The Grades of Recommendation Assessment, Development and Evaluation (GRADE) framework was used for determining the strength of recommendation and the quality of evidence.
The strength of recommendation is graded based on the quality of evidence, balance between benefits and harms, patients’ values, preferences, and clinical context. Recommendations are graded as:
Grade 1 recommendations are meant to identify practices for which benefit clearly outweighs risk. These recommendations can be made by clinicians and accepted by patients with a high degree of confidence. Grade 2 recommendations are made when the benefits and risks are more closely matched and are more dependent on specific clinical scenarios. In general, physician and patient preferences play a more important role in the decision-making process in these circumstances.
The quality of evidence rating is based on the risk of bias, precision, directness, consistency, and the size of the effect and is rated as:
Conclusions based on high-quality evidence are unlikely to change with further investigation, whereas those based on moderate-quality evidence are more likely to be affected by further scrutiny. Those based on low-quality evidence are the least supported by current data and the most likely to be subject to change in the future.