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.