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Table 4 Ways in which the SoBE gradings were reported in component CPGs and the SA-cSRG standard ‘faces’ system

From: Standardising evidence strength grading for recommendations from multiple clinical practice guidelines: a South African case study

NICE/ AHRQ[1] (consensus wording from evidence strength) VA/ DoD RCP (consensus on evidence strength), Sth Aust; NSW ACI AHA/ASA, Canada[2], Sth Africa[3] NZGG[4], Malaysia, SIGN ASF SA-cSRG standard approach
Evidence synthesis and consensus words Hierarchy and quality Evidence synthesis and consensus words Hierarchy and quality Hierarchy and quality Evidence strength words  
High confidence (positive) A Strong = should A A Strong ☺☺☺
Moderate confidence B Moderate = could B B Strong ☺☺
Low confidence C weak = apply with caution C C Weak
D D Weak
    Opinion Practice point Practice point ☺ or
Moderate confidence (negative)   Moderate not    
High confidence (negative)   Should not   A Strong (against)
  1. [1]After results were pooled, the overall quality of evidence for each outcome was scored using GRADE (NICE p46):
  2. • A quality rating was assigned, based on the study design. RCTs start HIGH and observational studies as LOW, uncontrolled case series as LOW or VERY LOW
  3. • The rating was then downgraded for the specified criteria: study limitations, inconsistency, indirectness, imprecision and reporting bias. These criteria are detailed below. Observational studies were upgraded if there was a large magnitude of effect, dose-response gradient and if all plausible confounding would reduce a demonstrated effect or suggest a spurious effect when results showed no effect. Each quality element considered to have ‘serious’ or ‘very serious’ risk of bias was rated down 1 or 2 points respectively
  4. • The downgraded/upgraded marks were then summed, and the overall quality rating was revised. For example, all RCTs started as HIGH and the overall quality became MODERATE, LOW or VERY LOW if 1, 2 or 3 points were deducted respectively
  5. • The reasons or criteria used for downgrading were specified in the footnotes
  6. [2]Canadian stroke best practice recommendations overview and methodology documentation available on the Canadian stroke best practices website at
  7. [3]Based on AHA recommendations and classifications
  8. [4]Based on earlier versions of Aust Stroke Foundation CPGs (ASF 2008–2010)
  9. NB: ASCHC did not provide any evidence strength; it reported only those guidelines that supported its summary recommendations