11
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 that the harms clearly exceed
the benefits in the case of a strong
negative recommendation) and that
the quality of the supporting evidence
is excellent (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 that
the harms exceed the benefits in the
case of a negative recommendation),
but the quality of evidence is not
as strong (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 An option means that either the
quality of evidence that exists 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 the American Academy of Pediatrics classification scheme.
