Table 4.7

Interpretation of the ACP Guideline Grading System

Grade of RecommendationBenefit Versus Risks and BurdensMethodological Quality of Supporting EvidenceInterpretationImplications
Strong recommendation; high-quality evidenceBenefits clearly outweigh risks and burden or vice versaRCTs without important limitations or overwhelming evidence from observational studiesFor patients, most would want the recommended course of action and only a small proportion would not; a person should request discussion if the intervention was not offered.
Strong recommendation; can apply to most patients in most circumstances without reservationFor clinicians, most patients should receive the recommended course of action.
For policymakers, the recommendation can be adopted as a policy in most situations.
Strong recommendation; moderate-quality evidenceBenefits clearly outweigh risks and burden or vice versaRCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies
Strong recommendation; low-quality evidenceBenefits clearly outweigh risks and burden or vice versaObservational studies or case seriesStrong recommendation but may change when higher-quality evidence becomes available
Weak recommendation; high-quality evidenceBenefits closely balanced with risks and burdenRCTs without important limitations or overwhelming evidence from observational studiesFor patients, most would want the recommended course of action and only a small proportion would not—a decision may depend on an individual's circumstances.
Weak recommendation; moderate-quality evidenceBenefits closely balanced with risks and burdenRCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studiesWeak recommendation; best action may differ depending on circumstances or patients' or societal valuesFor clinicians, different choices will be appropriate for different patients, and a management decision consistent with a patient's values, preferences, and circumstances should be reached.
Weak recommendation; low-quality evidenceBenefits closely balanced with risks and burdenObservational studies or case seriesVery weak recommendations; other alternatives may be equally reasonableFor policymakers, policymaking will require substantial debate and involvement of many stakeholders.
InsufficientBalance of benefits and risks cannot be determinedEvidence is conflicting, poor quality, or lackingInsufficient evidence to recommend for or against routinely providing the serviceFor patients, decisions based on evidence from scientific studies cannot be made.
For clinicians, decisions based on evidence from scientific studies cannot be made.
For policymakers, decisions based on evidence from scientific studies cannot be made.

Reproduced from Qaseem et al. (20).

ACP indicates American College of Physicians; and RCTs, randomized controlled trials.