Open Access Open Access  Restricted Access Subscription Access

Defining the meaning, role, and measurement of “values and preferences” in the development of practice guidelines: The case of GRADE

Mathew Mercuri, Amiram Gafni


Both the Evidence Based Medicine (EBM) and Person Centered Healthcare (PCH) movements recognize that decisions on how to manage the care of individual patients in the clinical encounter require more than simple application of those therapies shown effective in a clinical trial.  GRADE, a popular framework for developing clinical recommendations, identifies patient “values and preferences” as an important consideration in clinical decision making and a component in determining a clinical recommendation and its strength. However, how patient “values and preferences” are conceptualized in GRADE are problematic if one believes the individual patient’s care should be aligned with her values and preferences. GRADE focuses on “typical” patient “values and preferences” in the process of determining the recommendation. There is no guarantee that the values and preferences of the typical patient will represent that of the individual patient in the clinical encounter. Furthermore, the strength of the recommendation (“strong” vs. “weak”) appears to impact how much patient engagement is warranted (under GRADE), which affects the extent to which information on the “values and preferences” of the individual patient will be sought out or revealed in the clinical encounter. The issues raised in this paper stem from a lack of an underlying theory and empirical support to explain why certain elements have been included in the framework, and others not. A failure to clearly define, operationalize, and measure a patient’s “values and preferences” may limit the value of GRADE derived recommendations and subsequent clinical practice guidelines in managing the care of individual patients consistent with PCH.


Clinical practice guidelines, GRADE, evidence based medicine, person-centered care, recommendations

Full Text:



Guyatt, G.H., Haynes, R.B., Jaeschke, R.Z., Cook, D.J., Green, L., Naylor, C.D., Wilson, M.C. & Richardson, W.S. (2000). Users’ Guides to the Medical Literature: XXV. Evidence-based medicine: principles for applying the Users’ Guides to patient care. Journal of the American Medical Association 284 (10) 1290-1296.

Montori, V.M. & Guyatt, G.H. (2008). Progress in Evidence-Based Medicine. Journal of the American Medical Association 300 (15) 1814-1816.

Mercuri, M. & Gafni, A. (2018). The evolution of GRADE (Part 1): Is there a theoretical and/or empirical basis for the GRADE framework? Journal of Evaluation in Clinical Practice 24 (5) 1203-1210.

Mercuri, M. & Gafni, A. (2018). The evolution of GRADE (Part 2): Still searching for a theoretical and/or empirical basis for the GRADE framework. Journal of Evaluation in Clinical Practice 24 (5) 1211-1222.

Mercuri, M. & Gafni, A. (2018). The evolution of GRADE (Part 3): A framework built on science or faith? Journal of Evaluation in Clinical Practice 24 (5) 1223-1231.

Charles, C., Gafni, A. & Freeman, E. (2011). The evidence-based medicine model of clinical practice: scientific teaching or belief-based preaching? Journal of Evaluation in Clinical Practice 17, 597-605.

Charles, C. & Gafni, A. (2014). The vexing problem of defining the meaning, role and measurement of values in treatment decision-making. Journal of Comparative Effectiveness Research 3 (2) 197-209.

Kavanagh, B.P. (2009). The GRADE system for rating clinical guidelines. PLoS Medicine 6 (9) e1000094.

Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group. (2004). Grading quality of evidence and strength of recommendations. British Medical Journal 328, 1490-1494.

Guyatt, G.H., Oxman, A.D., Vist, G.E., Kunz, R., Falck-Ytter, Y., Alonso-Coello, P. & Schunemann, H.J. (2008). GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. British Medical Journal 336, 924-926.

Guyatt, G.H., Oxman, A.D., Schunemann, H.J., Tugwell, P. & Knottnerus, A. (2011). GRADE guidelines: A new series of articles in the Journal of Clinical Epidemiology. Journal of Clinical Epidemiology 64, 380-382.

Schunemann, H., Brozek, J., Guyatt, G. & Oxman, A. (2013). GRADE Handbook: Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. Available at: Accessed on October 19, 2018.

Neumann, I., Santesso, N., Akl, E.A., Rind, D.M., Vandvik, P.O., Alonso-Coello, P., Agoritsas, T., Mustafa, R.A., Alexander, P.E., Schünemann, H. & Guyatt, G.H. (2016). A guide for health professionals to interpret and use recommendations in guidelines developed with the GRADE approach. Journal of Clinical Epidemiology 72, 45-55.

Montori, V.M., Devereaux, P.J., Strauss, S., Haynes, B. & Guyatt, G. (2008). Advanced topics in moving from evidence to action: decision making and the patient. In: The Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. Second edn. Guyatt, G., Rennie, D., Meade, M. & Cook, D. (Eds.), pp. 643-661. New York, Ny: McGraw-Hill.

Andrews, J.C., Schunemann, H.J., Oxman, A.D., Pottie, K., Meerpohl, J.J., Alonso Coello, P. et al. (2013). GRADE guidelines: 15. Going from evidence to recommendation – determinants of a recommendation’s direction and strength. Journal of Clinical Epidemiology 66, 726-735.

Concise Oxford Dictionary. (2002). Tenth edn. New York: Oxford University Press Inc.

Zhang, Y., Alonso Coello, P., Brozek, J., Wiercioch, W., Etxeandia-Ikobaltzeta, I., Akl, E.A. et al. (2017). Using patient values and preferences to inform the importance of health outcomes in practice guideline development following the GRADE approach. Health and Quality of Life Outcomes 15 (52) 1-10.

Zhang, Y., Alonso Coello, P., Guyatt, G., Yepes-Nunez, J.J., Akl, E.A., Hazlewood, G. et al. (2018). GRADE Guidelines: 19. Assessing the certainty of evidence in the importance of outcomes or values and preferences - Risk of bias and indirectness. Journal of Clinical Epidemiology 111, 94-404.

Andrews, J., Guyatt, G., Oxman, A.D., Alderson, P., Dahm, P., Falck-Ytter, Y. et al. (2013). GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. Journal of Clinical Epidemiology 66, 719-725.

Mercuri, M. & Gafni, A. (2018). Reflecting on Evidence Based Medicine, Person Centered Medicine and Small Area Variations: how contemporary frameworks for medicine address (or not) the needs of the individual patient. European Journal for Person Centered Healthcare 6 (3) 454-461.

Guyatt, G.H., Oxman, A.D., Kunz, R., Falck-Ytter, Y., Vist, G.E., Liberati, A., Schünemann, H.J. & GRADE Working Group. (2008). GRADE: going from evidence to recommendations. British Medical Journal 336 (7652) 1049-1051.

Guyatt, G., Eikelboom, J.W., Akl, E.A., Crowther, M., Gutterman, D., Kahn, S.R., Schunemann, H. & Hirsh, J. (2013). A guide to GRADE guidelines for the readers of JTH. Journal of Thrombosis and Haemostasis 11 (8) 1603-1608.

Persell, S.D., Dolan, N.C., Friesema, E.M., Thompson, J.A., Kaiser, D. & Baker, D.W. (2010). Frequency of inappropriate medical exception to quality measures. Annals of Internal Medicine 152 (4) 225-231.

Mercuri, M., Sherbino, J., Sedran, R.J., Frank, J.R., Gafni, A. & Norman, G. (2015). When guidelines don’t guide: the effect of patient context on management decisions based on clinical practice guidelines. Academic Medicine 90 (2) 191-196.

Ben-Zion, U. & Gafni, A. (1983). Evaluation of Public Investment in Health Care: Is the Risk Irrelevant? Journal of Health Economics 2, 161-165.

Guyatt, G. (2007). An emerging consensus on grading recommendations? Chinese Journal of Evidence Based Medicine 7 (1) 1-8.



  • There are currently no refbacks.