Defining certainty of net benefit: A GRADE concept paper

Brian S. Alper, Peter Oettgen, Ilkka Kunnamo, Alfonso Iorio, Mohammed Toseef Ansari, M. Hassan Murad, Joerg J. Meerpohl, Amir Qaseem, Monica Hultcrantz, Holger J. Schünemann, Gordon Guyatt

Research output: Contribution to journalArticlepeer-review

13 Scopus citations


Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology is used to assess and report certainty of evidence and strength of recommendations. This GRADE concept article is not GRADE guidance but introduces certainty of net benefit, defined as the certainty that the balance between desirable and undesirable health effects is favourable. Determining certainty of net benefit requires considering certainty of effect estimates, the expected importance of outcomes and variability in importance, and the interaction of these concepts. Certainty of net harm is the certainty that the net effect is unfavourable. Guideline panels using or testing this approach might limit strong recommendations to actions with a high certainty of net benefit or against actions with a moderate or high certainty of net harm. Recommendations may differ in direction or strength from that suggested by the certainty of net benefit or harm when influenced by cost, equity, acceptability or feasibility.

Original languageEnglish (US)
Article numbere027445
JournalBMJ open
Issue number6
StatePublished - Jun 1 2019


  • clinical decision making
  • decision analysis
  • evidence synthesis
  • evidence-based medicine
  • guideline development

ASJC Scopus subject areas

  • Medicine(all)


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