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Evidence levels, recommendation levels

Evidence levels, recommendation levels

1. Levels of evidence

Level Type Max. bias risk
1++ High-quality meta-analyses, systematic reviews of RCTs or RCTs Very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of RCTs or RCTs Low risk of bias
1 Meta-analyses, systematic reviews of RCTs or RCTs High risk of bias
2+ Well-conducted case-control or cohort studies Low risk of confounding, bias or chance and at least a medium probability that the association is causal
2 Case-control or cohort studies high risk of confounding, bias or chance and at least a significant risk that the association is not causal
3 Non-analytical studies, e.g. case reports, case series
4 Expert opinion

2. Levels of recommendation

Level Recommendation
A At least one meta-analysis, systematic review or RCT that has been rated 1++ and is directly applicable to the target population;
or a systematic review of RCTs or a body of evidence consisting primarily of studies that are rated 1+, are directly applicable to the target population, and have overall consistency of results
B A body of evidence that includes studies that are rated 2++, are directly applicable to the target population, and demonstrate overall agreement of results
or extrapolated evidence from studies rated 1++ or 1+
C Body of evidence includes studies rated 2+ that are directly applicable to the target population and whose results are consistent overall
or extrapolated evidence from studies rated 2++
D Evidence level 3 or 4
or extrapolated evidence from studies rated 2+
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