6.2 Grading recommendations

The recommendations included in this guidance are based on information from all relevant sources of scientific knowledge on each topic. A grade for each recommendation was determined using the Australian National Health and Medical Research Council (NHMRC) matrix and grading system [6, 7]. Consensus-based recommendations were developed using the nominal group technique in the working party meetings [8]. Given the complexity of the topics, for some recommendations the NHMRC grading system was adapted to conservatively incorporate qualitative research. Single case studies were not included in the grading of recommendations. Refer to Table 1 for descriptions of the grades applied to recommendations.

Table 1 Grade of recommendation

Grade Description A Body of evidence can be trusted to guide practice. • One or more level I or several level II studies with low risk of bias, and all studies are consistent or inconsistency can be explained • Clinical impact is very large • Populations studied in the body of evidence are similar to the guidance population • Applicable to the Australian health care context with few caveats B Body of evidence can be trusted to guide practice in most situations. • One or two level II studies with low risk of bias, or a systematic review or multiple level II studies with low risk of bias, with most studies consistent or inconsistencies can be explained • Clinical impact is substantial • Populations studied in the body of evidence are similar to the guidance population • Applicable to the Australian health care context with few caveats BQ Body of evidence can be trusted to guide practice in most situations. • As above for quantitative studies • Qualitative studies included in the body of evidence; one or more qualitative studies of high quality and rigour (credibility, transferability, dependability, conformability) C Body of evidence provides some support for recommendation(s); however, care should be taken in its application to individual clinical and organisational circumstances. • One or two level II studies with low risk of bias, or level I or II studies with a moderate risk of bias • Some inconsistency reflecting some uncertainty • Clinical impact is moderate • Populations studied in the body of evidence differ from the guideline population, but it is sensible to apply the evidence to the guidance population • Applicable to the Australian health care context with some caveats CQ Body of evidence provides some support for recommendation(s); however, care should be taken in its application to individual clinical and organisational circumstances. • As above for quantitative studies • Qualitative studies included in the body of evidence; one or more qualitative studies of high quality and rigour (credibility, transferability, dependability, conformability) D Body of evidence is weak and recommendation must be applied with caution. • Level IV studies, or level I to II studies or systematic reviews with a high risk of bias • Evidence is inconsistent • Clinical impact is slight • Populations studied in the body of evidence differ from the guideline population, and hard to judge whether it is sensible to apply evidence to the guidance population Consensus Consensus-based recommendation • A systematic literature search was conducted. The recommendation was developed using the discovery and observational research available, plus contextual, expert and experiential knowledge to reach a consensus on the recommendation.