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Jan 15, 2002 Table of Contents (http://www.aafp.

org/afp/2002/0115/)

How to Write an Evidence-Based
Clinical Review Article
JAY SIWEK, M.D., and MARGARET L. GOURLAY, M.D., Georgetown University Medical Center,
Washington D.C.
DAVID C. SLAWSON, M.D., University of Virginia Health System, Charlottesville, Virginia
ALLEN F. SHAUGHNESSY, PHARM.D., Harrisburg Family Practice Residency, Harrisburg,
Pennsylvania
Am Fam Physician. 2002 Jan 15;65(2):251-258.
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 information to formulate the best
approach to diagnosis or treatment. 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 evidence-based clinical review article
for American Family Physician. First, the topic should be of common interest and relevance
to family practice. Include a table of the continuing medical education objectives of the
review. State how the literature search was done and include several sources of evidencebased 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 Physician, rate the level of evidence for key recommendations
according to the following scale: level A (randomized controlled trial [RCT], meta-analysis);
level B (other evidence); level C (consensus/expert opinion). Finally, provide a table of key
summary points.
American Family Physician is particularly interested in receiving clinical review articles that follow an
evidence-based format. Clinical review articles, also known as 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 analyze the literature and seek to answer a focused clinical question, using
rigorous statistical analysis of pooled research studies. An example is, “Do beta blockers reduce
mortality following myocardial infarction?”
The best clinical review articles base the discussion on existing systematic reviews and metaanalyses, and incorporate all relevant research findings about the management of a given disorder.

especially one designed for continuing medical education (CME) and incorporating CME objectives into its format. point this out in the text. choose common problems for which there is new information about diagnosis or treatment. Disease-Oriented Evidence . We encourage authors to review the literature and. treatment. Look for pertinent guidelines on the diagnosis. such as a National Institutes of Health Consensus Development Conference statement or a clinical guideline published by a major medical organization. especially for key recommendations. Keep in mind that much of traditional medical practice has not yet undergone rigorous scientific study. if valid. patching most traumatic corneal abrasions may actually cause more symptoms and delay healing compared with no patching. or prevention of the disorder being discussed.4 Searching the Literature When searching the literature on your topic.Such evidence-based updates provide readers with powerful summaries and sound clinical guidance. This process will help emphasize the summary points of the article and strengthen its teaching value. we present guidelines for writing an evidence-based clinical review article.3 Similarly. especially. If none appears to be available.1. Incorporate all high-quality recommendations that are relevant to the topic. would also be important to report. When reviewing the first draft. please consult several sources of evidence-based reviews (Table 1). try to cite an authoritative consensus statement or clinical guideline. Try to ensure that all recommendations are based on the highest level of evidence available. TABLE 1 Some Sources of Evidence-Based Medicine View Table In particular. wherever possible. seeking out the basis for the recommendation. Topic Selection Choose a common clinical problem and avoid topics that are rarities or unusual manifestations of disease or that have curiosity value only. return to the literature. Patient-Oriented vs. For example. try to find the answer in an authoritative compendium of evidence-based reviews. a lack of sufficient supporting evidence. In this article. or other factors. should prompt a change in clinical practice. Emphasize new information that. the slant of the article. new evidence showing that a standard treatment is no longer helpful. look for all key recommendations about diagnosis and. This article may be read as a companion piece to a previous article and accompanying editorial about reading and evaluating clinical review articles. treatment. and high-quality evidence may not exist to support conventional knowledge or practice. If no strong evidence exists to support the conventional approach to managing a given clinical situation. such as the recent evidence that spironolactone therapy improves survival in patients who have severe congestive heart failure. If you are not sure about the source or strength of the recommendation. Whenever possible.2 Some articles may not be appropriate for an evidence-based format because of the nature of the topic. rate key points of evidence. or at least try to find a meta-analysis or well-designed randomized controlled trial (RCT) to support it. but may be harmful.

9 See the AFP Web site (www.org/afp/authors)) for additional information about levels of evidence and see the accompanying editorial in this issue discussing the potential pitfalls and limitations of any rating system.. high-quality.8.With regard to types of evidence. or case-controlled studies with consistent findings. Although the results of DOE sometimes parallel the results of POEM. such as changes in morbidity. We have adopted the following convention. Preventive Services Task Force (USPSTF) emphasized the importance of rating not only the study type (RCT. we find that a simplified grading system is more useful in AFP. randomized clinical trials with important outcomes (POEM).. etc. nonrandomized clinical trials. Look for meta-analyses. Look for studies that describe patient populations that are likely to be seen in primary care rather than subspecialty referral populations. a surrogate marker for the true outcomes of importance—improved survival. the third U. the evidence supporting the efficacy of Papanicolaou smear screening). but also the study quality as measured by internal validity and the quality of the entire body of evidence on a topic.aafp. such as changes in laboratory values or other measures of response.8 While it is important to appreciate these evolving concepts.) TABLE 2 Comparison of DOE and POEM View Table Evaluating the Literature Evaluate the strength and validity of the literature that supports the discussion (see the following section. they do not always correspond (Table 2). .2 When possible. it has not yet been proved that PSA screening improves patient survival. Here is an example of how the latter situation might appear in the text: “Although prostate-specific antigen (PSA) testing identifies prostate cancer at an early stage. which may not stand up to the scrutiny of scientific study (e.org/afp/authors (http://www. Levels of Evidence). prescribing prolonged bed rest for low back pain). POEM deals with outcomes of importance to patients. Shaughnessy and Slawson5–7 developed the concept of PatientOriented Evidence that Matters (POEM). Criteria for high-quality studies are discussed in several sources. or well-designed. casecontrol study. decreased morbidity. mortality. use POEM-type evidence rather than DOE. uncontrolled studies are appropriate (e. historical.g. and improved quality of life. In some cases. Many different rating systems of varying complexity and clinical relevance are described in the medical literature.2 Levels of Evidence Readers need to know the strength of the evidence supporting the key clinical recommendations on diagnosis and treatment. in distinction to Disease-Oriented Evidence (DOE). Avoid anecdotal reports or repeating the hearsay of conventional wisdom. or quality of life. DOE deals with surrogate end points. clinical cohort studies.” (Note: PSA testing is an example of DOE. cohort study.). Shaughnessy and Slawson's guide for writers of clinical review articles includes a section on information and validity traps to avoid. Recently. indicate that key clinical recommendations lack the support of outcomes evidence.aafp. using an ABC rating scale. high-quality. When DOE is the only guidance available.g.S.

studies had to be independently rated as being high quality by an established evaluation process. The traditional way of doing this is to discuss the epidemiology of the condition. Emphasize the key CME objectives of the review and summarize them in a separate table entitled “CME Objectives. clinical cohort studies. For example. uncontrolled studies. expert opinion]” When scientifically strong evidence does not exist to support a given clinical recommendation. non-randomized clinical trial]” “The American Diabetes Association recommends screening for diabetes every three years in all patients at high risk of the disease.. or well-designed epidemiologic studies with compelling findings. stating how many people have it at one point in time (prevalence) or what percentage of the population is expected to develop it over a given period of time (incidence). Other evidence. [Evidence level C. most patients in congestive heart failure should be treated with an angiotensin-converting enzyme inhibitor. such as the Cochrane Collaboration). [Evidence level B. Level B (other evidence): A well-designed. Includes lower quality RCTs. (4) clinical cohort study.Level A (randomized controlled trial/meta-analysis): High-quality randomized controlled trial (RCT) that considers all important outcomes.” METHODS The methods section should briefly indicate how the literature search was conducted and what major sources of evidence were used. indicate what predetermined criteria were used to include or exclude studies (e. A more engaging way of doing this is to indicate how often a typical family physician is likely to encounter this problem during a week. including all adults 45 years and older. following a level B rating. Each rating is applied to a single reference in the article. nonrandomized clinical trial. Here are some examples of the way evidence ratings should appear in the text: “To improve morbidity and mortality. and case-controlled studies with nonbiased selection of study participants and consistent findings. [Evidence level A. High-quality meta-analysis (quantitative systematic review) using comprehensive search strategies. (6) historical uncontrolled study. A nonquantitative systematic review with appropriate search strategies and well-substantiated conclusions. B. RCT]” “The USPSTF recommends that clinicians routinely screen asymptomatic pregnant women 25 years and younger for chlamydial infection. followed by the specific type of study for that reference. you can point this out in the following way: “Physical therapy is traditionally prescribed for the treatment of adhesive capsulitis (frozen shoulder). such as highquality. Level C (consensus/expert opinion): Consensus viewpoint or expert opinion.” Format of the Review INTRODUCTION The introduction should define the topic and purpose of the review and describe its relevance to family practice. month. or career. although there are no randomized outcomes studies of this approach. (3) lower quality RCT. Ideally. not to the entire body of evidence that exists on a topic. (5) case-controlled study. (7) epidemiologic study. is also included. Each label should include the letter rating (A. historical. Be comprehensive in trying to .g. include one of these descriptors: (1) nonrandomized clinical trial. year. C). (2) nonquantitative systematic review.

The review will be comprehensive and balanced if it acknowledges controversies. It should touch on one or more of the following subtopics: etiology. (We will make more extensive reference lists available on our Web site or provide links to your personal reference list. and diagnostic imaging).10 When relevant.e. Critically evaluate the quality of research reviewed. whose level of evidence is rated. and present a step-wise. AFP prefers to include a succinct list of key references. In other words. Emphasize an evidencesupported approach or. If there is controversy on a topic. other viewpoints.. mention high-quality costeffectiveness analyses to help clarify the costs and health benefits associated with alternative interventions to achieve a given health outcome. laboratory evaluation. and systematic reviews) as the basis for determining the level of evidence. Highlight key points about diagnosis and treatment in the discussion and include a summary table of the key take-home points. figures. and information that would not usually be found in most general reference textbooks). specific quantitative data. treatment (goals. Generally.) .identify all major relevant research. and illustrations to highlight key points. laboratory testing. especially treatment recommendations. the supporting citation should be a primary research source of the information. diagnostic evaluation (history. metaanalyses. studies referred to. Rate only those statements that have corresponding references and base the rating on the quality and level of evidence presented in the supporting citations. not a secondary source (such as a nonsystematic review article or a textbook) that simply cites the original source. prognosis. algorithmic approach to diagnosis or treatment when possible. Use primary sources (original research. pathophysiology. although some of them will be. but acknowledge that solid support for these recommendations is lacking. We expect that most articles will have at most two to four key statements. new information. meta-analyses. Rate the evidence for key statements. some will have none. especially preventive services. RCTs. differential diagnosis. where little evidence exists. unresolved questions. you may describe generally accepted practices or discuss one or more reasoned approaches. REFERENCES The references should include the most current and important sources of support for key statements (i. Avoid selective referencing of only information that supports your conclusions. In the absence of a consensus viewpoint. address the full scope of the controversy. and future directions. or landmark articles. Although some journals publish exhaustive lists of reference citations. DISCUSSION The discussion can then follow the typical format of a clinical review article. a consensus viewpoint. and follow-up). controversial material. Use tables. Systematic reviews that analyze multiple RCTs are good sources for determining ratings of evidence. recent developments. patient education. clinical presentation (signs and symptoms). physical examination. These points are not necessarily the same as the key recommendations. and any apparent conflicts of interest or instances of bias that might affect the strength of the evidence presented. prevention. cost-effectiveness analyses may be important in deciding how to implement health care services. these references will be key evidence-based recommendations. medical/surgical therapy. In some cases.

TRIP Database). MEDLINE. Acknowledge controversies.)11 The level of evidence for key clinical recommendations is labeled using the following rating scale: level A (RCT/meta-analysis). Where possible.. important information about diagnosis or treatment.net/index. especially topics in which there is new. rather than subspecialty referral centers. and describes its relevance to family practice. Studies of patients likely to be representative of those in primary care practices.aspx?o=1116 (http://www. the Center for Research Support. or quality of life) rather than DOE (dealing with mechanistic explanations or surrogate end points. Use tables. and any apparent conflicts of interest or instances of bias that might affect the strength of the evidence presented. Studies that are not only statistically significant but also clinically significant are emphasized. The essential elements of this checklist are summarized in Table 3. algorithmic approach to diagnosis or treatment when possible. other viewpoints. A table of CME objectives for the review is included. Several sources of evidence-based reviews on the topic are evaluated (Table 1). Highlight key points about diagnosis and treatment in the discussion and include a summary table of key take-home points. Checklist for an Evidence-Based Clinical Review Article The topic is common in family practice.aspx? o=1116).cebm. figures. interventions with meaningful changes in absolute risk reduction and low numbers needed to treat. are emphasized.g. unless they are systematic reviews. The review states how you did your literature search and indicates what sources you checked to ensure a comprehensive assessment of relevant studies (e. rather than other review articles. TABLE 3 Essential Steps in Writing an Evidence-Based Clinical Review Article View Table . Emphasize evidence-based guidelines and primary research studies. and illustrations to highlight key points and present a step-wise. use the source list of reviews to identify important sources of evidence-based medicine materials.net/index. level B (other evidence).You may use the following checklist to ensure the completeness of your evidence-based review article. POEM (dealing with changes in morbidity.. e. such as changes in laboratory tests) is used to support key clinical recommendations (Table 2). and level C (consensus/expert opinion).cebm. mortality. the Cochrane Collaboration Database. recent developments. The introduction defines the topic and the purpose of the review.g. (See http://www.

The Authors JAY SIWEK. 1997. He is director and founder of the Center for Information Mastery and serves as section editor for The Journal of Family Practice POEMs. Dr. Shaughnessy AF. The authors indicate that they do not have any conflicts of interest.D. Pitt B. is currently the American Family Physician Medical Editing Fellow at Georgetown University Medical Center. Shaughnessy AF. Charleston. Address correspondence to Jay Siwek. Va.D.2069– 70. 1994. is the B. Siwek J.341:709–17. Slawson DC. Flynn CA. PHARM. D. Jr. Shaughnessy AF. REFERENCES 1. Washington. 6. Am Fam Physician. J Fam Pract. Mich. Chicago. N Engl J Med. for a helpful review and conceptual contributions to the manuscript.. 3. is director of research and associate director of the Harrisburg Family Practice Residency.georgetown. Becoming an information master: using POEMs to change practice with confidence.39:489–99. and he completed postdoctoral training in family medicine at the University of Virginia. Georgetown University Medical Center. Siwek completed his family practice residency at Middlesex Hospital in Middletown. A graduate of Rush Medical College.. The authors thank Ted Ganiats. J Fam Pract. 4. 2. 1999.55:2155–60.. DAVID C. Slawson DC. Shaughnessy AF. Sources of funding: none reported.D..2072. M. Pa. Becoming a medical information master: feeling good about not knowing everything. Getting the most from review articles: a guide for readers and writers. M. M. ALLEN F. Slawson DC. A graduate of Georgetown University School of Medicine. Zannad F. for the Randomized Aldactone Evaluation Study Investigators. J Fam Pract. Should we patch corneal abrasions? A meta-analysis. 215 Kober-Cogan Hall. . D'Amico F. Dr. Becoming an information master: a guidebook to the medical information jungle. Remme WJ..D.47:264–70. MARGARET L. He is also editor of American Family Physician.38:505–13. et al. Bennett JH..55:2064.edu (mailto:afp@family. she completed a residency in family medicine at the University of California. SLAWSON. Department of Family Medicine. Patient-oriented evidence that matters. professor of family medicine at the University of Virginia Health System in Charlottesville.D. Ann Arbor. M. Harrisburg. is professor and chair of the Department of Family Medicine at Georgetown University Medical Center.49:63–7. 2000. Am Fam Physician. Cody R. 1994.D. 1997. Reading and evaluating clinical review articles. Perez A. Bennett JH. Washington DC 20007 (e-mail: afp@family. San Diego. He completed his doctorate and fellowship training at the Medical University of South Carolina. Slawson is a graduate of the University of Michigan School of Medicine. M. GOURLAY. 1998. J Fam Pract. Conn. Lewis Barnett. Slawson DC.C. Reprints are not available from the authors. 7. 3750 Reservoir Rd. Medical Center. Castaigne A. 5.georgetown. SHAUGHNESSY. Smith G.edu)). The effect of spironolactone on morbidity and mortality in patients with severe heart failure. NW.

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