Explore our evidence-based methodology and literature surveillance process
Systematic Literature Surveillance
A state-of-the-art Systematic Literature Surveillance (SLS) program supports DynaMed’s evidence-based methodology by continually monitoring medical research as it is published. A team of practicing physicians and methodologists identify, objectively appraise, and summarize clinical trials and clinical practice guidelines that impact patient care.
To identify the evidence the Systematic Literature Surveillance (SLS) program monitors 250 medical journals and 200 guideline organizations publishing the most clinically relevant research and clinical practice guidelines across 28 specialties.
DynaMed’s partnership with McMaster University adds the power of the McMaster PLUS resource to its monitoring program. McMaster University’s Health Information Research Unit uses its Critical Appraisal Process to identify studies and systematic reviews that are scientifically sound from approximately 120 top journals.
To select the best available evidence DynaMed works with > 50 medical specialists who screen published research and clinical practice guidelines for relevance and potential impact on clinical decision-making and patient care. In addition, McMaster PLUS provides ratings and comments from their global network of more than 8,000 frontline clinicians through the McMaster Online Rating of Evidence (MORETM) system.
Every medical research paper identified and selected for inclusion in DynaMed undergoes an objective appraisal process by an editorial team that is rigorously trained in evidence-based medicine and critical appraisal of scientific/medical research. Critical appraisal is the process of systematically assessing the outcome of scientific/medical research to evaluate its trustworthiness, relevance, and value. It facilitates the application of research into practice, allowing a clinician to understand whether research is reliable and applicable to their patients.
DynaMed’s critical appraisal process involves consistently-applied, systematic identification of potential sources of bias in order to enable objective communication of the relevant clinical message in the context of study’s limitations. A team of practicing physicians and methodologist objectively appraise the most valid clinical trials and clinical practice guidelines and integrate the findings into the existing clinical framework.
A simple Level of Evidence rating system makes it easy for users to quickly understand the quality of the evidence being reported in an evidence summary, and the primary rationale behind the rating.
Level 1 (likely reliable) evidence represents research results that address clinical outcomes and meet an extensive set of quality criteria that minimizes bias.
Level 2 (mid-level) evidence represents research results that address clinical outcomes and demonstrate some method of scientific investigation but do not meet the quality criteria to achieve Level 1.
Level 3 (lacking direct) evidence represents either of the following:
- Reports that are not based on scientific analysis of clinical outcomes (e.g., case series, case reports, conclusions extrapolated indirectly from scientific studies)
- Research results that do not address clinical outcomes, regardless of the scientific rigor
In the Overview and Recommendations, DynaMed synthesizes current evidence, current clinical practice guidelines, and clinical expertise to provide recommendations to support clinical decision-making. The internationally-accepted Grading of Recommendations Assessment, Development and Evaluation (GRADE) system is used to classify synthesized recommendations as Strong or Weak.
- Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) do, or do not, outweigh the undesirable consequences (harms, costs, burdens).
- Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
DynaMed synthesized recommendations are determined with a systematic methodology:
- Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) who understand the best current evidence for benefits and harms and relevant recommendations from clinical practice guidelines.
- Recommendations are phrased to match the strength of the recommendation. Strong recommendations use “should do” or “should not do” language or phrasing that implies an expectation to perform (or not perform) the recommended action for most patients. Weak recommendations use “consider” or “suggested” language.
- Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
- Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest that are specific to the recommendation to be developed.
- Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through the DynaMed content development process.
- Evidence will be summarized for recommendation panel review including for each outcome the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and overall quality rating for the body of evidence.
- Recommendation panel members will be selected to include at least three members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
- All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
- Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment of dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation is made if there is insufficient confidence to make a recommendation.
- All steps in this process (including evidence summaries that are shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
- Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation development, with explicit confirmation that Strong recommendations are adequately supported.
- Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
- If consensus cannot be reached then the recommendation can be published with a notation of “dissenting commentary” and the dissenting commentary is included in the topic details.
- If recommendations are questioned during peer review or post-publication by a qualified individual, or re-evaluation is warranted based on new information identified through the Systematic Literature Surveillance program, the recommendation is subject to additional internal review
New Topic Development
New topics in DynaMed are developed under the direction of a Deputy Editor and undergo a rigorous writing and review process that includes methodologists, physician experts or specialists, and EBM experts. The topic development process leverages the SLS program for identifying evidence and selecting the best available evidence and the critical appraisal process.
DynaMed topics are developed to meet the information needs of clinicians and provide guidance to support effective and timely clinical decision-making. As a result, Topic and Section Editors in active clinical practice play an integral role in the topic development process and are listed on each topic they review.
The typical Topic/Section Editor is a physician who is active in academic and clinical practice and is board-certified in the appropriate specialty or devotes a portion of time caring for patients with the clinical entity in questions. Other experts (such as pharmacists) may be appropriate for selected topics to support a multidisciplinary approach to meeting the needs of clinicians. The Topic/Section Editor provides an initial clinical framework to guide the editorial team and then reviews the topic once it is developed to ensure that it is comprehensive, clinically relevant, and based on the best available evidence.
Prior to review by the Topic/Section Editor, the editorial team applies DynaMed’s evidence-based methodology to develop the topic, from performing a comprehensive literature search to integrating the best available evidence into the clinical framework. The content is reviewed for accuracy and application of critical appraisal by an editor as well as clinical relevance and usability at the point-of-care by a physician editor.
The final steps in the topic development process consist of an independent review by an EBM expert and review by the Deputy Editor. The EBM expert evaluates the Overview and Recommendations for adherence to sound recommendations and consistency.
DynaMed’s living reviews are updated regularly as new evidence is identified through the SLS program. In addition, topics undergo regular updating and review by the editorial team, Topic/Section Editors, and EBM experts. This ensures that DynaMed content keeps pace with the ever-growing evidence ecosystem and evolving standards of care.