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Low. There is low confidence that the evidence reflects the true effect. Further research is likely
to change the confidence in the estimate of effect and is likely to change the estimate.
Underlying studies may report conflicting results. Low rated bodies of evidence could contain
either quality B or C studies.

Insufficient. Evidence is either unavailable or does not permit a conclusion. There are sparse or
no data. In general, when only one study has been published, the evidence was considered
insufficient, unless the study was particularly large, robust, and of good quality.

These ratings provide a shorthand description of the strength of evidence supporting the
major questions we addressed. However, they by necessity may oversimplify the many complex
issues involved in appraising a body of evidence. It is important to remember that the individual
studies involved in formulating the composite rating differed in their design, reporting, and
quality. The strengths and weaknesses of the individual reports, as described in detail in the text
and tables, should also be taken into consideration.

Peer Review and Public Commentary

As part of a newly instituted process at AHRQ, the initial draft report was prereviewed by the
TOO and an AHRQ Associate Editor (a senior member of a sister EPC). Following revisions, the
draft report was sent to invited peer reviewers and was simultaneously uploaded to the AHRQ
Web site where it was available for public comment for 30 days. All reviewer comments (both
invited and from the public) were collated and individually addressed. The authors of the report
had final discretion as to how the report was revised based on the reviewer comments, with
oversight by the TOO and Associate Editor.

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