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Shekelle PG, Maglione MA, Luoto J, et al. Global Health Evidence Evaluation Framework [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Jan.

Global Health Evidence Evaluation Framework [Internet].

Table b.9 nhmrc evidence hierarchy: designations of ‘levels of evidence’ according to type of research question (including explanatory notes).

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Explanatory notes

Definitions of these study designs are provided on pages 7-8 How to use the evidence: assessment and application of scientific evidence (NHMRC 2000b) and in the accompanying Glossary.

These levels of evidence apply only to studies of assessing the accuracy of diagnostic or screening tests. To assess the overall effectiveness of a diagnostic test there also needs to be a consideration of the impact of the test on patient management and health outcomes (Medical Services Advisory Committee 2005, Sackett and Haynes 2002). The evidence hierarchy given in the ‘Intervention’ column should be used to assess the impact of a diagnostic test on health outcomes relative to an existing method of diagnosis/comparator test(s). The evidence hierarchy given in the ‘Screening’ column should be used to assess the impact of a screening test on health outcomes relative to no screening or opportunistic screening.

If it is possible and/or ethical to determine a causal relationship using experimental evidence, then the ‘Intervention’ hierarchy of evidence should be utilised. If it is only possible and/or ethical to determine a causal relationship using observational evidence (eg. cannot allocate groups to a potential harmful exposure, such as nuclear radiation), then the ‘Aetiology’ hierarchy of evidence should be utilised.

A systematic review will only be assigned a level of evidence as high as the studies it contains, excepting where those studies are of level II evidence. Systematic reviews of level II evidence provide more data than the individual studies and any meta-analyses will increase the precision of the overall results, reducing the likelihood that the results are affected by chance. Systematic reviews of lower level evidence present results of likely poor internal validity and thus are rated on the likelihood that the results have been affected by bias, rather than whether the systematic review itself is of good quality. Systematic review quality should be assessed separately. A systematic review should consist of at least two studies. In systematic reviews that include different study designs, the overall level of evidence should relate to each individual outcome/result, as different studies (and study designs) might contribute to each different outcome.

The validity of the reference standard should be determined in the context of the disease under review. Criteria for determining the validity of the reference standard should be pre-specified. This can include the choice of the reference standard(s) and its timing in relation to the index test. The validity of the reference standard can be determined through quality appraisal of the study (Whiting et al 2003).

Well-designed population based case-control studies (eg. population based screening studies where test accuracy is assessed on all cases, with a random sample of controls) do capture a population with a representative spectrum of disease and thus fulfil the requirements for a valid assembly of patients. However, in some cases the population assembled is not representative of the use of the test in practice. In diagnostic case-control studies a selected sample of patients already known to have the disease are compared with a separate group of normal/healthy people known to be free of the disease. In this situation patients with borderline or mild expressions of the disease, and conditions mimicking the disease are excluded, which can lead to exaggeration of both sensitivity and specificity. This is called spectrum bias or spectrum effect because the spectrum of study participants will not be representative of patients seen in practice (Mulherin and Miller 2002).

At study inception the cohort is either non-diseased or all at the same stage of the disease. A randomised controlled trial with persons either non-diseased or at the same stage of the disease in both arms of the trial would also meet the criterion for this level of evidence.

All or none of the people with the risk factor(s) experience the outcome; and the data arises from an unselected or representative case series which provides an unbiased representation of the prognostic effect. For example, no smallpox develops in the absence of the specific virus; and clear proof of the causal link has come from the disappearance of small pox after large-scale vaccination.

This also includes controlled before-and-after (pre-test/post-test) studies, as well as adjusted indirect comparisons (ie. utilise A vs B and B vs C, to determine A vs C with statistical adjustment for B).

Comparing single arm studies ie. case series from two studies. This would also include unadjusted indirect comparisons (ie. utilise A vs B and B vs C, to determine A vs C but where there is no statistical adjustment for B).

Studies of diagnostic yield provide the yield of diagnosed patients, as determined by an index test, without confirmation of the accuracy of this diagnosis by a reference standard. These may be the only alternative when there is no reliable reference standard.

Note A : Assessment of comparative harms/safety should occur according to the hierarchy presented for each of the research questions, with the proviso that this assessment occurs within the context of the topic being assessed. Some harms (and other outcomes) are rare and cannot feasibly be captured within randomised controlled trials, in which case lower levels of evidence may be the only type of evidence that is practically achievable; physical harms and psychological harms may need to be addressed by different study designs; harms from diagnostic testing include the likelihood of false positive and false negative results; harms from screening include the likelihood of false alarm and false reassurance results.

Note B: When a level of evidence is attributed in the text of a document, it should also be framed according to its corresponding research question eg. level II intervention evidence; level IV diagnostic evidence; level III-2 prognostic evidence.

Note C: Each individual study that is attributed a “level of evidence” should be rigorously appraised using validated or commonly used checklists or appraisal tools to ensure that factors other than study design have not affected the validity of the results.

Source: Hierarchies adapted and modified from: NHMRC 1999; Bandolier 1999; Lijmer et al. 1999; Phillips et al. 2001.

From: Appendix B, Using Six Different Frameworks To Assess the Evidence for Three Examples of Health Interventions or Programs

• Cite this Page Shekelle PG, Maglione MA, Luoto J, et al. Global Health Evidence Evaluation Framework [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Jan. Table B.9, NHMRC Evidence Hierarchy: designations of ‘levels of evidence’ according to type of research question (including explanatory notes)
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Evidence-Based Practice in Health

• Introduction
• PICO Framework and the Question Statement
• Types of Clinical Question
• Hierarchy of Evidence

The Evidence Hierarchy: What is the "Best Evidence"?

Systematic reviews versus primary studies: what's best, systematic reviews and narrative reviews: what's the difference, filtered versus unfiltered information, the cochrane library.

• Selecting a Resource
• Searching PubMed
• Module 3: Appraise
• Module 4: Apply
• Module 5: Audit
• Reference Shelf

What is "the best available evidence"?  The hierarchy of evidence is a core principal of Evidence-Based Practice (EBP) and attempts to address this question.  The evidence higherarchy allows you to take a top-down approach to locating the best evidence whereby you first search for a recent well-conducted systematic review and if that is not available, then move down to the next level of evidence to answer your question.

EBP hierarchies rank study types based on the rigour (strength and precision) of their research methods.  Different hierarchies exist for different question types, and even experts may disagree on the exact rank of information in the evidence hierarchies.  The following image represents the hierarchy of evidence provided by the National Health and Medical Research Council (NHMRC). 1

Most experts agree that the higher up the hierarchy the study design is positioned, the more rigorous the methodology and hence the more likely it is that the study design can minimise the effect of bias on the results of the study.  In most evidence hierachies current, well designed systematic reviews and meta-analyses are at the top of the pyramid, and expert opinion and anecdotal experience are at the bottom. 2

Systematic Reviews and Meta Analyses

Well done systematic reviews, with or without an included meta-analysis, are generally considered to provide the best evidence for all question types as they are based on the findings of multiple studies that were identified in comprehensive, systematic literature searches.  However, the position of systematic reviews at the top of the evidence hierarchy is not an absolute.  For example:

• The process of a rigorous systematic review can take years to complete and findings can therefore be superseded by more recent evidence.
• The methodological rigor and strength of findings must be appraised by the reader before being applied to patients.
• A large, well conducted Randomised Controlled Trial (RCT) may provide more convincing evidence than a systematic review of smaller RCTs. 4

Primary Studies

If a current, well designed systematic review is not available, go to primary studies to answer your question. The best research designs for a primary study varies depending on the question type.  The table below lists optimal study methodologies for the main types of questions.

Note that the Clinical Queries filter available in some databases such as PubMed and CINAHL matches the question type to studies with appropriate research designs. When searching primary literature, look first for reports of clinical trials that used the best research designs. Remember as you search, though, that the best available evidence may not come from the optimal study type. For example, if treatment effects found in well designed cohort studies are sufficiently large and consistent, those cohort studies may provide more convincing evidence than the findings of a weaker RCT.

What is a Systematic Review?

A systematic review synthesises the results from all available studies in a particular area, and provides a thorough analysis of the results, strengths and weaknesses of the collated studies.  A systematic review has several qualities:

• It addresses a focused, clearly formulated question.
• It uses systematic and explicit methods:

                  a. to identify, select and critically appraise relevant research, and                   b. to collect and analyse data from the studies that are included in the review

Systematic reviews may or may not include a meta-analysis used to summarise and analyse the statistical results of included studies. This requires the studies to have the same outcome measure.

What is a Narrative Review?

Narrative reviews (often just called Reviews) are opinion with selective illustrations from the literature.  They do not qualify as adequate evidence to answer clinical questions.  Rather than answering a specific clinical question, they provide an overview of the research landscape on a given topic and so maybe useful for background information.  Narrative reviews usually lack systematic search protocols or explicit criteria for selecting and appraising evidence and are threfore very prone to bias. 5

Filtered information appraises the quality of a study and recommend its application in practice.  The critical appraisal of the individual articles has already been done for you—which is a great time saver.  Because the critical appraisal has been completed, filtered literature is appropriate to use for clinical decision-making at the point-of-care. In addition to saving time, filtered literature will often provide a more definitive answer than individual research reports.  Examples of filtered resources include, Cochrane Database of Systematic Reviews , BMJ Clincial Evidence , and ACP Journal Club .

Unfiltered information are original research studies that have not yet been synthesized or aggregated. As such, they are the more difficult to read, interpret, and apply to practice.  Examples of unfiltered resources include, CINAHL , EMBASE , Medline , and PubMe d . 3

The Cochrane Collaboration is an international voluntary organization that prepares, maintains and promotes the accessibility of systematic reviews of the effects of healthcare. 

The Cochrane Library is a database from the Cochrane Collaboration that allows simultaneous searching of six EBP databases.  Cochrane Reviews are systematic reviews authored by members of the Cochrane Collaboration and available via The Cochrane Database of Systematic Reviews .  They are widely recognised as the gold standard in systematic reviews due to the rigorous methodology used. 

Abstracts of completed Cochrane Reviews are freely available through PubMed and Meta-Search engines such as TRIP database. 

National access to the Cochrane Library is provided by the Australian Government via the National Health and Medical Research Council (NHMRC).

1. National Health and Medical Research Council. (2009). [Hierarchy of Evidence] . Retrieved 2 July, 2014 from: https://www.nhmrc.gov.au/

2. Hoffman, T., Bennett, S., & Del Mar, C. (2013). Evidence-Based Practice: Across the Health Professions (2nd ed.). Chatswood, NSW: Elsevier.

3. Kendall, S. (2008). Evidence-based resources simplified. Canadian Family Physician , 54, 241-243

4. Davidson, M., & Iles, R. (2013). Evidence-based practice in therapeutic health care. In, Liamputtong, P. (ed.). Research Methods in Health: Foundations for Evidence-Based Practice (2nd ed.). South Melbourne: Oxford University Press.

5. Cook, D., Mulrow, C., & Haynes, R. (1997). Systematic reviews: synthesis of best evidence for clinical decisions. Annals of Internal Medicine , 126, 376–80.

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• Next: Module 2: Acquire >>
• Last Updated: Jul 24, 2023 4:08 PM
• URL: https://canberra.libguides.com/evidence

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Review article: systematic review of three key strategies designed to improve patient flow through the emergency department

Affiliations.

• 1 School of Nursing and Midwifery, Griffith Health, Gold Coast Campus, Griffith University, Brisbane, Queensland, Australia.
• 2 Department of Emergency Medicine and Griffith Health Institute, Gold Coast Hospital and Health Service and Griffith University, Gold Coast, Queensland, Australia.
• PMID: 26206428
• DOI: 10.1111/1742-6723.12446

To explore the literature regarding three key strategies designed to promote patient throughput in the ED. CINAHL, Medline, PubMed, Scopus and Australian Government databases were searched for articles published between 1980 and 2014 using the key search terms ED flow/throughput, ED congestion, crowding, overcrowding, models of care, physician-assisted triage, medical assessment units, nurse practitioner, did not wait (DNW) and ED length of stay (LOS). Abstracts and articles not published in English and articles published before 1980 were excluded from the review. Quantitative and qualitative studies were considered for inclusion. The National Health Medical Research Council (NHMRC) Level of Evidence Hierarchy (2009) was applied to included studies. Twenty-one articles met criteria for review. The level of evidence assessed using the NHMRC guidelines of studies ranged from I to IV, with the majority falling into the Level II-2 (n = 6) and III-3 (n = 9) range. ED LOS was the outcome most often reported. Study quality was limited with few studies adjusting for confounding factors. Only one level I systematic review was included in this review. Advanced practice nursing roles, physician-assisted triage and medical assessment units are models of care that can positively impact ED throughput. They have been shown to decrease ED LOS and DNW rates. Confounding factors, such as site specific staffing requirements, patient acuity and rest-of-hospital processes, can also impact on patient throughput through the ED.

Keywords: crowding; emergency department; medical assessment units; models of care; nurse practitioner; physician-assisted triage.

© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

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National Health and Medical Research Council (NHMRC)

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NHMRC, GPO Box 1421, Canberra, Australian Capital Territory, ACT,2601, Australia Tel: (61) 2 6217 9000 Fax: (61) 2 6217 9100 Email: [email protected] Website: www.nhmrc.gov.au Contact: Executive Director

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The National Health and Medical Research Council (NHMRC) (Australia) consolidates within a single national organization the often independent functions of research funding and development of advice. One of its strengths is that it brings together and draws upon the resources of all components of the health system, including governments, medical practitioners, nurses and allied health professionals, researchers, teaching and research institutions, public and private programme managers, service administrators, community health organizations, social health researchers and consumers.

Biomedical (C J Martin) Fellowships

Subjects: Biomedical sciences.

Purpose: To enable fellows to develop their research skills and work overseas on specific research projects within the biomedical sciences under nominated advisers.

Eligibility: Open to Australian citizens or graduates from overseas with permanent Australian resident status who are not under bond to any foreign government. Candidates should hold a Doctorate in a medical, dental or related field of research, be actively engaged in such research in Australia and have no more than 2 years postdoctoral experience at the time of application.

Level of Study: Postdoctorate

Type: Fellowship

Value: An allowance of Australian $5,000 per year is payable for research support, including conference travel, for the 2 year Australian portion of the Fellowship. Please check website for full detail

Length of Study: 4 years, the first 2 of which are to be spent overseas and the final 2 in Australia

Frequency: Annual

Study Establishment: Institutions approved by the NHMRC, such as teaching hospitals, universities and research institutes

Country of Study: Any country

No. of awards offered: Varies

Application Procedure: Application forms available from the website.

Closing Date: July 7th

Funding: Government

No. of awards given last year: 31

No. of applicants last year: 79

Additional Information: Please check website for more details.

Biomedical (Dora Lush) and Public Health Postgraduate Scholarships

Subjects: Biomedical sciences and public health.

Purpose: To encourage science Honours or equivalent graduates of outstanding ability to gain full-time health and medical research experience.

Eligibility: Open to Australian citizens who have already completed a science Honours degree (or equivalent) at the time of submission of the application, science Honours graduates and unregistered medical or dental graduates from overseas, who have permanent resident status and are currently residing in Australia. The scholarship shall be held within Australia.

Level of Study: Postgraduate

Type: Scholarship

Value: Varies

Length of Study: 1 year, renewable for up to 2 further years

Country of Study: Australia

Application Procedure: Applicants should visit the website at https://www.nhmrc.gov.au/grants-funding/apply-funding/postgraduate-scholarships/postgraduate-scholarships-categories-award for details.

Closing Date: Varies

No. of awards given last year: 51

No. of applicants last year: 133

For further information contact:

Centre for Research Management & Policy, NHMRC, GPO Box 9848, Canberra, Australian Capital Territory

Biomedical Australian (Peter Doherty) Fellowship

Purpose: To provide full-time training in basic biomedical sciences research in Australia.

Eligibility: Open to Australian citizens or graduates from overseas with permanent Australian resident status who are not under bond to any foreign government. Candidates should hold a Doctorate in a medical, dental or related field of research or have submitted a thesis for such by December in the year of application, be actively engaged in such research in Australia or overseas and have no more than 2 years postdoctoral experience at the time of application.

Value: Fellowship salary packages at the Training Support Package level 1 is $62,250. An allowance of $5,000 per year is payable for research support, including conference travel

Length of Study: 4 years

No. of awards given last year: 30

No. of applicants last year: 100

Career Development Fellowship

Subjects: Any human health-related research area.

Purpose: To help researchers to conduct research that is internationally competitive and to develop a capacity for independent research.

Eligibility: Open to Australian citizens or permanent residents, normally between 3 and 9 years postdoctoral experience.

Value: Australian $96,040–106,230 per year

Length of Study: 5 years

Study Establishment: Institutions approved by NHMRC, such as teaching hospitals, universities and research institutes

Application Procedure: Application forms available from the website www.nhmrc.gov.au .

Closing Date: March 19th

No. of awards given last year: 54

No. of applicants last year: 434

Clinical (Neil Hamilton Fairley) Fellowship

Subjects: All health-related fields.

Purpose: To provide training in scientific research methods.

Eligibility: Open to Australian citizens or graduates from overseas with permanent Australian resident status who are not under bond to any foreign government. Candidates should hold a Doctorate in a health-related field of research or have submitted a thesis for such by December of the year of application, be actively engaged in such research in Australia and have no more than 2 years postdoctoral experience at the time of application.

Value: Fellowship salary packages at the Training Support Package level 1 is currently at $62,250 and if appropriate, clinical loadings will be paid

Application Procedure: Application form available from the website.

No. of awards given last year: 4

No. of applicants last year: 10

Additional Information: For more information check website.

NHMRC Early Career Fellowship

Subjects: Scientific research, including the social and behavioural sciences, that can be applied to any area of clinical or community medicine.

Purpose: To undertake research that is both of major importance in its field and of benefit to Australian health.

Eligibility: Open to Australian citizens or graduates from overseas with permanent Australian resident status, who are not under bond to any foreign government. Candidates should hold a Doctorate in a health-related field of research or have submitted a thesis for such by December of the year of application, be actively engaged in such research in Australia or overseas and have no more than 2 years postdoctoral experience at the time of application.

Value: Funding is for 4 years at TSP1 Level, which currently is $67,508

Application Procedure: Application forms are available from the website.

Closing Date: May 1st

No. of awards given last year: 9

No. of applicants last year: 21

Additional Information: For more information check website www.nhmrc.gov.au/grants-funding/apply-funding/early-career-fellowships .

NHMRC Medical and Dental and Public Health Postgraduate Research Scholarships

Subjects: Medical, dental and public health research.

Purpose: To encourage medical and dental and public health graduates to gain full-time research experience.

Eligibility: Open to Australian citizens who are medical or dental and public health research graduates registered to practice in Australia, with the proviso that medical graduates can also apply during their intern year and that dental postgraduate research scholarships may be awarded prior to graduation provided that the evidence of high quality work is shown. Also open to medical and dental graduates from overseas who hold a qualification that is registered for practice in Australia, who have permanent resident status and are currently residing in Australia.

Study Establishment: Institutions approved by the NHMRC such as teaching hospitals, universities and research institutes

Application Procedure: Available from the website at www.nhmrc.gov.au/grants-funding/apply-funding/postgraduate-scholarships/postgraduate-scholarships-categories-award .

No. of awards given last year: 6

No. of applicants last year: 12

Additional Information: The award is divided into two categories: Medical and Dental Public Health Postgraduate Research Scholarships and Public HealthPostgraduate Research Scholarships.

NHMRC/INSERM Exchange Fellowships

Purpose: To enable Australian Fellows to work overseas on specific research projects in INSERM laboratories in France and vice versa.

Eligibility: Open to Australian citizens and permanent residents, who are not under bond to any foreign government, who hold a Doctorate in a medical, dental or related field of research or have submitted a thesis for such by December in the year of application, are actively engaged in such research in Australia and have no more than 2 years postdoctoral experience at the time of application.

Value: Fellowship stipend Australian $62,250. A maintenance allowance for research support of $5,000 per year For more information please check website www.nhmrc.gov.au/_files_nhmrc/file/grants/apply/training/insermfy.pdf

Length of Study: 4 years, the first 2 of which are to be spent in France and the final 2 in Australia

Study Establishment: Institutions approved by the NHMRC, such as teaching hospitals, universities and research institutes, and INSERM laboratories in France

Country of Study: France or Australia

No. of awards offered: 1

Application Procedure: Applications forms available from the website.

No. of awards given last year: 1

Additional Information: This fellowship is awarded in association with I’Institut National de la Santé et de la Recherche Médicale (INSERM), France.

Public Health Australian Fellowship

Subjects: Public health.

Purpose: To provide full-time training in public health research in Australia.

Eligibility: Applicants should hold a Doctorate in a health-related field of research or have submitted a PhD by December in the year of application and have no more than 2 years postdoctoral experience. Applicant must also, for years 1 and 2, nominate a department [preferably institution] and research group other than that where the applicant’s doctoral qualifications were obtained. Open to Australian citizens or permanent residents.

Value: Australian $67,508 and $5,000

No. of awards given last year: 17

No. of applicants last year: 61

Public Health Overseas (Sidney Sax) Fellowships

Purpose: To provide full-time training overseas and in Australia in public health research.

Eligibility: Applicants should hold a Doctorate in a health-related field of research or have submitted a PhD by December in the year of application and have no more than 2 years postdoctoral experience. Open to Australian citizens or permanent residents.

Value: Fellowship salary support packages at the Training Support Package level 1, that is $62,250, will be paid. Minimum cost airfares for the Fellow and dependants will be provided for direct travel to, and return from, the overseas centre. Additional overseas and Australian allowances are also payable

No. of awards given last year: 3

No. of applicants last year: 11

Training Scholarship for Indigenous Health Research

Subjects: Indigenous Australian Health Research.

Purpose: To provide support for research training or training leading to research areas of particular relevance to Indigenous Australians.

Eligibility: Applicant must be an Australian citizen or Australian permanent resident, have made prior arrangements with the Head of Department or Institution in which they propose to study, provide a specific study plan within a clearly defined area and conduct research of potential benefit to Australia.

Value: Depends on the qualification and current registration. Please check website

Length of Study: 1 year, renewable up to further 2 years

Application Procedure: Available from the website at www.nhmrc.gov.au/grants-funding/directory-previous-nhmrc-grants/training-scholarships-indigenous-health-research .

Closing Date: August 4th

No. of applicants last year: 6

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NHMRC Levels of Evidence

• Abbreviations and Definitions

For each statement, the primary reference has been graded according the NHMRC Levels of Evidence.

NHMRC levels of evidence were chosen as the NHMRC is the major funding body of the CCRE in Aphasia Rehabilitation and the levels align with the Australian Clinical Guidelines for Stroke Management (NSF, 2010).

Explanatory notes

• Definitions of these study designs are provided on pages 7-8 How to use the evidence: assessment and application of scientific evidence (NHMRC 2000b).
• The dimensions of evidence apply only to studies of diagnostic accuracy. To assess the effectiveness of a diagnostic test there also needs to be a consideration of the impact of the test on patient management and health outcomes (Medical Services Advisory Committee 2005, Sackett and Haynes 2002).
• If it is possible and/or ethical to determine a causal relationship using experimental evidence, then the ‘Intervention’ hierarchy of evidence should be utilised. If it is only possible and/or ethical to determine a causal relationship using observational evidence (ie. cannot allocate groups to a potential harmful exposure, such as nuclear radiation), then the ‘Aetiology’ hierarchy of evidence should be utilised.
• A systematic review will only be assigned a level of evidence as high as the studies it contains, excepting where those studies are of level II evidence. Systematic reviews of level II evidence provide more data than the individual studies and any meta-analyses will increase the precision of the overall results, reducing the likelihood that the results are affected by chance. Systematic reviews of lower level evidence present results of likely poor internal validity and thus are rated on the likelihood that the results have been affected by bias, rather than whether the systematic review itself is of good quality. Systematic review quality should be assessed separately. A systematic review should consist of at least two studies. In systematic reviews that include different study designs, the overall level of evidence should relate to each individual outcome/result, as different studies (and study designs) might contribute to each different outcome.
• The validity of the reference standard should be determined in the context of the disease under review. Criteria for determining the validity of the reference standard should be pre-specified. This can include the choice of the reference standard(s) and its timing in relation to the index test. The validity of the reference standard can be determined through quality appraisal of the study (Whiting et al 2003).
• Well-designed population based case-control studies (eg. population based screening studies where test accuracy is assessed on all cases, with a random sample of controls) do capture a population with a representative spectrum of disease and thus fulfil the requirements for a valid assembly of patients. However, in some cases the population assembled is not representative of the use of the test in practice. In diagnostic case-control studies a selected sample of patients already known to have the disease are compared with a separate group of normal/healthy people known to be free of the disease. In this situation patients with borderline or mild expressions of the disease, and conditions mimicking the disease are excluded, which can lead to exaggeration of both sensitivity and specificity. This is called spectrum bias or spectrum effect because the spectrum of study participants will not be representative of patients seen in practice (Mulherin and Miller 2002).
• At study inception the cohort is either non-diseased or all at the same stage of the disease. A randomised controlled trial with persons either non-diseased or at the same stage of the disease in both arms of the trial would also meet the criterion for this level of evidence.
• All or none of the people with the risk factor(s) experience the outcome; and the data arises from an unselected or representative case series which provides an unbiased representation of the prognostic effect. For example, no smallpox develops in the absence of the specific virus; and clear proof of the causal link has come from the disappearance of small pox after large-scale vaccination.
• This also includes controlled before-and-after (pre-test/post-test) studies, as well as adjusted indirect comparisons (ie. utilise A vs B and B vs C, to determine A vs C with statistical adjustment for B).
• Comparing single arm studies ie. case series from two studies. This would also include unadjusted indirect comparisons (ie. utilise A vs B and B vs C, to determine A vs C but where there is no statistical adjustment for B).
• Studies of diagnostic yield provide the yield of diagnosed patients, as determined by an index test, without confirmation of the accuracy of this diagnosis by a reference standard. These may be the only alternative when there is no reliable reference standard.

Note A: Assessment of comparative harms/safety should occur according to the hierarchy presented for each of the research questions, with the proviso that this assessment occurs within the context of the topic being assessed. Some harms are rare and cannot feasibly be captured within randomised controlled trials; physical harms and psychological harms may need to be addressed by different study designs; harms from diagnostic testing include the likelihood of false positive and false negative results; harms from screening include the likelihood of false alarm and false reassurance results.

Source: Hierarchies adapted and modified from: NHMRC 1999; Bandolier 1999; Lijmer et al. 1999; Phillips et al. 2001.

National Health and Medical Research Council. Additional levels of evidence and grades for recommendations for developers of guidelines 2008-2010

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What is the “Best Evidence”?

What is “the best available evidence”? The hierarchy of evidence is a core principal of Evidence-Based Practice (EBP) and attempts to address this question. The evidence hierarchy allows you to take a top-down approach to locating the best evidence whereby you first search for a recent well-conducted systematic review and if that is not available, then move down to the next level of evidence to answer your question.

EBP hierarchies rank study types based on the rigor (strength and precision) of their research methods. Different hierarchies exist for different question types, and even experts may disagree on the exact rank of information in the evidence hierarchies. The following image represents the hierarchy of evidence provided by the National Health and Medical Research Council (NHMRC). 1

Most experts agree that the higher up the hierarchy the study design is positioned, the more rigorous the methodology and hence the more likely it is that the study design can minimize the effect of bias on the results of the study. In most evidence hierarchies current, well designed systematic reviews and meta-analyses are at the top of the pyramid, and expert opinion and anecdotal experience are at the bottom. 2

Systematic Reviews versus Primary Studies: What’s Best?

Systematic reviews and meta analyses.

Well done systematic reviews, with or without an included meta-analysis, are generally considered to provide the best evidence for all question types as they are based on the findings of multiple studies that were identified in comprehensive, systematic literature searches. However, the position of systematic reviews at the top of the evidence hierarchy is not an absolute. For example:

• The process of a rigorous systematic review can take years to complete and findings can therefore be superseded by more recent evidence.
• The methodological rigor and strength of findings must be appraised by the reader before being applied to patients.
• A large, well conducted Randomized Controlled Trial (RCT) may provide more convincing evidence than a systematic review of smaller RCTs. 4

Primary Studies

If a current, well designed systematic review is not available, go to primary studies to answer your question. The best research designs for a primary study varies depending on the question type. The table below lists optimal study methodologies for the main types of questions.

Note that the  Clinical Queries   filter available in some databases such as PubMed and CINAHL matches the question type to studies with appropriate research designs.

When searching primary literature, look first for reports of clinical trials that used the best research designs. Remember as you search, though, that the best available evidence may not come from the optimal study type. For example, if treatment effects found in well designed cohort studies are sufficiently large and consistent, those cohort studies may provide more convincing evidence than the findings of a weaker RCT.

Systematic Reviews and Narrative Reviews: What’s the Difference?

What is a systematic review.

A systematic review synthesizes the results from all available studies in a particular area, and provides a thorough analysis of the results, strengths and weaknesses of the collated studies.  A systematic review has several qualities:

• It addresses a focused, clearly formulated question.
• It uses systematic and explicit methods:

a. to identify, select and critically appraise relevant research, and b. to collect and analyze data from the studies that are included in the review

Systematic reviews may or may not include a meta-analysis used to summaries and analyze the statistical results of included studies. This requires the studies to have the same outcome measure.

What is a Narrative Review?

Narrative reviews (often just called Reviews) are opinion with selective illustrations from the literature. They do not qualify as adequate evidence to answer clinical questions. Rather than answering a specific clinical question, they provide an overview of the research landscape on a given topic and so maybe useful for background information. Narrative reviews usually lack systematic search protocols or explicit criteria for selecting and appraising evidence and are therefore very prone to bias. 5

Filtered versus Unfiltered Information

Filtered information appraises the quality of a study and recommend its application in practice. The critical appraisal of the individual articles has already been done for you—which is a great time saver. Because the critical appraisal has been completed, filtered literature is appropriate to use for clinical decision-making at the point-of-care. In addition to saving time, filtered literature will often provide a more definitive answer than individual research reports. Examples of filtered resources include, Cochrane Database of Systematic Reviews ,  BMJ Clinical Evidence , and  ACP Journal Club .

Unfiltered information  are original research studies that have not yet been synthesized or aggregated. As such, they are the more difficult to read, interpret, and apply to practice.  Examples of unfiltered resources include,  CINAHL ,  EMBASE ,  Medline , and  PubMe d . 3

The Cochrane Library

Cochrane Library

The  Cochrane Collaboration  is an international voluntary organization that prepares, maintains and promotes the accessibility of systematic reviews of the effects of healthcare.

The Cochrane Library is a database from the Cochrane Collaboration that allows simultaneous searching of six EBP databases. Cochrane Reviews  are systematic reviews authored by members of the Cochrane Collaboration and available via  The Cochrane Database of Systematic Reviews . They are widely recognized as the gold standard in systematic reviews due to the rigorous methodology used.

Abstracts of completed Cochrane Reviews are freely available through PubMed and Meta-Search engines such as TRIP database.

National access to the Cochrane Library  is provided by the Australian Government via the National Health and Medical Research Council (NHMRC).

1. National Health and Medical Research Council. (2009).  NHMRC Levels of Evidence and Grades for Recommendations for Developers of Clinical Practice Guidelines . Retrieved 2 July, 2014 from:  https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf

2. Hoffman, T., Bennett, S., & Del Mar, C. (2013).  Evidence-Based Practice: Across the Health Professions   (2nd ed.). Chatswood, NSW: Elsevier.

3. Kendall, S. (2008). Evidence-based resources simplified.  Canadian Family Physician , 54, 241-243

4. Davidson, M., & Iles, R. (2013). Evidence-based practice in therapeutic health care. In, Liamputtong, P. (ed.).  Research Methods in Health: Foundations for Evidence-Based Practice  (2nd ed.). South Melbourne: Oxford University Press.

5. Cook, D., Mulrow, C., & Haynes, R. (1997). Systematic reviews: synthesis of best evidence for clinical decisions.  Annals of Internal Medicine , 126, 376–80.

Applying Research in Practice Copyright © by Duy Nguyen is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Centre asks states, UTs to implement over 150 Standard Treatment Workflows in 28 specialities | DETAILS

Standard treatment workflows (stws) are evidence-based guidelines or protocols designed to assist healthcare providers in delivering consistent, high-quality care for specific medical conditions..

What Union Health Secretary said? 

Chandra stated that the rapid advances and expanding body of scientific evidence in the field of medicine necessitate that healthcare providers remain updated with the latest treatment protocols and reference materials from across various medical specialities. The Health Ministry's directive is seen as a significant step towards enhancing the quality of healthcare services across India by ensuring that medical practices are consistent and evidence-based.

This necessitates the requirement of a simplified updated approach in the form of a pager app-based tool which can continuously guide the treating doctors as they manage the patient. "Recognising this need, the STW one pager concise document to be utilised at various levels of health care starting from primary to tertiary level care and are made available by Government of India to be adopted and followed by all providers," Chandra said in the letter issued on Tuesday. Indian Council of Medical Research (ICMR) in collaboration with the National Health Authority (NHA) and the World Health Organization, India Country Office has developed STWs for common and serious diseases encountered by the treating physicians at all levels of healthcare systems.

About Standard Treatment Workflows 

A major usefulness of these STWs lies in developing uniform standards of care for the Indian Public Health Care system, he stressed. "These would help in effective management and encourage rational use of essential drugs, essential diagnostics and other healthcare services. These have been prepared by national experts across India who have a cumulative experience of hundreds of patient care with feasibility considerations of the Indian healthcare system," Chandra stated.

STWs are one pager document with key indicative actions. So far, ICMR has prepared 157 STWs in 28 specialties. These are available on the ICMR website and as a downloadable mobile app for android as well as iOS (references-vide infra, weblink & QR codes for app), he added. 

(With inputs from PTI)

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Robert M. Pascuzzi, MD

Professor Emeritus of Neurology

Dr. Pascuzzi was born in Council Bluffs, Iowa, and raised in South Bend, Indiana. He attended the public school systems including John Adams High School in South Bend and received his undergraduate degree from Indiana University in Bloomington. Later, Dr. Pascuzzi earned an MD from IU School of Medicine and completed a neurology residency and fellowship training at the University of Virginia. In 1985, he joined the faculty at IU School of Medicine and served as chairman of the Department of Neurology from 2004-2020. Dr. Pascuzzi directs the Amyotrophic Lateral Sclerosis program at IU Health and the ALSA Multidisciplinary Clinic. Dr. Pascuzzi's professional emphasis relates to general adult clinical neurology and neurological education. His research focuses on therapeutic trials in neuromuscular diseases including ALS, myasthenia gravis and Lambert Eaton Syndrome. He has served as director of the American Board of Psychiatry and Neurology (chairman of the board in 2009), past member of the Neurology Residency Review Committee of the ACGME, past editor-in-chief of Seminars in Neurology and past chair of the Medical/Scientific Advisory Board of the Myasthenia Gravis Foundation of America. He has been selected Outstanding Professor in Neurology by the graduating medical school class at Indiana University on 26 occasions, is past recipient of the IU School of Medicine Faculty Teaching Award and the Teaching Excellence Recognition Award by the Indiana University Board of Trustees. Also, he has received the Golden Apple Award as the outstanding professional chosen by the graduating medical school class eleven times. Dr. Pascuzzi received the national Distinguished Neurology Teaching Award from the American Neurological Association in 2001.

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A comparison of prevalence estimates of smoking, alternative nicotine and alcohol use in Great Britain collected via telephone versus face-to-face: Smoking and Alcohol Toolkit surveys

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Background and Aims: Due to the COVID-19 pandemic, the survey mode of the Smoking and Alcohol Toolkit Study, a long-running repeat cross-sectional survey, had to change from face-to-face to telephone interviews. This study aimed to assess similarities and differences in sociodemographic, smoking, alternative nicotine and alcohol use estimates between the two survey modes, to understand the potential impacts of this change in methodology on prevalence estimates and trends over time. Design: After COVID-19 restrictions were lifted, we conducted parallel telephone and face-to-face household surveys in March 2022 and in January to March 2024, using a hybrid of random and quota sampling. Data from both years were aggregated. Setting and Participants: People aged 16+ years living in private households in Great Britain. Measurements: Sociodemographic characteristics, nicotine and alcohol use related estimates and their 95% CIs - unweighted and weighted - collected via telephone versus face-to-face in a household. Findings: In the unweighted analyses, the telephone sample included slightly younger and less socioeconomically advantaged groups than the face-to-face sample. After the samples were weighted, estimates of sociodemographic characteristics and nicotine and alcohol use were generally consistent across methodologies, including daily cigarette smoking (face-to-face: 11.1% [10.1-12.1] vs. telephone: 10.6% [9.5-11.7]), non-daily cigarette smoking (face-to-face: 2.7% [2.2-3.3] vs. telephone: 3.4% [2.8-4.1]), and e-cigarette use among people who smoke (face-to-face: 27.0% [23.5-30.5] vs. telephone: 29.3% [25.4-33.3]). However, compared with telephone participants, a lower proportion of face-to-face participants reported currently using e-cigarettes (face-to-face: 6.4% [5.6-7.1] vs. telephone: 10.4% [9.3-11.5]), and a higher proportion reported never drinking alcohol (face-to-face: 31.1% [29.7-32.5] vs. telephone: 25.0% [23.5-26.5]) and never having 6 or more standard drinks on one occasion (face-to-face: 46.6% [44.7-48.5] vs. telephone: 40.2% [38.4-42.1]). More participants provided "don't know" or "refused" responses in the telephone compared with the face-to-face interview, including in response to questions about tobacco use, e-cigarette device type, and the number of standard drinks on a typical day. Conclusions: Face-to-face and telephone surveys generally yield similar estimates of nicotine and alcohol use. However, there may be some underreporting of vaping and drinking in a face-to-face survey conducted in the home compared with telephone.

Competing Interest Statement

JB has received unrestricted research funding from Pfizer and J&J, who manufacture smoking cessation medications. LS has received honoraria for talks, unrestricted research grants and travel expenses to attend meetings and workshops from manufactures of smoking cessation medications (Pfizer; J&J) and has acted as paid reviewer for grant awarding bodies and as a paid consultant for health care companies. All authors declare no financial links with the tobacco, e-cigarette, or alcohol industry or their representatives.

Funding Statement

This work was supported by Cancer Research UK (PRCRPG-Nov21\100002) and the UK Prevention Research Partnership (MR/S037519/1), which is funded by the British Heart Foundation, Cancer Research UK, Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Health and Social Care Research and Development Division (Welsh Government), Medical Research Council, National Institute for Health Research, Natural Environment Research Council, Public Health Agency (Northern Ireland), The Health Foundation and Wellcome.

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I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The University College London Ethics Committee granted ethical approval for the Smoking and Alcohol Toolkit Study (ID 0498/001).

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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Transforming the understanding and treatment of mental illnesses.

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Research shows that mental illnesses are common in the United States, affecting tens of millions of people each year. Estimates suggest that only half of people with mental illnesses receive treatment. The information on these pages includes currently available statistics on the prevalence and treatment of mental illnesses among the U.S. population. In addition, information is provided about possible consequences of mental illnesses, such as suicide and disability.

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