Clinicians can often find treatment recommendations in
traditional narrative reviews and the discussion sections of original
articles and meta-analyses. Making a treatment recommendation involves
framing a question, identifying management options and outcomes,
collecting and summarizing evidence, and applying value judgments or
preferences to arrive at an optimal course of action. Each step in this
process can be conducted systematically (thus protecting against bias)
or unsystematically (leaving the process open to bias). Clinicians
faced with a plethora of recommendations may wish to attend to those
that are less likely to be biased. Therefore, we propose a hierarchy of
rigor of recommendations to guide clinicians when judging the
usefulness of particular recommendations. Recommendations with the
highest rigor consider all relevant options and outcomes, include a
comprehensive collection of the methodologically highest quality data
with an explicit strategy for summarizing the data (that is, a
systematic review), and make an explicit statement of the values or
preferences involved in moving from evidence to action. High rigor
recommendations come from systematically developed, evidence-based
practice guidelines or rigorously conducted decision analyses.
Systematic reviews, which typically do not consider all relevant
options and outcomes or make the preferences underlying recommendations
explicit, offer intermediate rigor recommendations. Traditional
approaches in which the collection and assessment of evidence remains
unsystematic, all relevant options and outcomes may not be considered,
and values remain implicit, provide recommendations of weak rigor. In
an era in which clinicians are barraged by recommendations as to how to
manage their patients, this hierarchy provides a potentially useful set
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