19
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, that 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,
that 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
a
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
Option resembles the "Weak Recommendation" utilized in the GRADE classification system:
Grading of Recommendations Assessment, Development and Evaluation.
