TO THE EDITOR: There are clear adva...

TO THE EDITOR: There are clear advantages to using a single evidence-grading rule that is simple, comprehensible, and usable for researchers, clinicians, and others. We applaud the authors of the article1 onward strength of recommendation taxonomy (SORT) in the February 1 2004 issue of American Family Physician for tackling this challenging and important task.

We think SORT (1) may manifest a good starting point. There are a certain quantity of areas that need polishing because of omissions and inconsistencies. We want to address a certain quantity of conceptual issues to engender further discussions.

The biggest issue is the potential for the application of SORT to follow in misleading conclusions of effectiveness for ineffective interventions. For example, observational studies of hormone therapy could earn SORT flush 2 for study quality (cohort studies like as Sullivan, et that would lead to grade B (clear recommendation of moderate strength) for secondary prevention of coronary artery disease, leading users to judge an effectiveness that we know is not faithful We very much like the focus forward patient-centeredness. However, we would approve this be separated from the issue of validity. A valid meditation of an intermediate marker not demonstrated to provide clinical benefit would receive a soft grade. Yet, over time, that marker might be rest to have clinical significance. It would be beneficial to have a rule that indicates that the meditation was valid.

Also, the use of grades A, B and C as a scale already has connotations in our cultivation (e.g., grade C is associated with "satisfactory" or a "passing" mark). In SORT, grade C evidence is not "passing" evidence. Furthermore, "strong" to "weak" implies a continuum in a range, when a certain "evidence" comes from studies for a like reason invalid it should not be considered evidence. We would commend demarcation of clearer lines, including a way to label a reflection as not being a profitable one, perhaps using a short descriptor.

This risk of being misled will not be mitigated by means of physicians simply applying their "understanding" of evidence-based medicine to "retranslate" SORT when they lack this understanding in the first place. The majority of physicians (76 percent) fail a simple critical appraisal pretest we give before our teaching programs. mostly physicians are not going to apply the mind at grade C evidence with an understanding that they should not draw conclusions from in the same state [i]or[/i] condition information.

We would encourage more emphasis onward "validity" in labeling preferential emblems of studies and in criteria. For example, systematic reviews or meta-analyses should proper criteria for validity, not just include valid studies. The last criterion for flushs of evidence in Figure 3 of the article1 omits many possible biases that could invalidate a study

We also don't find what authors deliver over to as "quantity" addressed in the grading scale. It appears possible for a single high-quality, powered, clinical trial with a excessively small "n" to achieve top grade.

The authors' (1) work is a major undertaking. We especially like having an algorithm that facilitates assessments. A simple, clear order would be a boon, and we apply the mind forward to learning others' ideas.

SHERI STRITE, B.A.

University of California, San Diego, drill of Medicine 3581 1st Ave. San Diego, CA 92103

MICHAEL E STUART, MD

President, Delfini cluster LLC University of Washington indoctrinate of Medicine 6831 31st Ave. NE Seattle, WA 98115

REFERENCES

(1) Ebell MH Siwek J Weiss BD Woolf SH Susman J Ewigman B et al. hardness of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56

(2) Sullivan JM Vander Zwaag R Hughes JP Maddock V Kroetz FW Ramanathan KB et al. Estrogen replacement and coronary artery disease. drift on survival in postmenopausal women Arch Intern M 1990;150:2557-62

TO THE EDITOR: The solidity of Recommendation Taxonomy (SORT) (1) discloseed by the family medicine editors is a significant contribution that may enhance evidence-based practice by the agency of simplifying the communication of evidence-based medicine (EBM) universals within the family medicine community.

DynaMed (www.DynamicMedical.com) is an evidence-based clinical hint with a user base of practicing clinicians who vary widely in awareness and acceptance of EBM conceptions DynaMed processes (systematic monitoring of the research literature with article selection based upon validity and relevance, summarization of clinically relevant information, and explicit descriptions of application of mind methodology) have been designed to provide the best available evidence in a transparent fashion, yet without "labeling" or branding the evidence. The DynaMed Systematic Literature Surveillance proces is described in succession their Web site at http://www.dynamicmedical.com/policy.

We have previously avoided codified evidence labeling in DynaMed because existing labeling hypothesiss were inconsistent, had potential for misinterpretation, and were not commonly used across different sources. We did not wish to independently create a fresh rating system and add to the problem