest, 1989, 95(2): 2S-4S.
15.	Cook DJ, Guyatt GH, Laupacis A,et al. Rules of evidence and cl inical recommendations on the use of antithrombotic agents. Chest, 1992, 102(4): 305S-311S.
16.	Cook DJ, Guyatt GH, Laupacis A, et al. Clinical recommendations using levels of evidence for antithrombotic agents. Chest, 1995, 108(4): 227S-230S.
17.	Guyatt GH, Cook DJ, Sackett DL, et al. Grades of recommendation for antithrombotic agents. Chest, 1998, 114(5 Suppl): 441S-444S.
18.	Guyatt G, Schünemann H, Cook D,et al . Grades of Recommendation for Antithrombotic Agents. Chest, 2001, 119(1): 3S-7S.
19.	Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidel ines: report from an american college of chest physicians task force. Chest, 2006, 129(1): 174-181.
20.	http://www.inclen.org/history.html.
21.	陈洁. 医学技术评估. 上海: 上海医科大学出版社. 1996.
22.	Cochrane A. Effectiveness and Efficiency: Random Reflections on Health Services. London: Nuffield Provincial Hospitals Trust, 1972.
23.	Guyatt GH. 循证医学的五个发展方向. 中国循证医学杂志, 2006, 6(3): 175-161.
24.	Cinical Practice Guideline No.1: acute pain management: operative or medical procedures and trauma. Rockville (MD): US Department of Health and Human Services. Agency for Health Care Pol icy and Research; 1993. AHCPR Publication No. 92-0023.
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26.	Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ, 2001, 323(7308): 334-336.
27.	Van Tulder W, Koes W, Bouter M. Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions. Spine, 1997, 22(18): 2128-2156.
28.	Working Party for Guidelines for the Management of Heavy Menstrual Bleeding.An evidence-based guideline for the management of heavy menstrual bleeding. N Z Med J,1999, 112(1088): 174-177.
29.	National Health and Medical Research Council (NHMRC). How to Use the Evidence: Assessment and Appl ication of Scientific Evidence. Canberra, Austral ia: NHMRC; 2000.
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32.	http://www.gradeworkinggroup.org/about_us.htm.
33.	http://library.downstate.edu/ebmdos/2100.htm.
34.	Aragon CL, Budsberg SC. Applications of Evidence-Based Medicine: Cranial Cruciate Ligament Injury Repair in the Dog Veterinary Surgery. 34(2): 93–98.
35.	李幼平, 陶铁军, 孙丁, 等. 我国专科医师分类研究初探. 中国循证医学杂志, 2004, 4(3): 173-180.
36.	谢瑜, 文进, 高晓凤, 等. 国外航空风险管理方法及绩效的循证评价——医疗风险系列研究之一. 中国循证医学杂志, 2006, 6(2): 131-138.
37.	高晓凤,谢瑜,文进, 等.我国煤矿业风险管理现状的循证评价——医疗风险系列研究之二. 中国循证医学杂志, 2006, (3): 202-208.
38.	文进, 谢瑜, 高晓凤, 等. 美国飓风风险管理的循证评价及其对我国医疗风险管理的启示——医疗风险系列研究之三. 中国循证医学杂志, 2006, (3): 209-217.
39.	杨克虎, 马彬, 田金徽, 等. 美国医疗风险监测预警机制现状及绩效的循证评价. 中国循证医学杂志, 2006, (6): 439-450.
40.	马彬, 杨克虎, 刘雅莉, 等. 英国医疗风险监管体系的循证评价及其对我国医疗风险管理的启示——关注病人安全, 预防医疗差错, 提高医疗质量. 中国循证医学杂志, 2006, (7): 514-522.
41.	刘雅莉, 景涛, 田金徽, 等. 新西兰医疗风险防范及监管机制现状的循证评价——完善诉讼体系,规范医疗行为, 防范医疗风险. 中国循证医学杂志, 2006, (9): 673-681.
42.	田金徽, 杨克虎, 马彬, 等. 加拿大医疗风险监测预警机制的循证评价——整合全国卫生资源,建立病人安全体系. 中国循证医学杂志, 2006, (12): 897-904.
43.	?杨克虎, 田金徽, 段明友, 等. 瑞典医疗风险监管体系的循证评价. 中国医院管理, 2007, (3): 21-24.
44.	?杨克虎, 刘雅莉, 田金徽, 等. 澳大利亚医疗风险监管现状及措施的循证评价. 中国医院管理, 2007, (10): 62-65.
45.	John Naisbitt. Megatrends: Ten New Directions transforming Our Lives. 1982. Warner Books Inc. New York, p: 24.
46.	Simpson RL. Nursing informatics core competencies. Nurs Manage,1994, 25(5):18, 20.
47.	李幼平, 王莉, 文进. 注重证据, 循证决策. 中国循证医学杂志, 2008, 8(1): 1-3.
48.	"Mad cows and ecstasy: chance and choice in an evidence-based society". Journal of the Royal Statistical Association, Series A 159(3): 367-383.
49.	Coomarasamy A, Khan KS. What is the evidence that postgraduate teaching in evidence based medicine changes anything A systematic review. BMJ, 2004, 329(7473): 1017.
50.	万学红, 张晓兰. 医学教育的循证研究. 中国循证医学杂志, 2006, 6(5): 318-320.
51.	Eldredge J. Do Clinical Librarians Matter The First Randomized Controlled Trial? in Librarianshi p. Evidence Based Library and Information Practice, 2007, 2(4): 84-87.
52.	何奔. 实践的“试金石”——2007年他汀循证证据回顾. 中国医学论坛报, 2008, 34(3). 2008-01-17.

1. McCol l A, Smith H,White P,et al .General practitioner’s perceptions of the route to evidence based medicine: a questionnaire survey. BMJ, 1998, 316(7128): 361-365.
2. Guyatt G, Meade M,Jaeschke R,et al. Practitioners of evidence based care: not all clinicians need to appraise evidence from scratch but all need some skills. BMJ, 2000, 320(7240): 954-955.
3. Glasziou P, Vandenbroucke JP, Chalmers I. assessing the qual ity of research. BMJ, 2004, 328(7430): 39-41.
4. Campbell DT, Stanley JC. Experimental and quasi-experimental designs for Research.Chicago, IL: Rand McNally College, 1963.
5. Chalmers I, Hedges L, Cooper H. A brief history of research synthesis. Evaluation & the health professions, 2002, 25(1): 12-37.
6. Canadian Task Force on the Periodic Health Examination: The periodic health examination. CMAJ, 1979, 121(19): 1193-1254.
7. Schünemann HJ, Best D, Vist G, et al. Letters, numbers, symbols and words: how to communicate grades of evidence and recommendations. CMAJ, 2003, 169(7): 677-680.
8. Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ, 2004, 328(7454): 1490-1494.
9. Goldbloom R. Weighing the evidence: the Canadian experience. Am J Clin Nutr, 1997, 65(2 suppl): 584S-586S.
10. Atkins D, Eccles M, Flottorp S. Systems for grading the quality of evidence and the strength of recommendations I: Critical appraisal of existing approaches. BMC Health Serv Res, 2004, 4(1): 38.
11. Sackett DL. Rules of evidence and cl inical recommendations on the use of antithrombotic agents. Chest, 1986, 89(2 Suppl): 2S-3S.
12. Sackett DL. Rules of evidence and cl inical recommendations on the use of antithrombotic agents. Archives Int Med, 1986, 146(3): 464-465.
13. Guyatt GH,Sackett DL,Sinclair JC,et al .Users’ guides to the medical literature.IX. A method for grading health care recommendations. Evidence-Based Medicine Working Group. JAMA, 1995, 274(22): 1800-1804.
14. Sackett DL. Rules of evidence and cl inical recommendations on the use of antithrombotic agents. Chest, 1989, 95(2): 2S-4S.
15. Cook DJ, Guyatt GH, Laupacis A,et al. Rules of evidence and cl inical recommendations on the use of antithrombotic agents. Chest, 1992, 102(4): 305S-311S.
16. Cook DJ, Guyatt GH, Laupacis A, et al. Clinical recommendations using levels of evidence for antithrombotic agents. Chest, 1995, 108(4): 227S-230S.
17. Guyatt GH, Cook DJ, Sackett DL, et al. Grades of recommendation for antithrombotic agents. Chest, 1998, 114(5 Suppl): 441S-444S.
18. Guyatt G, Schünemann H, Cook D,et al . Grades of Recommendation for Antithrombotic Agents. Chest, 2001, 119(1): 3S-7S.
19. Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidel ines: report from an american college of chest physicians task force. Chest, 2006, 129(1): 174-181.
20. http://www.inclen.org/history.html.
21. 陈洁. 医学技术评估. 上海: 上海医科大学出版社. 1996.
22. Cochrane A. Effectiveness and Efficiency: Random Reflections on Health Services. London: Nuffield Provincial Hospitals Trust, 1972.
23. Guyatt GH. 循证医学的五个发展方向. 中国循证医学杂志, 2006, 6(3): 175-161.
24. Cinical Practice Guideline No.1: acute pain management: operative or medical procedures and trauma. Rockville (MD): US Department of Health and Human Services. Agency for Health Care Pol icy and Research; 1993. AHCPR Publication No. 92-0023.
25. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.table.928626 Eccles M, Clapp Z, Grimshaw J, et al. Russell I: North of England evidence based guidelines development project: methods of guidel ine development. BMJ, 1996, 312(7033): 760-762.
26. Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ, 2001, 323(7308): 334-336.
27. Van Tulder W, Koes W, Bouter M. Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions. Spine, 1997, 22(18): 2128-2156.
28. Working Party for Guidelines for the Management of Heavy Menstrual Bleeding.An evidence-based guideline for the management of heavy menstrual bleeding. N Z Med J,1999, 112(1088): 174-177.
29. National Health and Medical Research Council (NHMRC). How to Use the Evidence: Assessment and Appl ication of Scientific Evidence. Canberra, Austral ia: NHMRC; 2000.
30. http://www.cebm.net/levels_of_evidence.asp.
31. 李幼平, 主编. 循证医学. 第1版. 北京: 高等教育出版社.
32. http://www.gradeworkinggroup.org/about_us.htm.
33. http://library.downstate.edu/ebmdos/2100.htm.
34. Aragon CL, Budsberg SC. Applications of Evidence-Based Medicine: Cranial Cruciate Ligament Injury Repair in the Dog Veterinary Surgery. 34(2): 93–98.
35. 李幼平, 陶铁军, 孙丁, 等. 我国专科医师分类研究初探. 中国循证医学杂志, 2004, 4(3): 173-180.
36. 谢瑜, 文进, 高晓凤, 等. 国外航空风险管理方法及绩效的循证评价——医疗风险系列研究之一. 中国循证医学杂志, 2006, 6(2): 131-138.
37. 高晓凤,谢瑜,文进, 等.我国煤矿业风险管理现状的循证评价——医疗风险系列研究之二. 中国循证医学杂志, 2006, (3): 202-208.
38. 文进, 谢瑜, 高晓凤, 等. 美国飓风风险管理的循证评价及其对我国医疗风险管理的启示——医疗风险系列研究之三. 中国循证医学杂志, 2006, (3): 209-217.
39. 杨克虎, 马彬, 田金徽, 等. 美国医疗风险监测预警机制现状及绩效的循证评价. 中国循证医学杂志, 2006, (6): 439-450.
40. 马彬, 杨克虎, 刘雅莉, 等. 英国医疗风险监管体系的循证评价及其对我国医疗风险管理的启示——关注病人安全, 预防医疗差错, 提高医疗质量. 中国循证医学杂志, 2006, (7): 514-522.
41. 刘雅莉, 景涛, 田金徽, 等. 新西兰医疗风险防范及监管机制现状的循证评价——完善诉讼体系,规范医疗行为, 防范医疗风险. 中国循证医学杂志, 2006, (9): 673-681.
42. 田金徽, 杨克虎, 马彬, 等. 加拿大医疗风险监测预警机制的循证评价——整合全国卫生资源,建立病人安全体系. 中国循证医学杂志, 2006, (12): 897-904.
43. ?杨克虎, 田金徽, 段明友, 等. 瑞典医疗风险监管体系的循证评价. 中国医院管理, 2007, (3): 21-24.
44. ?杨克虎, 刘雅莉, 田金徽, 等. 澳大利亚医疗风险监管现状及措施的循证评价. 中国医院管理, 2007, (10): 62-65.
45. John Naisbitt. Megatrends: Ten New Directions transforming Our Lives. 1982. Warner Books Inc. New York, p: 24.
46. Simpson RL. Nursing informatics core competencies. Nurs Manage,1994, 25(5):18, 20.
47. 李幼平, 王莉, 文进. 注重证据, 循证决策. 中国循证医学杂志, 2008, 8(1): 1-3.
48. "Mad cows and ecstasy: chance and choice in an evidence-based society". Journal of the Royal Statistical Association, Series A 159(3): 367-383.
49. Coomarasamy A, Khan KS. What is the evidence that postgraduate teaching in evidence based medicine changes anything A systematic review. BMJ, 2004, 329(7473): 1017.
50. 万学红, 张晓兰. 医学教育的循证研究. 中国循证医学杂志, 2006, 6(5): 318-320.
51. Eldredge J. Do Clinical Librarians Matter The First Randomized Controlled Trial? in Librarianshi p. Evidence Based Library and Information Practice, 2007, 2(4): 84-87.
52. 何奔. 实践的“试金石”——2007年他汀循证证据回顾. 中国医学论坛报, 2008, 34(3). 2008-01-17.

Chinese Journal of Evidence-Based Medicine

Evolution of Levels of Evidence and Strength of Recommendations in Medical Research

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