Introducing Levels of Evidence to the Journal of Orthopaedic Trauma: Implementation and Future Directions : Journal of Orthopaedic Trauma

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Introducing Levels of Evidence to the Journal of Orthopaedic Trauma

Implementation and Future Directions

Slobogean, Gerard MD, MPH, FRCSC; Bhandari, Mohit MD, PhD, FRCSC

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Journal of Orthopaedic Trauma 26(3):p 127-128, March 2012. | DOI: 10.1097/BOT.0b013e318247c931
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Beginning this month, the Journal is introducing the routine reporting of a level of evidence rating with all therapeutic, prognostic, diagnostic, and economic studies. The level of evidence system is an evidence-based medicine tool that applies a hierarchal rating to a study's strength of evidence based on its study design. Many readers are quite familiar with this tool, as its use has become widespread in medicine and orthopaedics. The purpose of this editorial is to briefly outline the new process for assigning the level of evidence, the rationale for its use, and future directions for the Journal.

For all new manuscript submissions, authors will be asked to include a level of evidence rating as part of the structured abstract. An online level of evidence calculator and reference table has been developed to simplify the process. Once a manuscript is accepted for publication, an evidence-based orthopaedic section editor will confirm the level of evidence. The rating system is summarized in Table 1.

Levels of Evidence by Study Type

The purpose of implementing the level of evidence system is primarily 3-fold. First, this rating system provides a concise description of a study's design, which allows readers to quickly identify potential high impact research. Second, drawing attention to a study's design may encourage authors to clarify their primary research question and to elevate the strength of their studies by including control groups or prospective study designs when possible. Finally, the widespread use of the levels of evidence rating system in other orthopaedic journals and subspecialty meetings has created a readership that is accustomed to obtain this information in a manuscript's abstract. Currently, leading journals in general orthopaedics, sports, pediatrics, and shoulder and elbow surgery have adopted the use of this rating system for their published manuscripts. Despite the benefits and enthusiasm for the levels of evidence rating system in the orthopaedic literature, we realize that there are limitations of the current system. Because it is based primarily on the study's design, other important quality criteria are not directly considered. Furthermore, level I studies are not possible for every clinical situation, particularly in trauma populations. For some research questions, a well-designed level III or IV study remains important to generate hypotheses and to fuel further research. This is demonstrated in the present issue by the prospective level IV study from Paul et al providing early data on the effects of fracture pattern and trochanteric entry nailing on gait parameters in intertrochanteric hip fractures.

Finally, introducing the levels of evidence rating system to the Journal will serve as a springboard for several other Journal led innovations to promote evidence-based orthopaedic traumatology. In the near future, we will begin to offer evidence-based reports for select high impact articles as an adjunct resource for the Journal's readership. These Advanced Clinical Evidence reports will be available online and will provide an independent critical appraisal in a journal club friendly format.

We encourage comments and feedback throughout the implementation process of the levels of evidence rating system and the other proposed changes.

© 2012 Lippincott Williams & Wilkins, Inc.