OBJECTIVE: To propose a taxonomy and framework that identifies and presents actionable statements in guidelines. STUDY DESIGN AND SETTING: We took an iterative approach reviewing case studies of guidelines produced by the World Health Organization and the American Society of Hematology to develop an initial conceptual framework. We then tested it using randomly selected recommendations from published guidelines addressing COVID-19 from different organizations, evaluated its results, and refined it before retesting. The urgency and availability of evidence for development of these recommendations varied. We consulted with experts in research methodology and guideline developers to improve the final framework. RESULTS: The resulting taxonomy and framework distinguishes five types of actional statements: formal recommendations; research recommendations; good practice statements; implementation considerations, tools and tips; and informal recommendations. These statements should respond to a priori established criteria and require a clear structure and recognizable presentation in a guideline. Most importantly, this framework identifies informal recommendations that differ from formal recommendations by how they consider evidence and in their development process. CONCLUSION: The identification, standardization and explicit labelling of actionable statements according to the framework may support guideline developers to create actionable statements with clear intent, avoid informal recommendations and improve their understanding and implementation by users.

American College of Physicians Philadelphia PA USA

Amsterdam University Medical Centers location Academic Medical Center University of Amsterdam Amsterdam Public Health research institute Amsterdam The Netherlands

Cochrane South Africa South African Medical Research Council Cape Town South Africa; Clinical Pharmacology Department of Medicine Stellenbosch University Cape Town South Africa

Department of Anesthesiology and Critical Care Medicine Division of Critical Care Medicine Université Laval Québec City QC Canada; Population Health and Optimal Health Practices Research Unit CHU de Québec Université Laval Research Center Québec City QC Canada

Department of Clinical Epidemiology and Public Health Institut d'Investigació Biomèdica Sant Pau

Department of Health Product Policy and Standards World Health Organization Geneva Switzerland

Department of Health Research Methods Evidence and Impact McMaster University Hamilton ON Canada

Department of Health Research Methods Evidence and Impact McMaster University Hamilton ON Canada; Biostatistics Unit The Research Institute St Joseph's Healthcare Hamilton ON Canada

Department of Health Research Methods Evidence and Impact McMaster University Hamilton ON Canada; Department of Internal Medicine Pontificia Universidad Catolica de Chile Santiago Chile

Department of Health Research Methods Evidence and Impact McMaster University Hamilton ON Canada; Department of Medicine McMaster University Hamilton ON Canada

Department of Health Research Methods Evidence and Impact McMaster University Hamilton ON Canada; Michael G DeGroote Cochrane Canada and GRADE Centre McMaster University Hamilton ON Canada

Department of Health Research Methods Evidence and Impact McMaster University Hamilton ON Canada; Michael G DeGroote Cochrane Canada and GRADE Centre McMaster University Hamilton ON Canada; Department of Internal Medicine American University of Beirut Beirut Lebanon

Department of Health Research Methods Evidence and Impact McMaster University Hamilton ON Canada; Michael G DeGroote Cochrane Canada and GRADE Centre McMaster University Hamilton ON Canada; Department of Medicine McMaster University Hamilton ON Canada; Dipartimento di Scienze Biomediche Humanitas University Milan Italy

Department of HIV Hepatitis and Sexually Transmitted Infections World Health Organization Geneva Switzerland

Department of Medicine McMaster University Hamilton ON Canada

European Commission Joint Research Centre Ispra Italy

Institute for Evidence in Medicine Medical Center and Faculty of Medicine University of Freiburg Freiburg Germany; Cochrane Germany Cochrane Germany Foundation Freiburg Germany

Instituto de Salud Carlos 3 Agencia de Evaluación de Tecnologías Sanitarias Madrid Spain

Joanna Briggs Institute Faculty of Health and Medical Sciences The University of Adelaide Australia

National Institute for Health and Care Excellence United Kingdom

Norwegian Institute of Public Health Oslo Norway; University of Oslo Oslo Norway

Postgraduate Institute of Medical Education and Research Chandigarh India

Public Health Agency of Canada Canada

Quality Assurance of Norms and Standards Department Science Division World Health Organization Geneva Switzerland

School of Epidemiology and Public Health University of Ottawa Canada; Departments of Family Medicine and Epidemiology and Community Medicine University of Ottawa; Bruyère Research Institute Ottawa Canada; Departments of Family Medicine and Epidemiology and Community Medicine University of Ottawa

The Czech National Centre for Evidence Based Healthcare and Knowledge Translation ; Institute of Health Information and Statistics of the Czech Republic Prague Czech Republic

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