For a study, researchers sought to comprehensively examine the phrasing of the recommendations in the American Urological Association (AUA) clinical practice guidelines. They systematically identified all AUA guideline documents that used the current AUA framework, extracted the individual recommendations, their statement type, and the corresponding evidence level (if applicable), and analyzed the recommendation wording, separating out the modal verbs (e.g., should, may, or must) and the main verbs (e.g., recommend, treat, perform). They used SPSS Version 27 to do descriptive statistics.

They included 18 publications with a total of 754 suggestions; the average number of recommendations per guideline was 36 (interquartile range: 29; 48.5). The most common statement type was expert opinion (193; 25.6%), followed by clinical principle (156; 20.7%). One hundred and forty-four suggestions were either strong, moderate, or conditional: 135 (17.9%), 187 (24.8%), and 83 (11.0%), respectively. To communicate a level of duty, most recommendation statements (701; 93.0%) employed modal verbs. Overall, “should” was the most commonly used modal verb (73.9%), followed by “may” (17.6%) and “must” (1.5%). “May” and “should” were used with all five statement categories, while “must” was only used with strong recommendations and clinical principles.

The language of AUA recommendation statements does not indicate the severity of the advice or the intended level of responsibility, which may be a barrier to guideline implementation. More uniform phrasing of recommendations based on strength may increase guideline comprehension, adoption, and adherence.