29
Strength of Action Terms in Guideline Statements and
Implied Levels of Obligation
Strength Definition Implied Obligation
Strong
Recommendation
A strong recommendation means
the benefits of the recommended
approach clearly exceed the harms
(or, in the case of a strong negative
recommendation, the harms clearly
exceed the benefits) and that the
quality of the supporting evidence is
high (Grade A or B).
a
In some clearly
identified circumstances, strong
recommendations may be made based
on lesser evidence when high-quality
evidence is impossible to obtain and
the anticipated benefits strongly
outweigh the harms.
Clinicians should
follow a strong
recommendation unless
a clear and compelling
rationale for an
alternative approach is
present.
Recommendation A recommendation means the benefits
exceed the harms (or, in the case of a
negative recommendation, the harms
exceed the benefits), but the quality
of evidence is not as high (Grade
B or C).
a
In some clearly identified
circumstances, recommendations may
be made based on lesser evidence when
high-quality evidence is impossible
to obtain and the anticipated benefits
outweigh the harms.
Clinicians should
also generally follow a
recommendation, but
should remain alert to
new information and
sensitive to patient
preferences.
Option
b
An option means that either the
quality of evidence is suspect (Grade
D)
a
or that well-done studies (Grade
A, B, or C)
a
show little clear advantage
to one approach versus another.
Clinicians should be
flexible in their decision-
making regarding
appropriate practice,
although they may set
bounds on alternatives.
Patient preference
should have a substantial
influencing role.
a
Adapted from American Academy of Pediatrics (AAP) classification scheme.
b
Option is similar to the "weak recommendation" used in the Grading of Recommendations
Assessment, Development and Evaluation (GRADE) classification.
