Wording of American Urological Association Guideline Recommendations Does Not Signal the Strength of Recommendation

Brent Cleveland, Andrew Lauwagie, Shahnaz Sultan, Nancy Santesso, Philipp Dahm

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Objective: To systematically analyze the wording of American Urological Association (AUA) clinical practice guidelines’ recommendations. Materials and Methods: We systematically identified all AUA guideline documents that used the current AUA framework and extracted the individual recommendations, their statement type, and their corresponding evidence level (if applicable), and analyzed the recommendation wording separating out the modal verbs (eg, should, may, or must) as well as the main verbs (eg, recommend, treat, perform). We performed descriptive statistics using SPSS Version 27. Results: We included 18 documents with 754 distinct recommendations; the median number of recommendations per guideline was 36 (interquartile range: 29; 48.5). Expert opinion was the most used statement type (193; 25.6%), followed by clinical principle (156; 20.7%). Four-hundred-four recommendations were either strong, moderate, or conditional: 135 (17.9%), 187 (24.8%) and 83 (11.0%), respectively. Most recommendation statements (701; 93.0%) used modal verbs to express a level of obligation. Overall, “should” was the most employed modal verb used (73.9%), followed by “may” (17.6%) and “must” (1.5%). Both “may” and “should” were used in conjunction with all five statement types, whereas “must” was limited to strong recommendations and clinical principles. Conclusion: The wording of AUA recommendation statements does not signal the strength of recommendation and the intended level of obligation, which may represent a barrier to guideline implementation. More consistent wording of recommendations by strength may improve guideline understanding, uptake, and adherence.

Original languageEnglish (US)
Pages (from-to)40-45
Number of pages6
StatePublished - Jun 2022

Bibliographical note

Funding Information:
None. Funding: None.

Publisher Copyright:
© 2021

PubMed: MeSH publication types

  • Journal Article


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