You are on page 1of 3

Reviews in Clinical Gerontology 2003 13; 103-105

0 2003 Cambridge University Press Printed in the United Kingdom DOI:10.1017/S0959259803013212

What is a clinical review?

Dr Norman Vetter
University of Wales College of Medicine, Cardiff, Wales, UK

Editorial include the sources of the evidence-based reviews,

such as the Cochrane Collaboration, DARE or the
Traditional clinical review articles, also known as
BMJ’s Clinical Evidence, or relevant web-sites, for
updates, differ from systematic reviews and meta-
instance a search on Google using specific terms.
analyses.’ Systematic reviews comprehensively
It may be helpful to include search terms, but
examine the medical literature, seeking to identify
these will always be tempered by the sieving
and synthesize all relevant information to formu-
late the best approach to diagnosis or treatment. process undertaken by the author, using that
Meta-analyses, sometimes known as quantitative unsurpassed instrument, the brain, to decide if the
systematic reviews seek to answer a narrow clin- paper identified is relevant to the subject or not.
ical question, often about the specific treatment of Even the best search strategy on a topic will still
a condition, using rigorous statistical analysis of find a huge amount of dross. The process of
pooled research studies. Updates review the med- assessing papers is known as critical appraisal.
ical literature almost as carefully as a systematic This has been described using the READER (Rel-
review but discuss the topic under question more evance, Education, Applicability, Discrimination,
broadly and make reasoned judgements where Overall Evaluation) model compared with free
there is little hard evidence, based upon the exper- critical appraisaL2 Participants using the READER
tise of the reviewer. It may not include evidence model gave a consistently lower overall score and
from foreign language journals or look for unpub- applied a more appropriate appraisal to the
lished data on a topic, so will tend to be more methodology of the studies. This method was
applicable to the local situation than a systematic both accurate and repeatable.
review, as it may take into account local short- This process can be dispiriting as you plough
ages of equipment or personnel. through a large number of poor quality papers to
A clinical review article is therefore on a find the nuggets of gold or even a bit of non-fer-
broader topic than the other two and is usually rous metal. This was underlined by a study com-
by someone versed in the topic, whereas a sys- paring the clinical trials on the treatment of
tematic review or meta-analysis may be carried schizophrenia.’ Data were extracted from 2000
out by a technician, usually with advice from a trials on the Cochrane Schizophrenia Group’s reg-
specialist in the field. A clinical review should be ister to examine the quality of the studies. Gen-
evidence based and should fulfil a number of erally, studies were short in duration; over half
wider requirements for Reviews in Clinical Geron- being for six weeks’ treatment or less, small with
tology. The topic should be of common interest a mean number of patients of 65 and poorly
and relevance to geriatricians, gerontologists or reported; 64% had a quality score of 2 or less
the professionals working in those areas. It should with a maximum score of 5 . Perhaps the most
be relevant to the continuing medical education concerning was that the studies showed no signs
needs of the readers and may include a list of the of improving in quality over time.
topics relevant to that need. It should include a Where possible evidence based on clinical out-
section on how the literature search was done and comes relating to morbidity, mortality, or quality
of life, and studies of primary care populations
should be included. In articles submitted to
Address for correspondence: N Vetter, Department of Reviews in Clinical Gerontology, it is good prac-
Epidemiology, Statistics and Public Health, University of
Wales College of Medicine Heath Park, Cardiff CF14 tice to rate the level of evidence for key recom-
4XN, UK. mendations. The key to this should be given with

Downloaded from Universitas Indonesia, on 10 Jul 2018 at 06:32:21, subject to the Cambridge Core terms of use, available at
104 Norman Vetter

the paper but the simplest example might be: level tematic reviews represent ‘the best available evi-
1 (randomized controlled trial, meta-analysis); dence’. Since this study, the Cochrane Collabora-
level 2 (other clinical trial evidence); level 3 (con- tion has taken steps to improve the quality of its
sensus/expert opinion). reviews through more thorough pre-publication
Non-systematic review articles have had a bad refereeing, training and support for reviewers,
press. A paper critically appraised all the clinical and improvements in peer review. Cochrane felt
reviews published in six general medical journals that the use of evidence-based criteria (i.e., the
in 1996.4They used explicit criteria that have been QUOROM ~ t a t e m e n t )for
~ reporting systematic
published and validated, to judge the reviews, and reviews may help further to improve their quality.
found that of 1.58 review articles, only two satis- There is doubt that, when given the same excel-
fied all 1 0 methodologic criteria. Less than a quar- lent data, people will come up with different rec-
ter of the articles described how evidence was ommendations. Good examples of this have been
identified, evaluated, or integrated; 34% addressed seen in a series of disputes between the National
a focused clinical question; and 39% identified gaps Institute of Clinical Excellence (NICE) and the
in existing knowledge. Of the 111 reviews that Drugs and Therapeutics Bulletin, where the two
made treatment recommendations, 48% provided august bodies have come to different conclusions
an estimate of the magnitude of potential benefits about the same treatment.’O What are we practi-
(and 34%, the potential adverse effects) of the tioners to do? Read as many reviews as possible,
treatment options, 45% mentioned randomized I guess, especially those found in Reviews in Clin-
clinical trials to support their recommendations, ical Gerontology, then take a consensus.
but only 6 % made any reference to costs. Another
paper by Bramwell, examining the reviews in the
Search strategy and selection criteria
Journal of Clinical Oncology in the USA, similarly
found poor result^.^ For this review of reviews, I searched the PubMed
Another paper on the subject looked at reviews database by the National Library of Medicine
on the treatment of neck pain,6 and assessed the website for the past 20 years, and, from review
quality, conclusions, and agreement between of the authors, titles, abstract, and source loca-
reviews on the conservative treatment of neck dis- tion, articles in full were selected for further
orders. Computerized bibliographic databases examination. Medline searches were repeated
were searched for reviews published before Janu- with Ovid Technologies, Version 4.4.1, through
ary 1998 that included neck pain and evaluated the BMA Search Site on 9 August 2003. I also
conservative therapies. Only reviews that reported searched the Internet using the Google search
at least one controlled clinical trial were consid- engine. References were selected according to the
ered. Of 2.5 review articles selected, 12 were sys- authors’ identification of relevant topics for the
tematic reviews. Statistical pooling was performed review and did not include non-English language
only in two high-quality systematic reviews. The papers. Articles and their abstracts were initially
evidence was inconclusive for the use of conserv- collected using Reference Manager v.10.
ative interventions or manipulation or traction in
neck pain, but many of the reviews displayed
major methodological flaws.
Even Cochrane Reviews can be improved upon. 1 Siwek J, Gourlay ML, Slawson DC, Shaughnessy
A recent study compared Cochrane reviews and AF. How to write an evidence-based clinical
reviews published in paper-based journals. Two review article. Am Fum Physician 2002; 65:
assessment tools were used to collect the data, a 251-58.
23-item checklist developed by Sacks’ and a nine- 2 MacAuley D, McCrum E, Brown C. Randomised
controlled trial of the READER method of
item scale developed by Oxman.8 Cochrane
critical appraisal in general practice. BMJ 1998;
reviews were found to be better at reporting some 316(7138): 1134-37.
items and paper-based reviews at reporting oth- 3 Thornley B, Adams C. Content and quality of
ers. The overall quality was found to be low. The 2000 controlled trials in schizophrenia over 50
authors make the point that this represents a seri- years. BMJ 1998; 317(7167): 1181-84.
ous situation because clinicians, health policy 4 McAlister FA, Clark HD, van Walraven C etal.
makers, and consumers are often told that sys- The medical review article revisited: has the

Downloaded from Universitas Indonesia, on 10 Jul 2018 at 06:32:21, subject to the Cambridge Core terms of use, available at
What is a clinical review? 105

science improved? Ann Intern Med 1999; 131: 63: 216-24.

947-5 1. 8 Oxman AD. Checklists for review articles. BMJ
5 Bramwell VH, Williams CJ. Do authors of review 1994; 309(6955): 648-51.
articles use systematic methods to identify, assess 9 Moher D, Cook DJ, Eastwood S, Olkin I, Rennie
and synthesize information? Ann Oncol 1997; 8: D, Stroup DF. Improving the quality of reports of
1185-95. meta-analyses of randomised controlled trials: The
6 Hoving JL, Gross AR, Gasner D etal. A critical QUOROM Statement. Onkologie 2000; 23:
appraisal of review articles on the effectiveness of 597-602.
conservative treatment for neck pain. Spine 2001; 10 Why not zanamivir? Drug Tber Bull 2001; 39:
26: 196-205. 9-10.
7 Sacks HS, Reitman D, Pagano D, Kupelnick B.
Meta-analysis: an update. M t Sinai J M e d 1996;

Downloaded from Universitas Indonesia, on 10 Jul 2018 at 06:32:21, subject to the Cambridge Core terms of use, available at