How to Write an Testify-Based Clinical Review Article

JAY SIWEK, M.D., and MARGARET 50. GOURLAY, Yard.D., Georgetown Academy Medical Center, Washington D.C.

ALLEN F. SHAUGHNESSY, PHARM.D., Harrisburg Family Do Residency, Harrisburg, Pennsylvania

Am Fam Doc. 2002 January xv;65(two):251-258.

Article Sections

  • Abstract
  • Topic Selection
  • Searching the Literature
  • Patient-Oriented vs. Illness-Oriented Evidence
  • Evaluating the Literature
  • Levels of Evidence
  • Format of the Review
  • Checklist for an Evidence-Based Clinical Review Commodity
  • References

Traditional clinical review articles, also known as updates, differ from systematic reviews and meta-analyses. Updates selectively review the medical literature while discussing a topic broadly. Nonquantitative systematic reviews comprehensively examine the medical literature, seeking to identify and synthesize all relevant data to formulate the best approach to diagnosis or treatment. Meta-analyses (quantitative systematic reviews) seek to answer a focused clinical question, using rigorous statistical assay of pooled research studies. This article presents guidelines for writing an evidence-based clinical review article for American Family Physician. First, the topic should be of common interest and relevance to family do. Include a table of the continuing medical education objectives of the review. Land how the literature search was done and include several sources of evidence-based reviews, such as the Cochrane Collaboration, BMJ'south Clinical Testify, or the InfoRetriever Web site. Where possible, use prove based on clinical outcomes relating to morbidity, mortality, or quality of life, and studies of master care populations. In manufactures submitted to American Family Physician, rate the level of evidence for primal recommendations co-ordinate to the post-obit calibration: level A (randomized controlled trial [RCT], meta-analysis); level B (other evidence); level C (consensus/adept opinion). Finally, provide a table of key summary points.

American Family Physician is peculiarly interested in receiving clinical review manufactures that follow an evidence-based format. Clinical review articles, also known equally updates, differ from systematic reviews and meta-analyses in important ways.1 Updates selectively review the medical literature while discussing a topic broadly. An example of such a topic is, "The diagnosis and treatment of myocardial ischemia." Systematic reviews comprehensively examine the medical literature, seeking to identify and synthesize all relevant information to formulate the best approach to diagnosis or treatment. Examples are many of the systematic reviews of the Cochrane Collaboration or BMJ's Clinical Evidence compendium. Meta-analyses are a special type of systematic review. They use quantitative methods to clarify the literature and seek to answer a focused clinical question, using rigorous statistical analysis of pooled research studies. An case is, "Exercise beta blockers reduce mortality following myocardial infarction?"

The best clinical review articles base of operations the discussion on existing systematic reviews and meta-analyses, and comprise all relevant research findings most the management of a given disorder. Such evidence-based updates provide readers with powerful summaries and sound clinical guidance.

In this article, we present guidelines for writing an prove-based clinical review commodity, especially ane designed for continuing medical pedagogy (CME) and incorporating CME objectives into its format. This article may be read every bit a companion piece to a previous article and accompanying editorial about reading and evaluating clinical review articles.1,2 Some articles may not exist appropriate for an bear witness-based format because of the nature of the topic, the slant of the article, a lack of sufficient supporting evidence, or other factors. We encourage authors to review the literature and, wherever possible, charge per unit key points of evidence. This process will help emphasize the summary points of the commodity and strengthen its teaching value.

Topic Pick

  • Abstract
  • Topic Choice
  • Searching the Literature
  • Patient-Oriented vs. Disease-Oriented Evidence
  • Evaluating the Literature
  • Levels of Show
  • Format of the Review
  • Checklist for an Evidence-Based Clinical Review Commodity
  • References

Choose a common clinical problem and avoid topics that are rarities or unusual manifestations of illness or that accept curiosity value only. Whenever possible, choose common problems for which there is new data virtually diagnosis or treatment. Emphasize new data that, if valid, should prompt a change in clinical practice, such as the contempo evidence that spironolactone therapy improves survival in patients who have astringent congestive heart failure.three Similarly, new show showing that a standard treatment is no longer helpful, but may be harmful, would also be of import to written report. For example, patching near traumatic corneal abrasions may actually cause more symptoms and filibuster healing compared with no patching.iv

Searching the Literature

  • Abstract
  • Topic Selection
  • Searching the Literature
  • Patient-Oriented vs. Disease-Oriented Prove
  • Evaluating the Literature
  • Levels of Prove
  • Format of the Review
  • Checklist for an Evidence-Based Clinical Review Commodity
  • References

When searching the literature on your topic, delight consult several sources of evidence-based reviews (Table i). Look for pertinent guidelines on the diagnosis, treatment, or prevention of the disorder beingness discussed. Comprise all high-quality recommendations that are relevant to the topic. When reviewing the outset draft, await for all fundamental recommendations nearly diagnosis and, especially, treatment. Endeavor to ensure that all recommendations are based on the highest level of evidence available. If you are not sure well-nigh the source or forcefulness of the recommendation, return to the literature, seeking out the basis for the recommendation.

Tabular array 1

Some Sources of Testify-Based Medicine

Agency for Healthcare Research and Quality (AHRQ), formerly known every bit the Agency for Health Intendance Policy and Research (AHCPR): Clinical Guidelines and Evidence Reports*

http://www.ahrq.gov/clinic

The AHRQ Web site includes links to the National Guideline Clearinghouse, Evidence Reports from the AHRQ'due south 12 Evidence-based Exercise Centers (EPC), and Preventive Services. The AHCPR released 19 Clinical Practice Guidelines between 1992 and1996 that were non subsequently updated.

American College of Physicians Journal Gild (ACPJC)

http://acpjc.acponline.org

ACP Journal Club evaluates testify in individual manufactures. Commentary past ACP author offers clinical recommendations. Access to the online version of ACPJC is a do good for members of the ACP-ASIM, only will be open to all until at least the end of 2001.

Bandolier*

http://www.jr2.ox.ac.uk/bandolier/

Features curt evaluations/discussions of private manufactures dealing with prove-based clinical practice.

Center for Evidence Based Medicine (CEBM)

http://world wide web.cebm.net/

The University of Oxford/Oxford Radcliffe Hospital Clinical Schoolhouse Web site includes links to CEBM inside the Kinesthesia of Medicine, a CATbank (Critically Appraised Topics), links to bear witness-based journals, and EBM-related pedagogy materials.

Centre for Inquiry Support, TRIP Database

http://www.tripdatabase.com/index.html

The AHRQ began the Translating Research into Practice (TRIP) initiative in 1990 to implement evidence-based tools and information. The TRIP Database features hyperlinks to the largest collection of EBM materials on the internet, including NGC, Poem, Cartel, Cochrane Library, CATbank, and individual articles. A good starting place for an EBM literature search.

Clinical Evidence ,BMJ Publishing Grouping*

http://www.clinicalevidence.org

Searches BMJ'southward Clinical Evidence compendium for up-to-date prove regarding effective health care. Lists available topics and describes the supporting body of evidence to appointment (e.m., number of relevant randomized controlled trials published to date). Concludes with interventions "likely to be beneficial" versus those with "unknown effectiveness." Individuals who have received a free copy of Clinical Evidence Issue 5 from the United Wellness Foundation are also entitled to free access to the total online content.

Cochrane Database of Systematic Reviews*

http://world wide web.cochrane.org/

Systematic bear witness reviews that are updated periodically by the Cochrane Group. Reviewers hash out whether acceptable data are bachelor for the development of EBM guidelines for diagnosis or management.

Database of Abstracts of Reviews of Effectiveness (DARE)*

http://www.crd.york.ac.uk/crdweb/

Structured abstracts written by University of York CRD reviewers (see NHS CRD). Abstract summaries review articles on diagnostic or treatment interventions and talk over clinical implications.

Effective Wellness Care*

http://www.york.air conditioning.uk/inst/crd/ehcb.htm

Bi-monthly, peer-reviewed bulletin for medical decision-makers. Based on systematic reviews and synthesis of enquiry on the clinical effectiveness, cost-effectiveness and acceptability of health service interventions.

Evidence-Based Medicine*

http://www.evidence-basedmedicine.com

Bimonthly publication launched in 1995 by the BMJ Publishing Group. Article summaries include commentaries by clinical experts. Subscription is required.

Evidence-Based Practise Newsletter (including JFP Patient-Oriented Evidence that Matters [Poem])*

http://www.ebponline.net

This JFP newsletter features up-to-date Verse form, Disease-Oriented Evidence (DOE), and tests canonical for Category i CME credit. Subscription required.

InfoPOEMs

http://www.infopoems.com

Includes the InfoRetriever search arrangement for the complete POEMs database and six additional evidence-based databases. Subscription is required.

Plant for Clinical Systems Improvement (ICSI)*

http://www.ICSI.org

ICSI is an independent, nonprofit collaboration of wellness intendance organizations, including the Mayo Clinic, Rochester, Minn. Web site includes the ICSI guidelines for preventive services and affliction management.

National Guideline Clearinghouse (NGC)

http://www.guideline.gov/

Comprehensive database of evidence-based clinical practise guidelines from authorities agencies and health intendance organizations. Describes and compares guideline statements with respect to objectives, methods, outcomes, evidence rating scheme, and major recommendations.

National Health Service (NHS) Centre for Reviews and Dissemination (CRD)

http://world wide web.crd.york.ac.united kingdom

Searches CRD Databases (includes DARE, NHS Economic Evaluation Database, Health Applied science Cess Database) for EBM reviews. More limited than TRIP Database.

Primary Care Clinical Practise Guidelines

http://medicine.ucsf.edu/resources/guidelines

Academy of California, San Francisco, Spider web site that includes links to NGC, CEBM, AHRQ, individual articles, and organizations.

U.Southward. Preventive Services Task Force (USPSTF)*

http://www.ahrq.gov/clinic/uspstfix.htm

This Web site features updated recommendations for clinical preventive services based on systematic show reviews by the U.South. Preventive Services Task Strength.

In item, try to find the answer in an authoritative compendium of evidence-based reviews, or at to the lowest degree try to find a meta-assay or well-designed randomized controlled trial (RCT) to support information technology. If none appears to be available, try to cite an administrative consensus statement or clinical guideline, such as a National Institutes of Wellness Consensus Development Conference statement or a clinical guideline published by a major medical organization. If no stiff evidence exists to support the conventional approach to managing a given clinical situation, point this out in the text, particularly for central recommendations. Continue in listen that much of traditional medical practise has not nevertheless undergone rigorous scientific study, and high-quality evidence may not exist to support conventional knowledge or exercise.

Patient-Oriented vs. Disease-Oriented Bear witness

  • Abstract
  • Topic Pick
  • Searching the Literature
  • Patient-Oriented vs. Disease-Oriented Testify
  • Evaluating the Literature
  • Levels of Evidence
  • Format of the Review
  • Checklist for an Show-Based Clinical Review Article
  • References

With regard to types of bear witness, Shaughnessy and Slawson5–7  developed the concept of Patient-Oriented Evidence that Matters (Poem), in distinction to Disease-Oriented Evidence (DOE). Poem deals with outcomes of importance to patients, such equally changes in morbidity, mortality, or quality of life. DOE deals with surrogate end points, such equally changes in laboratory values or other measures of response. Although the results of DOE sometimes parallel the results of Verse form, they do not always correspond (Table ii).2 When possible, utilise Poem-type evidence rather than DOE. When DOE is the only guidance available, bespeak that key clinical recommendations lack the support of outcomes evidence. Here is an example of how the latter state of affairs might appear in the text: "Although prostate-specific antigen (PSA) testing identifies prostate cancer at an early phase, it has not yet been proved that PSA screening improves patient survival." (Notation: PSA testing is an case of DOE, a surrogate marker for the true outcomes of importance—improved survival, decreased morbidity, and improved quality of life.)

Table 2

Comparison of DOE and POEM

Intervention DOE POEM Comment

Antiarrhythmic therapy

Antiarrhythmic drug 10 decreases the incidence of PVCs on ECGs

Antiarrhythmic drug X is associated with an increase in mortality

POEM results are reverse to DOE implications

Antihypertensive therapy

Antihypertensive drug treatment lowers claret pressure

Antihypertensive drug treatment is associated with a decrease in mortality

Verse form results are in concordance with DOE implications

Screening for prostate cancer

PSA screening detects prostate cancer at an early phase

Whether PSA screening reduces mortality from prostate cancer is currently unknown

Although DOE exists, the important Poem is currently unknown

Evaluating the Literature

  • Abstract
  • Topic Selection
  • Searching the Literature
  • Patient-Oriented vs. Affliction-Oriented Evidence
  • Evaluating the Literature
  • Levels of Show
  • Format of the Review
  • Checklist for an Evidence-Based Clinical Review Article
  • References

Evaluate the force and validity of the literature that supports the discussion (encounter the following section, Levels of Evidence). Look for meta-analyses, loftier-quality, randomized clinical trials with of import outcomes (POEM), or well-designed, nonrandomized clinical trials, clinical accomplice studies, or case-controlled studies with consistent findings. In some cases, high-quality, historical, uncontrolled studies are appropriate (e.g., the show supporting the efficacy of Papanicolaou smear screening). Avoid anecdotal reports or repeating the hearsay of conventional wisdom, which may not stand up to the scrutiny of scientific written report (e.g., prescribing prolonged bed remainder for low back pain).

Expect for studies that draw patient populations that are likely to be seen in main care rather than subspecialty referral populations. Shaughnessy and Slawson's guide for writers of clinical review articles includes a section on information and validity traps to avoid.2

Levels of Evidence

  • Abstruse
  • Topic Option
  • Searching the Literature
  • Patient-Oriented vs. Disease-Oriented Evidence
  • Evaluating the Literature
  • Levels of Testify
  • Format of the Review
  • Checklist for an Evidence-Based Clinical Review Commodity
  • References

Readers need to know the force of the evidence supporting the central clinical recommendations on diagnosis and treatment. Many different rating systems of varying complexity and clinical relevance are described in the medical literature. Recently, the 3rd U.Due south. Preventive Services Chore Force (USPSTF) emphasized the importance of rating non only the study type (RCT, cohort report, case-command study, etc.), only besides the study quality every bit measured by internal validity and the quality of the entire body of prove on a topic.8

While it is important to appreciate these evolving concepts, we observe that a simplified grading system is more useful in AFP. We have adopted the post-obit convention, using an ABC rating scale. Criteria for loftier-quality studies are discussed in several sources.8,ix Run into the AFP Web site (world wide web.aafp.org/afp/authors) for boosted information about levels of evidence and see the accompanying editorial in this upshot discussing the potential pitfalls and limitations of any rating organization.

  • Level A (randomized controlled trial/meta-analysis): High-quality randomized controlled trial (RCT) that considers all important outcomes. High-quality meta-analysis (quantitative systematic review) using comprehensive search strategies.

  • Level B (other evidence): A well-designed, nonrandomized clinical trial. A nonquantitative systematic review with appropriate search strategies and well-substantiated conclusions. Includes lower quality RCTs, clinical accomplice studies, and case-controlled studies with non-biased selection of study participants and consistent findings. Other evidence, such as high-quality, historical, uncontrolled studies, or well-designed epidemiologic studies with compelling findings, is also included.

  • Level C (consensus/expert opinion): Consensus viewpoint or expert opinion.

Each rating is practical to a single reference in the article, non to the entire body of evidence that exists on a topic. Each characterization should include the letter rating (A, B, C), followed past the specific type of study for that reference. For instance, post-obit a level B rating, include one of these descriptors: (1) nonrandomized clinical trial; (2) nonquantitative systematic review; (iii) lower quality RCT; (4) clinical cohort study; (5) instance-controlled written report; (half-dozen) historical uncontrolled study; (7) epidemiologic written report.

Hither are some examples of the way evidence ratings should appear in the text:

  • "To improve morbidity and bloodshed, most patients in congestive centre failure should be treated with an angiotensin-converting enzyme inhibitor. [Testify level A, RCT]"

  • "The USPSTF recommends that clinicians routinely screen asymptomatic meaning women 25 years and younger for chlamydial infection. [Evidence level B, non-randomized clinical trial]"

  • "The American Diabetes Clan recommends screening for diabetes every 3 years in all patients at loftier risk of the disease, including all adults 45 years and older. [Evidence level C, practiced opinion]"

When scientifically strong evidence does not exist to support a given clinical recommendation, you lot tin point this out in the following way:

  • "Concrete therapy is traditionally prescribed for the handling of adhesive capsulitis (frozen shoulder), although there are no randomized outcomes studies of this arroyo."

Format of the Review

  • Abstract
  • Topic Selection
  • Searching the Literature
  • Patient-Oriented vs. Illness-Oriented Prove
  • Evaluating the Literature
  • Levels of Testify
  • Format of the Review
  • Checklist for an Evidence-Based Clinical Review Article
  • References

INTRODUCTION

The introduction should define the topic and purpose of the review and describe its relevance to family unit practice. The traditional manner of doing this is to hash out the epidemiology of the status, stating how many people take it at one point in fourth dimension (prevalence) or what percentage of the population is expected to develop it over a given period of fourth dimension (incidence). A more engaging fashion of doing this is to point how often a typical family dr. is likely to encounter this trouble during a week, month, year, or career. Emphasize the key CME objectives of the review and summarize them in a separate table entitled "CME Objectives."

METHODS

The methods department should briefly betoken how the literature search was conducted and what major sources of testify were used. Ideally, indicate what predetermined criteria were used to include or exclude studies (e.g., studies had to exist independently rated as being high quality by an established evaluation procedure, such as the Cochrane Collaboration). Be comprehensive in trying to place all major relevant research. Critically evaluate the quality of research reviewed. Avoid selective referencing of only data that supports your conclusions. If in that location is controversy on a topic, accost the full scope of the controversy.

DISCUSSION

The discussion can and then follow the typical format of a clinical review article. It should touch on on one or more of the following subtopics: etiology, pathophysiology, clinical presentation (signs and symptoms), diagnostic evaluation (history, concrete exam, laboratory evaluation, and diagnostic imaging), differential diagnosis, treatment (goals, medical/surgical therapy, laboratory testing, patient education, and follow-upwards), prognosis, prevention, and futurity directions.

The review will be comprehensive and counterbalanced if it acknowledges controversies, unresolved questions, recent developments, other viewpoints, and any apparent conflicts of interest or instances of bias that might bear upon the forcefulness of the evidence presented. Emphasize an bear witness-supported approach or, where little evidence exists, a consensus viewpoint. In the absence of a consensus viewpoint, y'all may describe generally accepted practices or discuss 1 or more reasoned approaches, but acknowledge that solid back up for these recommendations is lacking.

In some cases, cost-effectiveness analyses may exist of import in deciding how to implement wellness intendance services, especially preventive services.10 When relevant, mention high-quality cost-effectiveness analyses to aid clarify the costs and health benefits associated with alternative interventions to achieve a given health outcome. Highlight key points most diagnosis and treatment in the discussion and include a summary tabular array of the key take-home points. These points are not necessarily the same equally the key recommendations, whose level of evidence is rated, although some of them will exist.

Use tables, figures, and illustrations to highlight primal points, and present a step-wise, algorithmic approach to diagnosis or handling when possible.

Rate the evidence for cardinal statements, especially treatment recommendations. We look that most articles will have at near 2 to four primal statements; some will have none. Rate but those statements that have corresponding references and base of operations the rating on the quality and level of show presented in the supporting citations. Utilize chief sources (original research, RCTs, meta-analyses, and systematic reviews) as the footing for determining the level of evidence. In other words, the supporting citation should be a primary research source of the data, not a secondary source (such equally a nonsystematic review article or a textbook) that simply cites the original source. Systematic reviews that clarify multiple RCTs are good sources for determining ratings of evidence.

REFERENCES

The references should include the about current and important sources of support for central statements (i.east., studies referred to, new data, controversial fabric, specific quantitative information, and information that would non usually exist found in most general reference textbooks). Generally, these references volition be primal evidence-based recommendations, meta-analyses, or landmark articles. Although some journals publish exhaustive lists of reference citations, AFP prefers to include a succinct list of key references. (Nosotros volition make more extensive reference lists available on our Web site or provide links to your personal reference listing.)

You may use the following checklist to ensure the abyss of your evidence-based review article; use the source list of reviews to identify important sources of testify-based medicine materials.

Checklist for an Evidence-Based Clinical Review Article

  • Abstract
  • Topic Option
  • Searching the Literature
  • Patient-Oriented vs. Disease-Oriented Prove
  • Evaluating the Literature
  • Levels of Prove
  • Format of the Review
  • Checklist for an Bear witness-Based Clinical Review Article
  • References

  • The topic is common in family unit practise, especially topics in which there is new, important information well-nigh diagnosis or handling.

  • The introduction defines the topic and the purpose of the review, and describes its relevance to family practice.

  • A table of CME objectives for the review is included.

  • The review states how you did your literature search and indicates what sources yous checked to ensure a comprehensive cess of relevant studies (e.g., MEDLINE, the Cochrane Collaboration Database, the Centre for Research Support, TRIP Database).

  • Several sources of testify-based reviews on the topic are evaluated (Table 1).

  • Where possible, Verse form (dealing with changes in morbidity, mortality, or quality of life) rather than DOE (dealing with mechanistic explanations or surrogate finish points, such as changes in laboratory tests) is used to support key clinical recommendations (Table ii).

  • Studies of patients likely to be representative of those in primary care practices, rather than subspecialty referral centers, are emphasized.

  • Studies that are not only statistically significant but as well clinically significant are emphasized; east.k., interventions with meaningful changes in absolute risk reduction and depression numbers needed to treat. (Seehttp://www.cebm.cyberspace/alphabetize.aspx?o=1116.)11

  • The level of prove for key clinical recommendations is labeled using the following rating scale: level A (RCT/meta-analysis), level B (other prove), and level C (consensus/expert stance).

  • Acknowledge controversies, recent developments, other viewpoints, and whatsoever apparent conflicts of involvement or instances of bias that might affect the strength of the show presented.

  • Highlight central points almost diagnosis and treatment in the discussion and include a summary table of central take-domicile points.

  • Utilize tables, figures, and illustrations to highlight key points and present a step-wise, algorithmic arroyo to diagnosis or treatment when possible.

  • Emphasize testify-based guidelines and primary enquiry studies, rather than other review articles, unless they are systematic reviews.

The essential elements of this checklist are summarized in Table 3.

Tabular array 3

Essential Steps in Writing an Evidence-Based Clinical Review Article

Choose a common, important topic in family practice.

Provide a tabular array with a list of continuing medical education (CME) objectives for the review.

Land how the literature search and reference selection were washed.

Apply several sources of evidence-based reviews on the topic.

Rate the level of evidence for key recommendations in the text.

Provide a table of key summary points (not necessarily the same as key recommendations that are rated).

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The Authors

show all writer info

JAY SIWEK, M.D., is professor and chair of the Section of Family Medicine at Georgetown University Medical Heart, Washington, D.C. He is also editor of American Family Doc. A graduate of Georgetown University School of Medicine, Dr. Siwek completed his family unit practice residency at Middlesex Infirmary in Middletown, Conn....

MARGARET L. GOURLAY, M.D., is currently the American Family Md Medical Editing Fellow at Georgetown University Medical Center. A graduate of Blitz Medical College, Chicago, she completed a residency in family unit medicine at the Academy of California, San Diego, Medical Center.

DAVID C. SLAWSON, Chiliad.D., is the B. Lewis Barnett, Jr. professor of family medicine at the University of Virginia Health Organisation in Charlottesville, Va. He is director and founder of the Center for Information Mastery and serves equally section editor for The Journal of Family unit Practice POEMs. Dr. Slawson is a graduate of the University of Michigan Schoolhouse of Medicine, Ann Arbor, Mich., and he completed postdoctoral training in family unit medicine at the Academy of Virginia.

ALLEN F. SHAUGHNESSY, PHARM.D., is director of research and associate director of the Harrisburg Family unit Practice Residency, Harrisburg, Pa. He completed his doctorate and fellowship preparation at the Medical Academy of South Carolina, Charleston.

Accost correspondence to Jay Siwek, M.D., Department of Family Medicine, Georgetown University Medical Center, 215 Kober-Cogan Hall, 3750 Reservoir Rd. NW, Washington DC 20007 (e-post:afp@family.georgetown.edu). Reprints are not available from the authors.

The authors thank Ted Ganiats, Grand.D. for a helpful review and conceptual contributions to the manuscript.

The authors indicate that they exercise not have whatsoever conflicts of interest. Sources of funding: none reported.

REFERENCES

bear witness all references

one. Siwek J. Reading and evaluating clinical review articles. Am Fam Physician. 1997;55:2064,2069–lxx,2072. ...

ii. Shaughnessy AF, Slawson DC. Getting the well-nigh from review articles: a guide for readers and writers. Am Fam Md. 1997;55:2155–lx.

3. Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, et al. for the Randomized Aldactone Evaluation Study Investigators. The effect of spironolactone on morbidity and mortality in patients with severe middle failure. N Engl J Med. 1999;341:709–17.

four. Flynn CA, D'Amico F, Smith G. Should we patch corneal abrasions? A meta-analysis. J Fam Pract. 1998;47:264–70.

5. Slawson DC, Shaughnessy AF, Bennett JH. Becoming a medical information principal: feeling skillful about not knowing everything. J Fam Pract. 1994;38:505–13.

6. Shaughnessy AF, Slawson DC, Bennett JH. Becoming an information chief: a guidebook to the medical information jungle. J Fam Pract. 1994;39:489–99.

seven. Slawson DC, Shaughnessy AF. Becoming an information master: using POEMs to alter practice with confidence. Patient-oriented evidence that matters. J Fam Pract. 2000;49:63–7.

viii. Harris RP, Helfand Yard, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al. Methods Piece of work Group, Third U.Southward. Preventive Services Task Force. Current methods of the U.S. Preventive Services Task Force. A review of the process. Am J Prev Med. 2001;20(3 suppl):21–35.

9. CATbank topics: levels of evidence and grades of recommendations. Retrieved Nov 2001, from: http://www.cebm.net/.

10. Saha S, Hoerger TJ, Pignone MP, Teutsch SM, Helfand M, Mandelblatt JS. for the Toll Work Grouping of the Tertiary U.S. Preventive Services Job Force. The art and scientific discipline of incorporating toll effectiveness into evidence-based recommendations for clinical preventive services. Am J Prev Med. 2001;20(3 suppl):36–43.

11. Bear witness-based medicine glossary. Retrieved November 2001, from: http://world wide web.cebm.internet/index.aspx?o=1116.

Copyright © 2002 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing information technology online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This fabric may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether at present known or afterwards invented, except every bit authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

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