Table 3.

Interpretation of American College of Physicians grading system

Grade of recommendation	Benefit versus risks and burdens	Interpretation	Implications
Strong recommendation
High-quality of evidence Moderate-quality of evidence Low-quality of evidence	Benefits clearly outweigh risks and burden or vice versa.	Strong recommendation, can apply to most patients in most circumstances without reservation. Strong recommendation, but may change when higher-quality evidence becomes available.	For patients: most would want the recommended course and only a small proportion would not. For clinicians: most patients should receive the recommended course of action.
Weak recommendation
High-quality of evidence Moderate-quality of evidence Low-quality of evidence	Benefits closely balanced with risk and burden. Uncertainty in the estimates of benefits, risks, and burden; benefits, risks, and burden may be closely balanced.	Weak recommendation, best action may differ depending on circumstances or patients’ or societal values. Very weak recommendation, other alternatives may be reasonable.	For patients: most would want the recommended course of action but some would not. A decision may depend on an individual’s circumstances. For 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.
No recommendation
Insufficient evidence	Balance of benefits and risks can not be determined.	Insufficient evidence to recommend for or against routinely providing the service.	For patients: decisions based on evidence from scientific studies can not be made.
			For clinicians: decisions based on evidence from scientific studies can not be made.