Evidence-Based Emergency Medicine Article Categories
3 categories of articles will be considered for publication in the Evidence-Based Emergency Medicine (EBEM) section of the Annals of Emergency Medicine:
- EBEM reviews of clinical questions
- Skills for evidence-based emergency care instructional articles
- Evidence-based medicine abstracts of systematic reviews
EVIDENCE-BASED EMERGENCY MEDICINE (EBEM) REVIEWS:
These articles formulate and seek to answer clinical questions through consideration of relevant clinical evidence. They use a simplified form of the methodology of systematic reviews.1 EBEM reviews seek to promote the use of information drawn from clinical research in routine clinical practice and to enhance clinicians? ability to use summaries of clinical evidence for this purpose. Articles in this series undergo independent blinded peer review.
As reviews of focused clinical queries, the primary objective of EBEM reviews is to address the best clinical research relevant to specific clinical settings and to assess its validity and applicability using defined criteria for critical appraisal for pertinent study designs. A secondary objective of the EBEM reviews is to serve as instructional articles, aimed at educating emergency practitioners–particularly those in non-academic settings–in the use of specific searching and appraisal skills relevant to the systematic use of clinical research in decision making. These 2 aspects–the review and the instructional components- are developed in parallel. The instructional components, if included, are presented as short explanatory text inserts to the principal manuscript. A 1 to 2 page Critically Appraised Topic (CAT) summary completes the review. This is a structured condensation in a form designed to facilitate the use of the content of the review at the point-of-care.
Questions selected for the EBEM reviews should be commonly encountered in emergency care. Although not all topics need to have the clinical impact and profile of thrombolysis for ischemic stroke, they do need to be of practical interest to emergency practitioners. In some cases, EBEM reviews may be considered for electronic publication with separately indexed citations in the print journal. The question addressed in an EBEM review should pertain to the magnitude of effect of a therapeutic intervention, the performance of a diagnostic test or clinical decision rule the likelihood of a harmful effect of a therapy, or the prognosis of a clinical entity routinely identified and treated in an emergency care setting. For a topic to be appropriate, there should be relevant clinical research of a sufficiently developed nature to warrant the application of the methodological appraisal criteria appropriate to the preferred study designs for such a question.2 Systematic reviews or meta-analyses should be considered, and if located, should be appraised using accepted methodological criteria.
The body of the EBEM review should have the following components:
Title
This should identify the topic being addressed and can be in the form of a clinical question.
Abstract
This should be a 250 word structured summary of the importance of the question (introduction), the methods used to locate the evidence, the results of the reviewers? estimate of the strength of the studies and importance of the reported results, and a bottom line conclusion aimed at clinical application.
Clinical Scenario
Develop a short clinical scenario designed to help the reader to locate the clinical importance of the question to be addressed in the context of everyday practice.
Formulating the Question
Consider important features of patient population, the intervention(s) to be considered, including doses and issues of time sensitivity of treatment, and important outcomes as viewed from a patient/practitioner perspective.3-6
Searching for and Selecting the Best Evidence
State the criteria used to select articles for the review. Identify the study designs to be considered as meeting the minimum standards for admissible clinical evidence. Document the search strategies employed and their results, using figures or tables as appropriate. MEDLINE, the Cochrane Library and, if available, Emergency Medical Abstracts comprise a minimum set of databases to be considered for most emergency medicine questions.6
Analyzing the Evidence
The critical appraisal criteria elaborated in the JAMA Users Guides series,7 more recently revised and expanded,2 correspond to time tested and widely accepted approaches to evaluating studies pertinent to most clinical questions. They are recommended for use in EBEM reviews. Identify explicitly the criteria set to be used. Report on the assessment of the individual criteria and provide a global summary of the study quality. When methodological weaknesses are identified, consider the likely direction of resulting bias and evaluate the probable effect upon the reported results. Address the precision of the reported results, with emphasis upon confidence intervals. Present the results in the most clinically useful form. Number needed to treat is appropriate for therapy studies; likelihood ratios are appropriate for studies on diagnostic tests. Use tables and graphs to summarize the most clinically relevant results. Confidence intervals for relative risk reduction and number needed to treat may be calculated from data provided in studies on therapy and prevention using the University of British Columbia online calculator (http://statpages.org/ctab2x2.html) or other online calculators. Confidence intervals for likelihood ratios for simple dichotomized test results may be calculated using another calculator on the same site (http://statpages.org/ctab2x2.html). Statistical pooling of results reported in multiple included studies is not required for EBEM reviews.
Applying the Evidence
Address the criteria described in the User's Guides for the type of question being considered.2 Consider the appropriateness of the study population and the clinical significance of the results, such as the impact of a therapy on the quality of life of patients, or the effect of a diagnostic test result on the likelihood of a disease, condition, or injury. Evaluate tradeoffs between observed benefits and the possibility of harm from the interventions of interest. Identify patient and physician values, rights, and preferences relevant to decision making. Formulate a "bottom line" conclusion and identify the criteria used to arrive at it. Take into account weakness or inadequacies of the evidence as well as issues of patient values and circumstances.
EBEM reviews are not practice guidelines; clinicians will ultimately decide for themselves whether, when and how to utilize the information gleaned from these reviews. Rather than attempting broad health care recommendations, consider a set of contingency-related suggestions. For example, in a particular setting one might conclude "many patients may consider that the cost of this therapy outweighs the importance of its likely benefit; however, patients with a particular need to avoid sedation during daylight hours may find it to be worth the extra expense." Elements of the original clinical scenario may be drawn on for purposes of illustration. Keep in mind that the principal purpose of EBEM reviews is to identify and appraise relevant clinical evidence with a high degree of confidence and to highlight the considerations that might be brought to bear on decision making in actual clinical practice.
Critically Appraised Topic Summary
The CAT summary is a 1-2 page synopsis of the entire review and is intended as an adjunct that the clinician reader may choose to cut out or to copy for access at the point of care. There is intended redundancy between the CAT summary, the abstract and the text of the review. Use a 2-column format with the following row headers:
Title: This is the same as the reformulated question, upon which the literature search was based. Reviewed by: Same as the authorship of the review.
Date: This is the date that the principal search was done.
Expiration date: This is the date proposed by the authors for updating the primary search. It will vary according to how rapidly evidence is accumulating in the area in question.
Clinical bottom line: This can be very close or identical to the last sentences in the main text of the review.
Search strategy: Provide a concise summary of the search strategies used. Identify search engine and MESH terms used, years searched, and the number of relevant studies found. The search should be reproducible using the information given.
Citations: Restrict citations to the studies included in the review. Use Annals of Emergency Medicine bibliographical format.
Study characteristics: Summarize the patient populations, interventions and outcome measures for each included study.
Critical appraisal: Summarize concisely the application of the critical appraisal criteria and give the global quality rating ("weak", "fair", "very good", "excellent") for each included study.
Results: Summarize the results, and confidence intervals where possible, for each included study. Emphasize clinically significant outcome measures, such as number needed to treat for questions regarding therapy and likelihood ratios for questions regarding the performance of diagnostic tests.
Figures and Tables
Figures and tables are particularly appropriate vehicles for reporting the search strategies and their results, and the characteristics and results of the included studies, particularly when there are several. When a table is used to summarize the individual studies, it should emphasize the categories of "patient characteristics", the "interventions" or "observations" and the "outcome measures". When figures and tables are used, avoid redundancy between their content and the text.
Instructional Inserts
Text inserts, and figures and tables when appropriate, may be used to elaborate and explain specific methodological concepts pertinent to the content of the review. The Annals of Emergency Medicine EBEM editorial team will, with input from the authors, identify the most pertinent instructional points for a particular review. Authors may elect to submit an EBEM review without the instructional elements or may include proposals or drafts pertaining to this aspect of the articles. The decision to accept or reject a review will be unaffected by the stage of development of the instructional elements at the time of initial submission. If the editors decide that an instructional insert is appropriate, they will either write the inserts or assist the authors in writing them. When relevant, previous articles in the "Skills for Evidence-Based Emergency Care" series of the Annals? EBEM section should be cited. Section I of the EBEM page of the Annals Website can be consulted for a listing of these installments (EBEM).
References
Limit references to the citations included in the review, essential background references and relevant citations from previously published articles in the Annals EBEM.
Format and Manuscript Preparation
Standard Annals of Emergency Medicine instructions for authors for manuscript preparation and submission should be followed (Instructions for Authors).
References
1. Wyer PC, Rowe BH, Guyatt GH, Cordell WH. The clinician and the medical literature: When can we take a shortcut? Ann Emerg Med. 2000;36:149-155.
2. Guyatt G, Rennie D. Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. . Chicago: American Medical Association; 2002.
3. Corrall CJ, Wyer PC, Zick LS, Bockrath CR. How to find evidence when you need it, part 1: Databases, search programs and strategies. Ann Emerg Med. 2002;39:302-306.
4. Gallagher PE, Allen TY, Wyer PC. How to find evidence when you need it, part 2: A clinician's guide to MEDLINE: The basics. Ann Emerg Med. 2002;39:436-440.
5. Gallagher PE, Allen TY, Wyer PC. How to find evidence when you need it, part 3: A clinician's guide to MEDLINE: Tricks and special skills. Ann Emerg Med. 2002;39:547-551.
6. Wyer PC, Allen TY, Corrall CJ. Skills for evidence-based emergency care:How to find evidence when you need it: Part 4: Matching Clinical Questions to Appropriate Databases. Ann Emerg Med. 2003;42:136-149.
7. Guyatt GH, Rennie D. User's guides to the medical literature. JAMA. 1993;270:2096-2097.
SKILLS FOR EVIDENCE-BASED EMERGENCY CARE:
Installments in the "Skills for Evidence-based Emergency Care" series are instructional articles. They elaborate concepts required for an independent appraisal of the quality and applicability of research to clinical practice and are aimed at non-academic readers of the Annals of Emergency Medicine. Articles in this category may deal with topics such as likelihood ratios and confidence intervals that are relevant to the reporting of original research. Submissions to this series undergo independent blinded peer review.
The "Skills for Evidence-based Emergency Care" series focuses on what clinicians need to understand to be able to decide whether and how to apply the results of research to clinical decision making. The appropriateness of an article for this series is determined by several considerations, including the topic, the style and the clinical focus. Articles in this series are frequently invited by the EBEM editorial team. Prospective authors are encouraged to submit proposals for installments in this series prior to undertaking the work of writing them. Examples of previous articles in this series can be viewed on the Annals of Emergency Medicine Website (EBEM) Inquires may be directed to Dr. Peter Wyer (pwyer@att.net).
Manuscripts in this series should include the following elements:
Abstract
A short unstructured abstract should describe the objectives and content of the article, emphasizing the intended, practitioner, target audience.
Title
Identify the specific skill or concept to be demonstrated and identify its importance to clinical practice.
Introduction
Clearly identify the skill to be covered in the feature and its importance as a clinical problem-solving tool. A clinical scenario may be useful in many cases but is not a required element. Give a definition of the concept or skill that highlights its clinical importance. Include a table that gives the statistical definition of skill components such as likelihood ratios, relative risks, etc.
Demonstration
Provide a step-by-step "walk-through" of how the component in question is derived and applied to clinical problems. Use specific clinical examples where possible without overly expanding the content of the feature. Start with the simplest example and progress to slightly more challenging cases. Advanced applications may be referenced but should in general be deferred to a subsequent Skills feature. If the feature itself involves an advanced application, make this clear at the outset. In such a case, an entry-level Skills feature should already have been published in the series and that can be cited.
Conclusion
An elaborate summary and conclusion is not required. The clarity of the explanations and demonstrations should speak for themselves. The reader can be referred at the end to more advanced and detailed treatments of the topic elsewhere.
References
Limit references to essential citations.
Format and Manuscript Preparation
Standard Annals of Emergency Medicine Instructions for Authors for manuscript preparation and submission should be followed (Instructions for Authors).
EVIDENCE-BASED EMERGENCY MEDICINE ABSTRACTS OF SYSTEMATIC REVIEWS
Cochrane Review Clinical Synopses
The EBEM SYSTEMATIC REVIEW ABSTRACT (EBEM/SRA) section selects topical systematic reviews from the Cochrane Library to highlight for readers of Annals of Emergency Medicine. Each clinical synopsis features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area.
Rationale
Topics relevant to emergency medicine are prevalent in the Cochrane Database of Systematic Reviews.1 Although there is now an Emergency Medicine Field within the Cochrane Collaboration, many reviews relevant to emergency practice can be found among other fields within the Cochrane Library. The aim of the EBEM/SRA section is to provide clinical synopses of these high-quality systematic reviews for point-of-care use by the busy emergency clinician.2
Approach to development of synopsis
After selecting a topic, EBEM/SRA authors must follow the instructions below. In order to avoid duplication of effort, the proposed topic can be sent initially to the section editor, Dr. Michael Brown (brownm@msu.edu), for preliminary feedback. Articles in this series undergo review by one or more members of the EBEM editorial team. Examples of the abstracts and commentaries may be found on the Annals of Emergency Medicine Web site (em/em-ebm2). SRA authors are encouraged to submit SRA updates when there has been a substantial revision of the Cochrane Review; these updates will be published on the Annals Web site and listed in the Table of Contents of the print version of the journal.
Requirements
1) You may select the Cochrane Systematic Review you would prefer to abstract; however, the Annals Board has the ultimate say on which reviews will be published in the EBEM/SRA series. 2) Developing an EBEM SR Abstract is not a guarantee of acceptance for publication. 3) You must have access to the Cochrane Review in its entirety (including MetaView graphs). 4) You must condense the original abstract in the Cochrane Library. 5) Once you have received approval by Dr. Brown, you must submit the complete EBEM/SRA via the Editorial Manager Web site for Annals (http://www.editorialmanager.com/annemergmed/).
Format
1) The title of the EBEM/SRA is not the same as that of the Cochrane Review. One approach is to frame the topic in the form of a question, such as "Does acetaminophen treat fever in children?"
2) Provide a "Take Home Message" statement.
3) Summarize the Cochrane Review methods using the following headings:
METHODS (max 110 words excluding headings):
- data sources (summarize the Cochrane reviewers' search strategy)
- study selection (summarize the criteria used to select studies in the review)
- data extraction and synthesis (summarize the methodology used to review the quality and tabulate the results of the included studies)
RESULTS (comment on the effects of study quality and summarize the results pertaining to the most clinically relevant outcomes using a simple table whenever possible)
4) Provide a commentary (max 180 230 words) under the header "Commentary." Discuss the review's findings and focus on how this review is useful to the emergency clinician. Use no more than 5 references to support your commentary.
5) The last section of the EBEM/SRA is standardized: Under the header "Systematic Review Source," use the exact wording of the following paragraph, supplying the details appropriate to the particular Cochrane review being abstracted:
"This is a systematic review abstract, a regular feature of the Annals' Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area. The source for this systematic review abstract is: [authors]. [title]. Cochrane Database Syst Rev [year], ([issue number]): CD[CD number]. DOI:[DIO]. The Annals EBEM editors assisted in the preparation of the abstract of this Cochrane systematic review."
6) Insert the name and contact details of the Cochrane author responsible for the review.
7) The EBEM editors may choose to further edit or condense any submission for purposes of fitting into the Annals of Emergency Medicine clinical synopsis format.
References
1. Emond SD, Wyer PC, Brown MD, Cordell WH, Spooner CH, Rowe BH. How relevant are the systematic reviews in The Cochrane Library to Emergency Medical Practice? Ann Emerg Med. 2002;39:153-158.
2. Rowe, BH, Wyer PC, Cordell WH. Improving the Dissemination of Systematic Reviews in Emergency Medicine. (Editorial) Ann Emerg Med 2002;39:293-295.
Rational Clinical Examination Clinical Synopses
The EBEM RATIONAL CLINICAL EXAMINATION ABSTRACT (EBEM/RCEA) section selects topical reviews from the Rational Clinical Examination series in the Journal of the American Medical Association to highlight for readers of Annals of Emergency Medicine. Each clinical synopsis features an abstract of a review from series and a commentary by an emergency physician knowledgeable in the subject area.
Rationale
Emergency physicians make critical decisions on the basis of patients' answers to questions and the results of physical examination. Such questions and assessments constitute diagnostic tests, and their accuracy and performance characteristics have been examined in much the same way as laboratory or imaging tests. The installments of the JAMA Rational Clinical Examination series include systematic reviews that assess and summarize the evidence available from such studies. This evidence is relevant and useful to emergency physicians, who pursue clinical diagnosis and deal with presentations of disease on a daily basis. The aim of the EBEM/RCEA series is therefore to provide brief synopses of these reviews that can be used at the point-of-care.(1)
Approach to development of synopsis
After selecting a topic, EBEM/RCEA authors must follow the instructions below. In order to avoid duplication of effort, the proposed topic can be sent initially to the section editor, Dr. David H. Newman (dnewman@chpnet.org), for preliminary feedback. Articles in this series undergo review by one or more members of the EBEM editorial team. Examples of the abstracts and commentaries may be found on the Annals of Emergency Medicine Web site (em/em-ebm2).
Requirements
1) You may select the Rational Clinical Examination installment you would prefer to abstract; however, the Annals Board has the ultimate say on which reviews will be published in the EBEM/RCEA series.
2) Developing an EBEM/RCEA is not a guarantee of acceptance for publication.
3) You must have access to the JAMA RCE collection. 4) Once you have received approval by Dr. Newman, you must submit the complete EBEM/RCEA via the Editorial Manager Web site for Annals (http://www.editorialmanager.com/annemergmed/).
Format
1) The title of the EBEM/RCEA may or may not be not the same as that of the Rational Clinical Examination installment. It should be brief and often takes the form of a question such as "Does this adult patient have appendicitis?"
2) Provide a "Take Home Message" statement.
3) Summarize the Rational Clinical Examination methods using the following headings:
METHODS (max 110 words excluding headings):
- data sources (summarize the reviewers' search strategy)
- study selection (summarize the criteria used to select studies in the review)
- data extraction and synthesis (summarize the methodology used to review the quality and tabulate the results of the included studies)
RESULTS (summarize the results pertaining to the most clinically relevant outcomes using a simple table)
4) Provide a commentary (max 180 230 words) under the header "Commentary". Discuss the review's findings and focus on how this review is useful to the emergency clinician. Use no more than 5 references to support your commentary.
5) The last section of the EBEM/RCEA is standardized: Under the header "Rational Clinical Examination Source," use the exact wording of the following paragraph, supplying the details appropriate to the particular review being abstracted:
"This is a Rational Clinical Examination abstract, a regular feature of the Annals' Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of an installment of the Rational Clinical Examination series from the Journal of the American Medical Association and a commentary by an emergency physician knowledgeable in the subject area. The source for this systematic review abstract is: [authors]. [title]. [year]. JAMA. [year]; [Volume(issue)]: [pp] The Annals EBEM editors assisted in the preparation of the abstract of this Rational Clinical Examination review."
6) Insert the name and contact details of the original author responsible for the review.
7) The EBEM editors may choose to further edit or condense any submission for purposes of fitting into the Annals of Emergency Medicine clinical synopsis format.
References
1. Newman DH, Rowe BH, Wyer PC. Improving the dissemination of the rational clinical examination series in emergency medicine. Annals of Emergency Medicine. 2004; 44(1): 74-75)
