Table 3.

Definitions of the certainty in the evidence and strength of recommendations, and implications for patients, clinicians, and policy makers^*

Definition of certainty (quality) in the evidence
Category	Definition
High	We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate	We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low	Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low	We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
Definition of strong and conditional recommendations and implications for users
Implications	Strong recommendations	Conditional recommendations
For patients	Most individuals in this situation would want the recommended course of action and only a small proportion would not. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.	The majority of individuals in this situation would want the suggested course of action, but many would not.
For clinicians	Most individuals should receive the intervention. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator.	Recognize that different choices will be appropriate for individual patients and that you must help each patient arrive at a management decision consistent with his or her values and preferences. Decision aids may be useful helping individuals making decisions consistent with their values and preferences.
For policy makers	The recommendation can be adapted as policy in most situations.	Policymaking will require substantial debate and involvement of various stakeholders.

^*Sources: Andrews 2013, Guyatt 2008

Andrews J, Guyatt G, Oxman AD, et al. GRADE guidelines: 14. Going from evidence to recommendations—the significance and presentation of recommendations. J Clin Epidemiol. 2013;66(7):719–725.

Andrews JC, Schunemann HJ, Oxman AD, et al. GRADE guidelines: going from evidence to recommendation—determinants of a rec ommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726–735.

Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924–6.