Users' guides to the medical literature XVI. How to use a treatment recommendation

Gordon H. Guyatt*, Jack Sinclair, Deborah J. Cook, Paul Glasziou

*Corresponding author for this work

Research output: Contribution to journalReview articleResearchpeer-review

146 Citations (Scopus)


Clinicians can often find treatment recommendations in traditional narrative reviews and the discussion sections of original articles and metaanalyses. Making a treatment recommendation involves framing a question, identifying management options and outcomes, collecting and summarizing evidence, and applying value judgments or preferences to arrive at an optimal course of action. Each step in this process can be conducted systematically (thus protecting against bias) or unsystematically (leaving the process open to bias). Clinicians faced with a plethora of recommendations may wish to attend to those that are less likely to be biased. Therefore, we propose a hierarchy of rigor of recommendations to guide clinicians when judging the usefulness of particular recommendations. Recommendations with the highest rigor consider all relevant options and outcomes, include a comprehensive collection of the methodologically highest quality data with an explicit strategy for summarizing the data (that is, a systematic review), and make an explicit statement of the values or preferences involved in moving from evidence to action. High rigor recommendations come from systematically developed, evidence-based practice guidelines or rigorously conducted decision analyses. Systematic reviews, which typically do not consider all relevant options and outcomes or make the preferences underlying recommendations explicit, offer intermediate rigor recommendations. Traditional approaches in which the collection and assessment of evidence remains unsystematic, all relevant options and outcomes may not be considered, and values remain implicit, provide recommendations of weak rigor. In an era in which clinicians are barraged by recommendations as to how to manage their patients, this hierarchy provides a potentially useful set of guides.

Original languageEnglish
Pages (from-to)1836-1843
Number of pages8
JournalJournal of the American Medical Association
Issue number19
Publication statusPublished - 19 May 1999
Externally publishedYes


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