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January 2008

Systematic ReviewsGrading Recommendations and Evidence Quality

Arch Dermatol. 2008;144(1):97-99. doi:10.1001/archdermatol.2007.28

With the profusion of medical information and its ease of access, dermatologists need a reliable source that carefully weighs the data presented in clinical studies and observations. The Archives of Dermatology endeavors to be that source. Our publication of a study or observation and the accompanying invited editorial sends a strong signal to clinicians about the importance of implementing the recommendations. In 2007, the Archives gradually shifted the focus of review articles to emphasize systematic reviews that rank the available evidence (Table 1).1 Systematic reviews help to define medical practice standards and are learning tools for medical students and residents.

Table 1. 
Systematic Reviews and Review Articles
Systematic Reviews and Review Articles

Evidence-based practice relies on 3 key areas to reach a treatment decision: the best available research evidence; patient and family characteristics, values, and preferences; and the experience and expertise of the practitioner (Figure).2 From 2001 to 2006, people turned to the Internet, with an 18–percentage point increase in the use of the Internet for health information (40% never used it in 2001 vs 22% in 2006).3 In 2007, our Web site, http://www.archdermatol.com, averaged 350 000 individual uses per month. Based on this volume of Web site use and the number of inquiries that the editorial office receives from patients, we believe that patients and their families access publications in the Archives. As physicians become comfortable with people expressing their preferences, variations in treatment for common conditions will come to incorporate patient and family preferences.

The components of evidence-based practice. Adapted from the Institute of Medicine.

The components of evidence-based practice. Adapted from the Institute of Medicine.2

In 2007, we added a new type of clinical review, Critically Appraised Topic, for a total of 4 types of clinical reviews (Table 2).4 To assist the understanding and implementation of the systematic reviews by dermatologists, authors will be asked to make recommendations according to the quality of the supporting evidence.510 To this end, the Archives of Dermatology will require authors of systematic reviews to grade the strength of clinical recommendations as strong or weak according to risks, benefits, and cost; to assess the quality of the supporting evidence as high, moderate, or low according to study design; and to report consistent findings that matter to patients, such as morbidity, mortality, symptom improvement, cost reduction, and quality of life (Table 3).10,11 Authors who are certain that benefits outweigh risks and burdens should make a strong recommendation (grade 1). If the benefits and risks and burdens are less certain, they should offer a weak recommendation.

Table 2. 
Categories of Clinical Review
Categories of Clinical Review
Table 3. 
Assessing the Quality of the Evidence to Support Recommendationsa
Assessing the Quality of the Evidence to Support Recommendationsa

For example, the strongest evidence for treatment or prevention will come from a large, well-designed and reported randomized controlled trial (RCT) with a definitive treatment effect or 2 or more well-designed and well-executed RCTs with treatment effects of similar magnitude and direction (Table 3).9 Strong evidence may also come from observational studies with very large treatment effects, which represents the so-called all-or-none effects (eg, insulin for diabetes).13 The weak strength category will include randomized trials with important limitations and inconsistent results among trials and cohort and case-control studies. Other evidence (eg, case series, expert opinion, or usual practice) will comprise the lowest evidence category (Table 3). As we encourage authors to make recommendations, we recognize that areas of dermatology may have only published evidence in the lowest categories; thus, only weak recommendations can be made.

Recommendations should be provided in a table that lists the recommendation, the strength of the recommendation, and the level of evidence provided by the references reviewed. The references, which are grouped by the level of evidence for each recommendation, are cited in the table alphabetically by the last name of the author and the numeric reference citation. References cited solely in the table may be considered to be at the end of the manuscript, which places them at the end of the reference list.14

By adopting transparency in the quality of the evidence in our systematic reviews with graded recommendations, we hope that physicians and their patients will be able to carefully weigh their decisions, thus, improving the quality of care, decreasing the burden of disease, enhancing patient's perception of improved quality of life, and potentially saving resources. Authors who choose to publish in the Archives have the potential to shift the practitioners' decision paradigm from beliefs formed by anecdotes learned from teachers, colleagues, and speakers at meetings and snippets of vaguely remembered clinical experience to evidence-based decisions. Then, physicians need to put the decisions into routine practice to deliver consistent care.15

Correspondence: Dr Robinson, 132 E Delaware Pl, #5806, Chicago, IL 60611 (archdermatol@jama-archives.org).

Financial Disclosure: None reported.

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