Chest
SupplementAntithrombotic and Thrombolytic Therapy, 8th ED: ACCP GuidelinesGrades of Recommendation for Antithrombotic Agents: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
Section snippets
STRENGTH OF THE RECOMMENDATION
In determining the strength of recommendations, our grading system focuses on the degree of confidence in the balance between the desirable and the undesirable effects of an intervention (Table 1). Desirable effects or benefits can include beneficial health outcomes, decreased burden of treatment, and decreased resource use (usually measured as costs). Undesirable effects or downsides can include uncommon major adverse events, common minor side effects, greater burden of treatment, and more
INTERPRETING STRONG AND WEAK RECOMMENDATIONS
One way to interpret strong and weak recommendations is in relation to patient values and preferences. For decisions in which it is clear that benefits far outweigh downsides, or downsides far outweigh benefits, almost all patients will make the same choice, and guideline developers can offer a strong recommendation.
For instance, results from an extremely large high-quality randomized trial suggest that ASA reduces the relative risk of death after myocardial infarction by approximately 25%.
HOW METHODOLOGIC QUALITY CONTRIBUTES TO GRADES OF RECOMMENDATION
In our grading system, the highest-quality evidence comes from one or more well-designed and well-executed randomized controlled trials (RCTs) yielding consistent and directly applicable results. High-quality evidence can also come from well-done observational studies yielding very large effects (our guideline for a very large effect is an RRR of at least 80%) [Table 4 ]. RCTs with important limitations and well-done observational studies yielding large effects constitute the moderate-quality
INTERPRETING THE RECOMMENDATIONS
Clinicians, third-party payers, institutional review committees, and the courts should not construe these guidelines as absolute. In general, anything other than a Grade 1A recommendation indicates that the chapter authors acknowledge that other interpretations of the evidence and other clinical policies may be reasonable and appropriate. Even Grade 1A recommendations will not apply to all circumstances and all patients. For instance, we have been conservative in our considerations of cost, and
SUMMARY
The strength of any recommendation depends on two factors: the tradeoff between benefits, risks, burden, and cost, and our confidence in estimates of those benefits and risks. The American College of Chest Physicians grading system classifies the tradeoff between benefits and risks in two categories: strong (Grade 1 recommendations), in which the tradeoff is clear enough that most patients, despite differences in values, would make the same choice; and weak (Grade 2), in which the trade off is
CONLICT OF INTEREST DISCLOSURES
Dr. Guyattreveals no real or potential conflicts of interest or commitment.
Dr. Schünemannreports no personal payments from for-profit organizations, but he has received research grants and/or honoraria that were deposited into research accounts or received by a research group that he belongs to from AstraZeneca (research grant, honoraria), Amgen (research grant), Barilla (research grant), Chiesi Foundation (honorarium), Lily (honorarium), Pfizer (research grant, honorarium), Roche (honorarium),
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