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The benefits of the recommendation clearly exceed the harms (or the harms clearly exceed the benefits in the case of a negative recommendation) and the quality of evidence is excellent (Grade A or B). In some clearly identified circumstances, a strong recommendation may be made on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. This recommendation should be followed unless clear and compelling rationale for an alternative approach is present. Recommendation: The benefits of the recommendation exceed the harms (or the harms exceed the benefits in the case of a negative recommendation) but the quality of evidence is not as strong (Grade B or C). In some clearly identified circumstances, a recommendation may be made on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. This recommendation should generally be followed, but remain alert for new information. Discretional: The current evidence is insufficient to assess the balance of benefits and harms of the recommendation. Evidence may be lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. There should be an awareness of this recommendation, but a flexibility in clinical decision-making, as well as remaining alert for new information. Clinical Notes and Statements Quality of evidence grades (A, B, C, or D) are shown throughout the guideline for clinical notes and statements. For example, a clinical note or statement with a quality of evidence grade of “B” is shown as “(Evidence Grade: B)”. Evidence-Based Action Statements will be highlighted in an “Action” box, with the quality of evidence, level of confidence, and clinical recommendation grading information listed. For example: EVIDENCE-BASED ACTION STATEMENT: Individuals with diabetes should be educated about the longterm benefits of glucose control in reducing the risk of onset and progression of diabetic retinopathy.11,118-121 Evidence Quality: Grade A. Randomized Clinical Trials, Cohort-prospective Study Level of Confidence: High Clinical Recommendation Strength: Strong Recommendation. This recommendation should be followed unless clear and compelling rationale for an alternative approach is present. Evidence Statements:
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