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Otitis Media with Effusion

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21 Strength of Action Terms in Guideline Statements and Implied Levels of Obligation Strength Definition Implied Obligation Strong Recommendation (S) A strong recommendation means the benefits of the recommended approach clearly exceed the harms (or, in the case of a strong negative recommendation, that the harms clearly exceed the benefits) and that the quality of the supporting evidence is high (Grade A or B). 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 (R) A recommendation means the benefits exceed the harms (or, in the case of a negative recommendation, that the harms exceed the benefits), but the quality of evidence is not as high (Grade B or C). 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 and modifying factors. Option (O) An option means that either the quality of evidence is suspect (Grade D) or that well-done studies (Grade A, B, or C) 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.

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