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Concordance between these guidelines\u2019 strength of recommendation (SOR) ratings and corresponding level of evidence (LOE) ratings is unclear.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>Evaluate concordance between SOR and LOE ratings for guideline recommendations.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Cross-sectional analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Research Subjects<\/jats:title>\n                    <jats:p>Recommendations from 309 clinical practice guideline documents issued by 23 US-based medical societies from 2019 to 2023.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main Measures<\/jats:title>\n                    <jats:p>\n                      Recommendation-level variables: SOR and LOE ratings. Society-level variables: methodology for assigning SOR and LOE ratings and society\u2019s specialty type. SOR-LOE ratings were concordant if the LOE rating was at least as strong as the SOR rating, with concordance quantified using modified Cohen\u2019s kappa [\n                      <jats:italic>\u03ba<\/jats:italic>\n                      ].\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Key Results<\/jats:title>\n                    <jats:p>\n                      Among 7582 recommendations, society guideline writing committees rated SOR as strong for 2303 (30%) recommendations, moderate for 1351 (18%), weak for 2028 (27%), and 1900 recommendations (25%) had no strength assigned. Regarding LOE ratings, 768 (10%) recommendations had strong evidence, 1676 (22%) had moderate evidence, 2421 (32%) had weak or very weak evidence, and 2717 (36%) had evidence lacking an LOE rating. Overall, 5088 (67.1%) recommendations had SOR-LOE rating concordance, and overall SOR-LOE rating concordance was moderate (\n                      <jats:italic>\u03ba<\/jats:italic>\n                      \u2009=\u20090.67; 95% confidence interval (CI) 0.66\u20130.68). Strong recommendations, however, had minimal SOR-LOE concordance (\n                      <jats:italic>\u03ba<\/jats:italic>\n                      \u2009=\u20090.27; 95% CI 0.25\u20130.28;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001), with 1690 (73%) having LOE ratings weaker than strong. Recommendations based on a Modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework (\n                      <jats:italic>\u03ba<\/jats:italic>\n                      \u2009=\u20090.33; 95% CI 0.30\u20130.37,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001), and issued by obstetrics\/gynecology (\n                      <jats:italic>\u03ba<\/jats:italic>\n                      \u2009=\u20090.46; 95% CI 0.40\u20130.51,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001) or neurology\/psychiatry (\n                      <jats:italic>\u03ba<\/jats:italic>\n                      \u2009=\u20090.22; 95% CI 0.18\u20130.26,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001) societies had significantly lower rating concordance.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Among recently issued CPG recommendations, overall SOR-LOE rating concordance was moderate, although recommendations with strong SOR ratings had minimal rating concordance. CPG authors could provide clearer rationales for strong recommendations when the corresponding evidence does not reflect commensurate certainty.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s11606-025-10088-6","type":"journal-article","created":{"date-parts":[[2025,12,22]],"date-time":"2025-12-22T15:25:56Z","timestamp":1766417156000},"page":"3466-3476","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Level of Evidence and Strength of Recommendations in US Medical Society Clinical Practice Guidelines, 2019\u20132023: A Cross-Sectional Analysis"],"prefix":"10.1007","volume":"41","author":[{"given":"Omar","family":"Qureshi","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph S.","family":"Ross","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Reshma","family":"Ramachandran","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6629-8749","authenticated-orcid":false,"given":"Anand R.","family":"Habib","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,12,22]]},"reference":[{"key":"10088_CR1","unstructured":"Institute of Medicine Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. 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Dr. Ross currently receives research support through Yale University from Johnson and Johnson, the US Food and Drug Administration for the Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation (CERSI) program (U01FD005938), from the Agency for Healthcare Research and Quality (R01HS022882), and from Arnold Ventures; formerly received research support from the Medical Device Innovation Consortium as part of the National Evaluation System for Health Technology (NEST) and from the National Heart, Lung and Blood Institute of the National Institutes of Health (NIH) (R01HS025164, R01HL144644); and in addition, Dr. Ross was an expert witness at the request of Relator\u2019s attorneys, the Greene Law Firm, in a qui tam suit alleging violations of the False Claims Act and Anti-Kickback Statute against Biogen Inc. that was settled September 2022. Dr. Ramachandran receives research support through Yale University from the Stavros Niarchos Foundation, the US Food and Drug Administration, and Arnold Ventures, as well as consultant fees from the Johns Hopkins Bloomberg School of Public Health in 2022 for work funded by the Swedish International Development and Cooperation Agency, all outside the submitted work. Dr. Habib serves as an Associate Editor for the Journal of General Internal Medicine, for which he receives no remuneration; he had no role in the review or decision regarding publication of this manuscript.","order":2,"name":"Ethics","label":"Conflict of interest","group":{"name":"EthicsHeading","label":"Declarations"}}]}}