By Akira Takayama
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The relation between levels of evidence and grades of recommendation Level of evidence Level I: Level II: Level III: Level IV: Level V: Large randomized trials with clear-cut results (and low risk of error) Small randomized trials with uncertain results (and moderate to high risk of error) Nonrandomized, contemporaneous controls Nonrandomized, historical controls No controls, case series only Grade of recommendation Grade A Grade B Grade B Grade C Grade C Source: Cook et al. (1992). It is interesting to note that many of the recommendations for using antithrombotic agents in specific clinical conditions are supported by Grade C evidence (Dalen and Hirsh 1992).
However, question 4b relates to the precision (reliability) of the estimate of effectiveness and, most importantly, to the issue of whether the trial was large enough to demonstrate a clinically important difference if in truth such a difference existed (Detsky et al. 1987). This last issue relates to the power of the trial, the sensitivity of the trial for detecting a true difference, or its complement, and the risk of making a Type 2 error (declaring a therapy ineffective when in truth it 22 Allan S.
Perhaps the best known cohort studies supporting a health care intervention are those demonstrating that smoking was related to the subsequent development of lung cancer (Doll and Hill 1950; Doll and Peto 1976). Although RCTs (Rose et al. 1982), following the cohort studies, demonstrated the risk of smoking (thereby supporting interventions aimed at helping patients stop smoking or preventing them from starting at all), they did not demonstrate a statistically significant positive relationship.