To The Editor:
In his Presidential Address to the American Academy of Orthopaedic Surgeons
(AAOS), "Knowledge Is Our Business"
(2004;86:1575-8), Dr. Bucholz,
as they say, hit the nail on the head. Knowledge is the business of the
American Academy of Orthopaedic Surgeons. As he so eloquently stated, the
Academy is "the authority for up-to-date, accurate knowledge on
musculoskeletal diseases and patient care." With that thought in mind, I
would propose that the Academy begin to integrate level-of-evidence ratings
into their activities. Levels of evidence are a way of grading the quality of
the studies on the basis of their methodology, where Level I, a randomized
clinical trial, is the highest level and Level V, expert opinion, is the
lowest level of evidence.
Levels of evidence were introduced to The Journal of Bone and Joint
Surgery in January 20031. Since that time, every clinical
article published in The Journal is accompanied by a
level-of-evidence rating at the end of the abstract.
How could levels of evidence be used by the AAOS? First, level-of-evidence
ratings could accompany abstracts submitted for the AAOS Annual Meeting. For
the past three years, the Pediatric Orthopaedic Society of North America has
required that abstracts submitted to the Annual Meeting have an accompanying
level-of-evidence rating. After the accuracy of the level-of-evidence rating
has been ensured, this rating could accompany the published abstract and
thereby immediately place the study into context for surgeons. Furthermore,
level-of-evidence ratings are likely to provide subtle pressure and, with
time, promote better-quality studies in orthopaedics.
Another way in which level-of-evidence ratings could be used is in the
major educational outputs of the AAOS, such as Orthopaedic Knowledge
Update or The Journal of the American Academy of Orthopaedic
Surgeons. In these review-type publications, levels of evidence for
individual studies could be summarized together with use of Grades of
Recommendation, such as those of the Canadian Task Force on Preventive Health
Care, in which Grade "A" indicates high-quality, consistent
evidence; Grade "B," fair evidence; and Grade "C,"
conflicting evidence in support of treatment recommendations.
Dr. Bucholz states that new strategies are needed. Levels of evidence could
be one strategy to maintain the AAOS as the leader in orthopaedic
knowledge.
R.W. Bucholz replies:
I appreciate the kind and constructive comments of Dr. Wright regarding my
2004 Presidential Address to the American Academy of Orthopaedic Surgeons
(AAOS). They are especially meaningful since they originated from an
institution that is a leader in clinical research and evidence-based medicine
in our specialty.
The two suggestions in his letter have been partially addressed by the
American Academy of Orthopaedic Surgeons. Starting with the February 2005
Annual Meeting in Washington, DC, all submitted abstracts must be accompanied
by a grade indicating their level of evidence. By 2006, all abstracts will be
weighted according to their level-of-evidence rating so that those studies
with better scientific methodology will have an improved chance of acceptance
on the program.
The AAOS has also started grading levels of evidence in some of its
publications. The two recently released IMCA (Improving Musculoskeletal Care
in America) documents on osteoarthritis of the knee and hip provide levels of
evidence and grades of recommendation for most of their diagnostic and
therapeutic conclusions. Similarly, the Evidence-Based Practice Committee of
the AAOS has issued multiple clinical practice guidelines on specific disease
entities and position statements with comparable grading. Because of the
number of authors involved and the lack of sufficient training in
level-of-evidence rating, grading in all AAOS educational review publications,
including The Journal of the American Academy of Orthopaedic
Surgeons, is not feasible at this time.
At the June AAOS Board of Directors meeting, a strategic discussion on how
to incorporate evidence-based medicine into our educational offerings and into
the orthopaedic practices of our fellows was conducted. Michael Goldberg,
chair of the AAOS Evidence-Based Practice Committee, presented a compelling
argument to move ahead aggressively in this area.
It is clear that in the near future, the public, the government, and,
hopefully, our fellowship will demand levels of evidence in most, if not all,
of our educational materials. The Journal of Bone and Joint Surgery
has been an orthopaedic leader in this arena, and its example should be
followed.
Wright JG, Swiontkowski MF, Heckman JD.
Introducing levels of evidence to the journal. J Bone Joint Surg
Am.2003;85:
1-3.851
2003
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