Levels of evidence of articles in podiatric medical journals

Abstract

The authors reviewed 322 articles in podiatric medical journals to determine their level of evidence. Only 1% of the articles reviewed were randomized controlled trials. The authors concluded that if the podiatric medical profession wishes to become a participant in evidence-based medicine, greater emphasis must be placed on studies that assess hypotheses.

On April 14, 1999, the Health Systems Committee of the American Podiatric Medical Association held a meeting in Chicago, Illinois, to discuss its Evidence-Based Medicine Project. The committee proposes collecting practice data of podiatric physicians to determine the most cost-effective practice patterns. It plans to use this practice data to develop and validate treatment protocols. This “evidence” will then be used to demonstrate to the payers and gatekeepers of health care that podiatry is the cost-effective provider of choice for foot care.

Evidence-based medicine can be defined as a process of lifelong, self-directed learning that involves the integration of clinical expertise with the best available clinical evidence from a systematic search [1]. Evidence-based medicine groups have classified journal articles into several categories—for example, therapy [2], diagnostic studies [3], harm [4], prognosis [5], and practice guidelines [6]. Within each category, the nature of the article largely determines the strength-of-evidence level [7]. For therapy articles, meta-analyses and randomized controlled trials are thought to offer the strongest evidence (level 1) for therapeutic decision making, and expert opinions the weakest evidence (level 5) (

Table 1. Levels of Evidence in Therapy Articles.

). Evidence-based medicine groups have further described how to critically analyze the medical literature in order to evaluate the quality of the studies [2,3,4,5,6]. The Ohio College of Podiatric Medicine has developed a worksheet to analyze the quality of therapy articles (Fig. 1). The authors undertook a study to determine the level of evidence of articles published in podiatric medical journals.

Materials and Methods

During the spring of 1999, the authors reviewed original articles published in JAPMA (D.K.) and the Journal of Foot and Ankle Surgery (M.A.T.) for the purpose of classifying them into levels of evidence as described by evidence-based medicine groups. Three additional categories were used: literature reviews, animal/cadaver studies, and unclassified. Letters to the editor, editorials, and reviews or summaries of published articles were not considered. The years 1993 and 1998 were chosen arbitrarily for review. The authors worked independently except when one author was unsure of the classification. No attempt was made to analyze the articles to determine their quality.

Results

The authors reviewed 322 articles. Neither JAPMA nor the Journal of Foot and Ankle Surgery published a meta-analysis study for the years reviewed. A total of four randomized controlled trials [8,9,10,11] were published in 1998; none were published in 1993 (

Table 2. Classification of Journal Articles Reviewed.

). The most common types of study were the case series and case report, which together accounted for 68% of all of the articles published. There were a large number of unclassified articles in JAPMA in 1993 because a special issue was published on podiatric medical education.

Discussion

It is difficult not to be reminded on a daily basis of the unparalleled growth in the cost of modern health care in the United States. The demand for services has increased while the ability of the system to pay has decreased. Proponents of evidence-based medicine believe that treatment decisions should be based on the strength and quality of clinical evidence whenever possible [1,2]. In the future, payers and gatekeepers of health care may find this approach very appealing.

Of the published articles reviewed in this study, 1% presented what would be considered level 1 evidence. A large majority of the published articles reviewed dealt with generating, rather than testing, hypotheses. If the podiatric medical profession wishes to be a participant in the evidence-based medicine movement, greater emphasis should be placed on publications that are on levels 1 through 3. Further research could be conducted that reviews articles published by podiatric physicians in nonpodiatric journals to determine their level of evidence. It would also be interesting to analyze the quality of the level 1 evidence produced by the profession. Finally, the profession should try to determine what percentage of what podiatric physicians commonly do is based on level 1 evidence versus clinical experience and intuition.