Grade Definitions After July 2012

What the Grades Mean and Suggestions for Practice

The USPSTF updated its definition of and suggestions for practice for the grade C recommendation. This new definition applies to USPSTF recommendations voted on after July 2012. Describing the strength of a recommendation is an important part of communicating its importance to clinicians and other users. Although most of the grade definitions have evolved since the USPSTF first began, none has changed more noticeably than the definition of a C recommendation, which has undergone three major revisions since 1998. Despite these revisions, the essence of the C recommendation has remained consistent: at the population level, the balance of benefits and harms is very close, and the magnitude of net benefit is small. Given this small net benefit, the USPSTF has either not made a recommendation “for or against routinely” providing the service (1998), recommended “against routinely” providing the service (2007), or recommended “selectively” providing the service (2012). Grade C recommendations are particularly sensitive to patient values and circumstances. Determining whether or not the service should be offered or provided to an individual patient will typically require an informed conversation between the clinician and patient.

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.