ATS GUIDELINES Bundle

Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)-Based Recommendations Strength of a GRADE-based recommendation 1 e strength of a recommendation indicates the committee's confidence that the desirable consequences of the recommended course of action exceed the undesirable consequences. Certainty in the evidence e higher the certainty in the evidence, the more likely a "strong" recommendation is warranted. e lower the certainty in the evidence, the more likely the recommendation warrants qualification as "conditional." Balance e larger the differences between the desirable consequences (i.e., benefits) and undesirable consequences (i.e., adverse effects, burden, cost), the more likely a "strong" recommendation is warranted. e smaller the net benefit, the more likely the recommendation warrants qualification as "conditional." Interpreting certainty in the evidence: (based on risk of bias, inconsistency of effect, estimate imprecision, or indirectness of comparison). 2 High Clinicians can be very confident that the true effect lies close to the calculated estimate of the effect. Moderate Clinicians can be confident that the true effect is likely to be close to the estimate of the effect, but there is a possibility that the truth may be substantially different. Low Certainty in currently available evidence is insufficient to provide clinicians with unqualified confidence in the effect estimate. e true effect may be substantially different from the estimated effect. Very Low Certainty in currently available evidence is insufficient to provide clinicians with unqualified confidence in the effect estimate. e potential for the estimated effect to be substantially different from the true effect is high. Clinical implications of: Strong Recommendations Conditional Recommendations Clinicians Most patients should receive the recommended course of action. Most patients should receive the recommended course of action. However, conversation with the patient regarding the uncertainty in the anticipated balance of effects is warranted. Policy makers e recommendation can be adapted as policy in most situations including for the use as performance indicators. Policies are likely to vary between regions/health systems, but should be based on adequate deliberation over alternative available management options. Patients Most patients in this situation would want the recommended intervention. e majority of individuals in this situation would want the suggested intervention. However, a conversation regarding alternative available management options may be warranted.

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