Table 3. Strength of Recommendation and Quality of Evidence
Strength of
Recommendation/
Quality of Evidence
Clarity of Balance
Between Desirable and
Undesirable Effects
Methodological
Quality of Supporting
Evidence (examples) Implications
S/H
Desirable effects clearly
outweigh undesirable
effects, or vice versa
Consistent evidence
from well-performed
RCTs or exceptionally
strong evidence from
unbiased observational
studies
Recommendation can apply
to most patients in most
circumstances. Further
research is unlikely to
change our confidence in
the estimate of effect
S/M
Desirable effects clearly
outweigh undesirable
effects, or vice versa
Evidence from RCTs
with important
limitations
(inconsistent results,
methodological flaws,
indirect, or imprecise)
or exceptionally strong
evidence from unbiased
observational studies
Recommendation can apply
to most patients in most
circumstances. Further
research (if performed) is
likely to have an important
impact on our confidence
in the estimate of effect and
may change the estimate.
S/L
Desirable effects clearly
outweigh undesirable
effects, or vice versa
Evidence for at least
one critical outcome
from observational
studies, RCTs with
serious flaws or indirect
evidence
Recommendation may
change when higher quality
evidence becomes available.
Further research (if
performed) is likely to have
an important impact on our
confidence in the estimate
of effect and is likely to
change the estimate
S/VL
(very rarely
applicable)
Desirable effects clearly
outweigh undesirable
effects, or vice versa
Evidence for at least one
critical outcome from
unsystematic clinical
observations or very
indirect evidence
Recommendation may
change when higher quality
evidence becomes available;
any estimate of effect for at
least one critical outcome is
very uncertain.
W/H
Desirable effects
closely balanced with
undesirable effects
Consistent evidence
from well- performed
RCTs or exceptionally
strong evidence from
unbiased observational
studies
e best action may
differ depending on
circumstances or patients
or societal values. Further
research is unlikely to
change our confidence in
the estimate of effect.
W/M
Desirable effects
closely balanced with
undesirable effects
Evidence from RCTs
with important
limitations
(inconsistent results,
methodological flaws,
indirect, or imprecise)
or exceptionally strong
evidence from unbiased
observational studies
Alternative approaches
likely to be better for
some patients under some
circumstances. Further
research (if performed) is
likely to have an important
impact on our confidence
in the estimate of effect and
may change the estimate
