In general, the strength of recommendation follows the level of evidence, but not always, as other domains may increase or decrease the strength. The evidence review used for the development of recommendations, conducted by ECRI, assessed the confidence in the quality of the evidence base using GRADE methodology and assigned a rating of High, Moderate, Low, or Very Low. The outcomes judged to be critical were used to determine the overall quality of evidence. Per GRADE, if the quality of evidence differs across the critical outcomes, the lowest quality of evidence for any of the relevant critical outcomes determines the overall quality of the evidence for a recommendation; the overall confidence cannot be higher than the lowest confidence in effect estimates for any outcome that is determined to be critical for clinical decision making.[24,157] The elements that go into the confidence in the quality of the evidence include: Is there high or moderate quality evidence that answers this question? What is the overall certainty of this evidence? Values and preferences is an overarching term that includes patients perspectives, beliefs, expectations, and goals for health and life. More precisely, it refers to the processes that individuals use in considering the potential benefits, harms, costs, limitations, and inconvenience of the therapeutic or preventive measures in relation to one another. For some, the term values has the closest connotation to these processes. For others, the connotation of preferences best captures the notion of choice. In general, values and preferences increase the strength of the recommendation when there is high concordance and decrease it when there is great variability. 