Appendix A: How the U.S. Preventive Services Task Force Grades Its Recommendations

Guide to Clinical Preventive Services, 2014

The Task Force assigns each of its recommendations a letter grade (A, B, C, or D) or issues an I statement, based on the certainty of the evidence and on the balance of benefits and harms of the preventive service as displayed in the recommendation grid below. The USPSTF changed its grade definitions based on a change in methods in May 2007.

U.S. Preventive Services Task Force Recommendation Grid: Letter Grade of Recommendation or Statement of Insufficient Evidence Assessing Certainty and Magnitude of Net Benefit

Certainty of Net Benefit Magnitude of Net Benefit
Substantial Moderate Small Zero/negative
High A B C D
Moderate B B C D
Low Insufficient

Grade Definitions

What the Grades Mean and Suggestions for Practice

The USPSTF updated its definitions of the grades it assigns to recommendations and now includes “suggestions for practice” associated with each grade. The USPSTF has also defined levels of certainty regarding net benefit.

Grade Definition Suggestions for Practice
A The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service.
B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide this service.
C The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small. Offer or provide this service for selected patients depending on individual circumstances.
D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Discourage the use of this service.
I Statement The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

Levels of Certainty Regarding Net Benefit

Level of Certainty* Description
High The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.
Moderate The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as:
  • The number, size, or quality of individual studies.
  • Inconsistency of findings across individual studies.
  • Limited generalizability of findings to routine primary care practice.
  • Lack of coherence in the chain of evidence.

As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.

Low The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of:
  • The limited number or size of studies.
  • Important flaws in study design or methods.
  • Inconsistency of findings across individual studies.
  • Gaps in the chain of evidence.
  • Findings not generalizable to routine primary care practice.
  • Lack of information on important health outcomes.

More information may allow estimation of effects on health outcomes.

* The USPSTF defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.

Grade Definitions Prior to May 2007

The definitions below (of USPSTF grades and quality of evidence ratings) were in use prior to the update in methods and apply to recommendations voted on by the USPSTF prior to May 2007

A — Strongly Recommended: The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

B — Recommended: The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.

C — No Recommendation: The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

D — Not Recommended: The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.

I — Insufficient Evidence to Make a Recommendation: The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that [the service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

Quality of Evidence Prior to May 2007

The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor):

Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

Return to Contents
Proceed to Next Section

Current as of June 2014
Internet Citation: Appendix A: How the U.S. Preventive Services Task Force Grades Its Recommendations: Guide to Clinical Preventive Services, 2014. June 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/appendix-a.html