How to Write an Bear witness-Based Clinical Review Commodity

JAY SIWEK, M.D., and MARGARET Fifty. GOURLAY, G.D., Georgetown Academy Medical Center, Washington D.C.

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

Am Fam Md. 2002 Jan 15;65(2):251-258.

Commodity Sections

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

Traditional clinical review articles, besides 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 all-time approach to diagnosis or handling. Meta-analyses (quantitative systematic reviews) seek to answer a focused clinical question, using rigorous statistical analysis of pooled research studies. This article presents guidelines for writing an bear witness-based clinical review commodity for American Family Physician. First, the topic should be of mutual interest and relevance to family practice. Include a tabular array 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's Clinical Evidence, or the InfoRetriever Web site. Where possible, use evidence based on clinical outcomes relating to morbidity, mortality, or quality of life, and studies of primary care populations. In articles submitted to American Family Medico, rate the level of evidence for central recommendations co-ordinate to the following scale: level A (randomized controlled trial [RCT], meta-assay); level B (other evidence); level C (consensus/expert opinion). Finally, provide a table of key summary points.

American Family Doctor is particularly interested in receiving clinical review articles that follow an show-based format. Clinical review articles, too known every bit updates, differ from systematic reviews and meta-analyses in important means.1 Updates selectively review the medical literature while discussing a topic broadly. An case 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'southward Clinical Evidence compendium. Meta-analyses are a special type of systematic review. They use quantitative methods to analyze the literature and seek to answer a focused clinical question, using rigorous statistical analysis of pooled research studies. An instance is, "Do beta blockers reduce mortality following myocardial infarction?"

The best clinical review articles base the give-and-take on existing systematic reviews and meta-analyses, and incorporate all relevant research findings about 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 article, especially one designed for continuing medical education (CME) and incorporating CME objectives into its format. This article may be read as a companion piece to a previous commodity and accompanying editorial well-nigh reading and evaluating clinical review articles.i,2 Some articles may not exist advisable for an prove-based format because of the nature of the topic, the slant of the commodity, a lack of sufficient supporting evidence, or other factors. We encourage authors to review the literature and, wherever possible, rate key points of testify. This procedure volition help emphasize the summary points of the article and strengthen its pedagogy value.

Topic Selection

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

Choose a common clinical problem and avoid topics that are rarities or unusual manifestations of illness or that have curiosity value only. Whenever possible, choose common problems for which there is new information about diagnosis or handling. Emphasize new information that, if valid, should prompt a change in clinical practise, such as the recent evidence that spironolactone therapy improves survival in patients who have severe congestive middle failure.three Similarly, new evidence showing that a standard treatment is no longer helpful, but may be harmful, would also be important to report. For example, patching almost traumatic corneal abrasions may actually cause more symptoms and delay healing compared with no patching.four

Searching the Literature

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

When searching the literature on your topic, please consult several sources of evidence-based reviews (Tabular array 1). Look for pertinent guidelines on the diagnosis, treatment, or prevention of the disorder being discussed. Comprise all high-quality recommendations that are relevant to the topic. When reviewing the first draft, await for all key recommendations about diagnosis and, especially, handling. Try to ensure that all recommendations are based on the highest level of show available. If you are not sure about the source or strength of the recommendation, return to the literature, seeking out the ground for the recommendation.

TABLE 1

Some Sources of Evidence-Based Medicine

Agency for Healthcare Research and Quality (AHRQ), formerly known as the Agency for Wellness Care Policy and Inquiry (AHCPR): Clinical Guidelines and Evidence Reports*

http://www.ahrq.gov/dispensary

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

American Higher of Physicians Journal Guild (ACPJC)

http://acpjc.acponline.org

ACP Journal Order evaluates evidence in private articles. Commentary by ACP author offers clinical recommendations. Access to the online version of ACPJC is a benefit for members of the ACP-ASIM, merely will exist open to all until at least the end of 2001.

Bandolier*

http://www.jr2.ox.ac.u.k./bandolier/

Features short evaluations/discussions of individual articles dealing with evidence-based clinical practise.

Centre for Prove Based Medicine (CEBM)

http://www.cebm.cyberspace/

The Academy of Oxford/Oxford Radcliffe Infirmary Clinical Schoolhouse Web site includes links to CEBM within the Faculty of Medicine, a CATbank (Critically Appraised Topics), links to testify-based journals, and EBM-related teaching materials.

Center for Research Support, TRIP Database

http://world wide web.tripdatabase.com/alphabetize.html

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

Clinical Evidence ,BMJ Publishing Group*

http://www.clinicalevidence.org

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

Cochrane Database of Systematic Reviews*

http://www.cochrane.org/

Systematic evidence reviews that are updated periodically by the Cochrane Group. Reviewers discuss whether adequate 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 (run across NHS CRD). Abstract summaries review articles on diagnostic or treatment interventions and hash out clinical implications.

Constructive Health Care*

http://world wide web.york.air conditioning.u.k./inst/crd/ehcb.htm

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

Evidence-Based Medicine*

http://www.show-basedmedicine.com

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

Evidence-Based Do Newsletter (including JFP Patient-Oriented Evidence that Matters [POEM])*

http://www.ebponline.cyberspace

This JFP newsletter features up-to-date POEM, Disease-Oriented Bear witness (DOE), and tests approved for Category 1 CME credit. Subscription required.

InfoPOEMs

http://world wide web.infopoems.com

Includes the InfoRetriever search organization for the complete POEMs database and six additional bear witness-based databases. Subscription is required.

Constitute for Clinical Systems Improvement (ICSI)*

http://www.ICSI.org

ICSI is an independent, nonprofit collaboration of health care 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 testify-based clinical practice guidelines from regime agencies and health care organizations. Describes and compares guideline statements with respect to objectives, methods, outcomes, show rating scheme, and major recommendations.

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

http://world wide web.crd.york.ac.uk

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

Primary Intendance Clinical Do Guidelines

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

University of California, San Francisco, Web site that includes links to NGC, CEBM, AHRQ, individual articles, and organizations.

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

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

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

In particular, try to observe the answer in an authoritative compendium of evidence-based reviews, or at least try to observe a meta-analysis or well-designed randomized controlled trial (RCT) to support it. If none appears to exist bachelor, try to cite an authoritative consensus argument or clinical guideline, such as a National Institutes of Wellness Consensus Development Briefing argument or a clinical guideline published by a major medical system. If no stiff evidence exists to support the conventional approach to managing a given clinical situation, betoken this out in the text, especially for key recommendations. Proceed in mind that much of traditional medical exercise has not withal undergone rigorous scientific study, and high-quality evidence may not exist to back up conventional knowledge or do.

Patient-Oriented vs. Disease-Oriented Bear witness

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

With regard to types of evidence, Shaughnessy and Slawson5–vii  developed the concept of Patient-Oriented Evidence that Matters (Poem), in stardom to Illness-Oriented Prove (DOE). Poem deals with outcomes of importance to patients, such as changes in morbidity, mortality, or quality of life. DOE deals with surrogate end points, such as 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 stand for (Table 2).2 When possible, utilize Poem-type evidence rather than DOE. When DOE is the only guidance available, betoken that key clinical recommendations lack the support of outcomes show. Here is an case of how the latter situation might appear in the text: "Although prostate-specific antigen (PSA) testing identifies prostate cancer at an early stage, information technology has not however been proved that PSA screening improves patient survival." (Note: PSA testing is an instance of DOE, a surrogate marking for the true outcomes of importance—improved survival, decreased morbidity, and improved quality of life.)

Table 2

Comparing of DOE and Poem

Intervention DOE Verse form Comment

Antiarrhythmic therapy

Antiarrhythmic drug Ten decreases the incidence of PVCs on ECGs

Antiarrhythmic drug X is associated with an increase in mortality

Verse form results are contrary to DOE implications

Antihypertensive therapy

Antihypertensive drug treatment lowers blood pressure

Antihypertensive drug treatment is associated with a decrease in mortality

Verse form results are in cyclopedia with DOE implications

Screening for prostate cancer

PSA screening detects prostate cancer at an early on stage

Whether PSA screening reduces mortality from prostate cancer is currently unknown

Although DOE exists, the important Verse form is currently unknown

Evaluating the Literature

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

Evaluate the strength and validity of the literature that supports the discussion (see the post-obit section, Levels of Evidence). Look for meta-analyses, high-quality, randomized clinical trials with important outcomes (Verse form), or well-designed, nonrandomized clinical trials, clinical cohort studies, or instance-controlled studies with consistent findings. In some cases, loftier-quality, historical, uncontrolled studies are appropriate (due east.thousand., the bear witness supporting the efficacy of Papanicolaou smear screening). Avoid anecdotal reports or repeating the hearsay of conventional wisdom, which may non stand up to the scrutiny of scientific report (e.g., prescribing prolonged bed remainder for low back hurting).

Look for studies that depict patient populations that are likely to exist seen in primary intendance rather than subspecialty referral populations. Shaughnessy and Slawson'due south guide for writers of clinical review articles includes a section on information and validity traps to avert.2

Levels of Evidence

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

Readers need to know the forcefulness of the evidence supporting the key clinical recommendations on diagnosis and handling. Many different rating systems of varying complexity and clinical relevance are described in the medical literature. Recently, the third U.S. Preventive Services Task Force (USPSTF) emphasized the importance of rating not just the study type (RCT, cohort study, case-control report, etc.), just likewise the report quality equally measured by internal validity and the quality of the entire torso of evidence on a topic.eight

While it is of import to appreciate these evolving concepts, nosotros find that a simplified grading system is more than useful in AFP. We accept adopted the post-obit convention, using an ABC rating scale. Criteria for loftier-quality studies are discussed in several sources.8,9 See the AFP Web site (www.aafp.org/afp/authors) for additional information nigh levels of evidence and see the accompanying editorial in this issue discussing the potential pitfalls and limitations of whatever rating system.

  • 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 advisable search strategies and well-substantiated conclusions. Includes lower quality RCTs, clinical accomplice studies, and example-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 applied to a single reference in the article, non to the entire body of testify that exists on a topic. Each label should include the letter rating (A, B, C), followed by the specific blazon of report for that reference. For instance, following a level B rating, include 1 of these descriptors: (i) nonrandomized clinical trial; (2) nonquantitative systematic review; (three) lower quality RCT; (4) clinical cohort study; (v) case-controlled report; (6) historical uncontrolled study; (vii) epidemiologic study.

Here are some examples of the way show ratings should appear in the text:

  • "To improve morbidity and mortality, almost patients in congestive heart failure should be treated with an angiotensin-converting enzyme inhibitor. [Evidence level A, RCT]"

  • "The USPSTF recommends that clinicians routinely screen asymptomatic pregnant women 25 years and younger for chlamydial infection. [Bear witness level B, not-randomized clinical trial]"

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

When scientifically strong evidence does not exist to support a given clinical recommendation, you can indicate this out in the following mode:

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

Format of the Review

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

INTRODUCTION

The introduction should ascertain the topic and purpose of the review and draw its relevance to family unit practise. The traditional manner of doing this is to discuss the epidemiology of the condition, stating how many people have it at one point in fourth dimension (prevalence) or what per centum of the population is expected to develop information technology over a given menstruation of time (incidence). A more engaging mode of doing this is to indicate how often a typical family physician is likely to run across this problem during a week, month, year, or career. Emphasize the central CME objectives of the review and summarize them in a split table entitled "CME Objectives."

METHODS

The methods section 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 (due east.g., studies had to be independently rated equally existence loftier quality past an established evaluation process, such every bit the Cochrane Collaboration). Be comprehensive in trying to identify all major relevant research. Critically evaluate the quality of research reviewed. Avoid selective referencing of just data that supports your conclusions. If there is controversy on a topic, address the full scope of the controversy.

Word

The discussion can then follow the typical format of a clinical review article. Information technology should impact 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-upward), prognosis, prevention, and time to come directions.

The review will be comprehensive and counterbalanced if it acknowledges controversies, unresolved questions, recent developments, other viewpoints, and any apparent conflicts of involvement or instances of bias that might bear on the strength of the evidence presented. Emphasize an evidence-supported approach or, where little evidence exists, a consensus viewpoint. In the absence of a consensus viewpoint, you lot may describe generally accepted practices or discuss one or more reasoned approaches, merely acknowledge that solid support for these recommendations is defective.

In some cases, cost-effectiveness analyses may exist important in deciding how to implement health care services, especially preventive services.ten When relevant, mention high-quality cost-effectiveness analyses to help clarify the costs and wellness benefits associated with alternative interventions to achieve a given wellness outcome. Highlight central points well-nigh diagnosis and treatment in the discussion and include a summary table of the key take-home points. These points are not necessarily the aforementioned every bit the key recommendations, whose level of bear witness is rated, although some of them will exist.

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

Rate the evidence for key statements, especially treatment recommendations. We expect that nigh articles volition accept at virtually two to four fundamental statements; some will have none. Rate merely those statements that have corresponding references and base the rating on the quality and level of evidence presented in the supporting citations. Utilize principal sources (original enquiry, RCTs, meta-analyses, and systematic reviews) every bit the footing for determining the level of evidence. In other words, the supporting commendation should be a primary research source of the information, non a secondary source (such equally a nonsystematic review commodity or a textbook) that just cites the original source. Systematic reviews that analyze multiple RCTs are skilful sources for determining ratings of show.

REFERENCES

The references should include the most current and important sources of support for fundamental statements (i.e., studies referred to, new information, controversial material, specific quantitative data, and data that would not usually exist found in near full general reference textbooks). Mostly, these references will be primal evidence-based recommendations, meta-analyses, or landmark manufactures. Although some journals publish exhaustive lists of reference citations, AFP prefers to include a succinct list of key references. (We volition brand more extensive reference lists bachelor on our Web site or provide links to your personal reference list.)

You may use the post-obit checklist to ensure the completeness of your show-based review article; utilise the source listing of reviews to place of import sources of evidence-based medicine materials.

Checklist for an Show-Based Clinical Review Article

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

  • The topic is mutual in family do, especially topics in which at that place is new, of import information almost diagnosis or treatment.

  • 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 you checked to ensure a comprehensive assessment of relevant studies (due east.g., MEDLINE, the Cochrane Collaboration Database, the Center for Research Back up, TRIP Database).

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

  • Where possible, POEM (dealing with changes in morbidity, bloodshed, 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 (Tabular array ii).

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

  • Studies that are not only statistically significant but too clinically meaning are emphasized; e.one thousand., interventions with meaningful changes in absolute chance reduction and low numbers needed to treat. (Seehttp://www.cebm.internet/alphabetize.aspx?o=1116.)xi

  • The level of evidence for key clinical recommendations is labeled using the following rating calibration: level A (RCT/meta-assay), level B (other evidence), and level C (consensus/skilful stance).

  • Admit controversies, contempo developments, other viewpoints, and any apparent conflicts of interest or instances of bias that might affect the strength of the show presented.

  • Highlight fundamental points about diagnosis and handling in the discussion and include a summary table of key take-dwelling house points.

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

  • Emphasize evidence-based guidelines and main research studies, rather than other review articles, unless they are systematic reviews.

The essential elements of this checklist are summarized in Tabular array 3.

TABLE 3

Essential Steps in Writing an Testify-Based Clinical Review Article

Cull a common, important topic in family unit practice.

Provide a table with a list of continuing medical teaching (CME) objectives for the review.

State how the literature search and reference option were done.

Use 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 (non necessarily the same as fundamental recommendations that are rated).

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The Authors

show all author info

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

MARGARET Fifty. GOURLAY, G.D., is currently the American Family unit Doc Medical Editing Boyfriend at Georgetown University Medical Heart. A graduate of Rush Medical Higher, Chicago, she completed a residency in family medicine at the University of California, San Diego, Medical Center.

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

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

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

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

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

REFERENCES

bear witness all references

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

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

three. Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, et al. for the Randomized Aldactone Evaluation Report Investigators. The issue of spironolactone on morbidity and bloodshed in patients with severe heart failure. Due north Engl J Med. 1999;341:709–17.

4. 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 master: feeling expert virtually not knowing everything. J Fam Pract. 1994;38:505–13.

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

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

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

nine. CATbank topics: levels of evidence and grades of recommendations. Retrieved November 2001, from: http://www.cebm.cyberspace/.

10. Saha S, Hoerger TJ, Pignone MP, Teutsch SM, Helfand One thousand, Mandelblatt JS. for the Cost Work Group of the Tertiary U.S. Preventive Services Task Forcefulness. The art and science of incorporating cost effectiveness into evidence-based recommendations for clinical preventive services. Am J Prev Med. 2001;twenty(iii suppl):36–43.

11. Evidence-based medicine glossary. Retrieved Nov 2001, from: http://www.cebm.net/index.aspx?o=1116.

Copyright © 2002 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may non otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or subsequently invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

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