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Research ArticleSpecial Communications

Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approach to Grading Evidence in the Medical Literature

Mark H. Ebell, Jay Siwek, Barry D. Weiss, Steven H. Woolf, Jeffrey Susman, Bernard Ewigman and Marjorie Bowman
The Journal of the American Board of Family Practice January 2004, 17 (1) 59-67; DOI: https://doi.org/10.3122/jabfm.17.1.59
Mark H. Ebell
MD, MS
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Jay Siwek
MD
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Barry D. Weiss
MD
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Steven H. Woolf
MD, MPH
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Jeffrey Susman
MD
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Bernard Ewigman
MD, MPH
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Marjorie Bowman
MD, MPA
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    Figure 1.

    The Strength of Recommendation Taxonomy (SORT). SR, systematic review; RCT, randomized controlled trial.

  • Figure 2.
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    Figure 2.

    Algorithm for determining the strength of a recommendation based on a body of evidence (applies to clinical recommendations regarding diagnosis, treatment, prevention, or screening). Although this algorithm provides a general guideline, authors and editors may adjust the strength of recommendation based on the benefits, harms, and costs of the intervention being recommended. USPSTF, US Preventive Services Task Force.

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    Figure 3.

    Algorithm for determining the level of evidence for an individual study.

Tables

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    Table 1.

    Examples of Inconsistency between Disease-Oriented and Patient-Oriented Outcomes

    Disease Or ConditionDisease-Oriented OutcomePatient-Oriented Outcome
    Doxazosin for blood pressure12Reduces blood pressureIncreases mortality in blacks
    Lidocaine for arrhythmia after acute myocardial infarction13Suppresses arrhythmiasIncreases mortality
    Finasteride for benign prostatic hypertrophy14Improved urinary flow rateNo clinically important change in symptom scores
    Sleeping infants on their stomach or side16Knowledge of anatomy and physiology suggests that this will decrease the risk of aspirationIncreased risk of sudden infant death syndrome
    Vitamin E for heart disease17Reduces levels of free radicalsNo change in mortality
    Histamine antagonists and proton-pump inhibitors for nonulcer dyspepsia18Significantly reduce gastric pH levelsLittle or no improvement in symptoms in patients with nongastroesophageal reflux disease, nonulcer dyspepsia
    Arthroscopic surgery for osteoarthritis of the knee15Improved appearance of cartilage after debridementNo change in function or symptoms at 1 year
    Hormone therapy19Reduced low-density lipoprotein cholesterol, increased high-density lipoprotein cholesterolNo decrease in cardiovascular or all-cause mortality and an increase in cardiovascular events in women older than 60 years (Women’s Health Initiative) with combined hormone therapy
    Insulin therapy in type 2 diabetes mellitus20Keeps blood sugar below 120 mg/dL (6.7 mmol/L)Does not reduce overall mortality
    Sodium fluoride for fracture prevention21Increases bone densityDoes not reduce fracture rate
    Lidocaine prophylaxis after acute myocardial infarction22Suppresses arrhythmiasIncreases mortality
    Clofibrate for hyperlipidemia23Reduces lipidsDoes not reduce mortality
    β-blockers for heart failure24Reduce cardiac outputReduce mortality in moderate to severe disease
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    Table 2.

    Examples of How to Apply the SORT in Practice

    Example 1: Although a number of observational studies (level of evidence—2) suggested a cardiovascular benefit from vitamin E, a large, well-designed, randomized trial with a diverse patient population (level of evidence—1) showed the opposite. The strength of recommendation against routine, long-term use of vitamin E to prevent heart disease, based on the best available evidence, should be A.
    Example 2: A Cochrane review finds 7 clinical trials that are consistent in their support of a mechanical intervention for low back pain, but the trials were poorly designed (ie, unblinded, nonrandomized, or with allocation to groups unconcealed). In this case, the strength of recommendation in favor of these mechanical interventions is B (consistent but lower quality clinical trials).
    Example 3: A meta-analysis finds 9 high-quality clinical trials of the use of a new drug in the treatment of pulmonary fibrosis. Two of the studies find harm, 2 find no benefit, and 5 show some benefit. The strength of recommendation in favor of this drug would be B (inconsistent results of good-quality, randomized controlled trials).
    Example 4: A new drug increases the forced expiratory volume in 1 second (FEV1) and peak flow rate in patients with an acute asthma exacerbation. Data on symptom improvement is lacking. The strength of recommendation in favor of using this drug is C (disease-oriented evidence only).
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    Table 3

    Suggested Walkovers between Taxonomies for Assessing the Strength of a Recommendation Based on a Body of Evidence

    SORTCEBMBMJ’s Clinical Evidence
    A. Recommendation based on consistent and good quality patient-oriented evidenceA. Consistent level 1 studiesBeneficial
    B. Recommendation based on inconsistent or limited-quality patient-oriented evidenceB. Consistent level 2 or 3 studies or extrapolations from level 1 studiesLikely to be beneficial Likely to be ineffective or harmful (recommendation against)
    C. Level 4 studies or extrapolations from level 2 or 3 studiesUnlikely to be beneficial (recommendation against)
    C. Recommendation based on consensus, usual practice, disease-oriented evidence, case series for studies of treatment or screening, and/or opinionD. Level 5 evidence or troublingly inconsistent or inconclusive studies of any levelUnknown effectiveness
    • SORT, Strength Of Evidence Taxonomy; CEBM, Centre for Evidence-Based Medicine; BMJ, BMJ Publishing Group.

    • View popup
    Table 4.

    Suggested Walkover between the CEBM and the SORT Taxonomies for Assessing the Level of Evidence of an Individual Study

    SORTCEBM
    Treatment/ScreeningOther Categories
    Level 1Levels 1a to 1cLevels 1a to 1c
    Level 2Level 2 or 3Levels 2 to 4
    Level 3Level 4 or 5 and any study that measures intermediate or surrogate outcomesLevel 5 and any study that measures intermediate or surrogate outcomes
    • CEBM, Centre for Evidence-Based Medicine; SORT, Strength of Recommendation Taxonomy.

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The Journal of the American Board of Family Practice: 17 (1)
The Journal of the American Board of Family Practice
Vol. 17, Issue 1
1 Jan 2004
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Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approach to Grading Evidence in the Medical Literature
Mark H. Ebell, Jay Siwek, Barry D. Weiss, Steven H. Woolf, Jeffrey Susman, Bernard Ewigman, Marjorie Bowman
The Journal of the American Board of Family Practice Jan 2004, 17 (1) 59-67; DOI: 10.3122/jabfm.17.1.59

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Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approach to Grading Evidence in the Medical Literature
Mark H. Ebell, Jay Siwek, Barry D. Weiss, Steven H. Woolf, Jeffrey Susman, Bernard Ewigman, Marjorie Bowman
The Journal of the American Board of Family Practice Jan 2004, 17 (1) 59-67; DOI: 10.3122/jabfm.17.1.59
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