Article Figures & Data
Figures
- Figure 1.
The Strength of Recommendation Taxonomy (SORT). SR, systematic review; RCT, randomized controlled trial.
- 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.
- Figure 3.
Algorithm for determining the level of evidence for an individual study.
Tables
Disease Or Condition Disease-Oriented Outcome Patient-Oriented Outcome Doxazosin for blood pressure12 Reduces blood pressure Increases mortality in blacks Lidocaine for arrhythmia after acute myocardial infarction13 Suppresses arrhythmias Increases mortality Finasteride for benign prostatic hypertrophy14 Improved urinary flow rate No clinically important change in symptom scores Sleeping infants on their stomach or side16 Knowledge of anatomy and physiology suggests that this will decrease the risk of aspiration Increased risk of sudden infant death syndrome Vitamin E for heart disease17 Reduces levels of free radicals No change in mortality Histamine antagonists and proton-pump inhibitors for nonulcer dyspepsia18 Significantly reduce gastric pH levels Little or no improvement in symptoms in patients with nongastroesophageal reflux disease, nonulcer dyspepsia Arthroscopic surgery for osteoarthritis of the knee15 Improved appearance of cartilage after debridement No change in function or symptoms at 1 year Hormone therapy19 Reduced low-density lipoprotein cholesterol, increased high-density lipoprotein cholesterol No 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 mellitus20 Keeps blood sugar below 120 mg/dL (6.7 mmol/L) Does not reduce overall mortality Sodium fluoride for fracture prevention21 Increases bone density Does not reduce fracture rate Lidocaine prophylaxis after acute myocardial infarction22 Suppresses arrhythmias Increases mortality Clofibrate for hyperlipidemia23 Reduces lipids Does not reduce mortality β-blockers for heart failure24 Reduce cardiac output Reduce mortality in moderate to severe disease 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). - Table 3
Suggested Walkovers between Taxonomies for Assessing the Strength of a Recommendation Based on a Body of Evidence
SORT CEBM BMJ’s Clinical Evidence A. Recommendation based on consistent and good quality patient-oriented evidence A. Consistent level 1 studies Beneficial B. Recommendation based on inconsistent or limited-quality patient-oriented evidence B. Consistent level 2 or 3 studies or extrapolations from level 1 studies Likely to be beneficial Likely to be ineffective or harmful (recommendation against) C. Level 4 studies or extrapolations from level 2 or 3 studies Unlikely 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 opinion D. Level 5 evidence or troublingly inconsistent or inconclusive studies of any level Unknown effectiveness SORT, Strength Of Evidence Taxonomy; CEBM, Centre for Evidence-Based Medicine; BMJ, BMJ Publishing Group.
- Table 4.
Suggested Walkover between the CEBM and the SORT Taxonomies for Assessing the Level of Evidence of an Individual Study
SORT CEBM Treatment/Screening Other Categories Level 1 Levels 1a to 1c Levels 1a to 1c Level 2 Level 2 or 3 Levels 2 to 4 Level 3 Level 4 or 5 and any study that measures intermediate or surrogate outcomes Level 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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