Annals Journal Club: Symbiosis Instead of Competing Demands: A Tale of 2 Preventive Services
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The *Annals of Family Medicine* encourages readers to develop a learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club and sharing the results of your discussions in the *Annals* online discussion for the featured articles. RADICAL is an acronym for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word *radical* also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care and then acting on those discussions.1

## HOW IT WORKS

In each issue, the *Annals* selects an article or articles and provides discussion tips and questions. We encourage you to take a RADICAL approach to these materials and to post a summary of your conversation in our online discussion. (Open the article online and click on “TRACK Comments: Submit a response.”) You can find discussion questions and more information online at: [http://www.AnnFamMed.org/AJC/](http://www.AnnFamMed.org/AJC/).

## CURRENT SELECTION

### Article for Discussion

Hahn DL. Importance of evidence grading for guideline implementation: the example of asthma. Ann Fam Med. 2009;7(4):364–369.[Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy80LzM2NCI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vNy80L2lpaS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

## DISCUSSION TIPS

This article is unusual for a journal club selection. The article and its appendices are an analysis of how evidence-based guidelines are influenced by the approach used to grade the quality of scientific information. The analysis uses the specific example of the *Guidelines for the Diagnosis and Management of Asthma* (*EPR-3*), which was developed by the National Heart, Lung and Blood Institute. You may want to look at these guidelines2 during the course of reading and discussing this article, as well as consider examining evidence rating system criteria.3,4

## DISCUSSION QUESTIONS

*   What question is addressed by the article? How does the question fit with what already is known?

*   How useful are the author’s “4 important questions” for assessing evidence quality?

*   What questions would you want answered to evaluate the quality of scientific evidence that goes into a clinical practice guideline or decision on how to apply evidence to the care of your patients?

*   What are the main points from the asthma guideline used as the example?2

*   How do the author’s recommended review criteria3 compare with other recommended criteria for grading scientific evidence?4

*   What problems with the asthma guidelines does the author identify?

*   How do these problems affect the validity and relevance of the guidelines to caring for your patients?

*   What biases are apparent in the author’s analysis? How do these affect your interpretation and application of his conclusions?

*   How will this article affect your interpretation and application of other guidelines to caring for your patients?

*   What are some next steps for applying the findings or answering other questions that this study raises?

*   What policy recommendations do you have based on this article?

Please consider sharing thoughts from your group’s discussion with others at: [http://www.annfammed.org/cgi/eletters/7/4/iii](http://www.annfammed.org/cgi/eletters/7/4/iii).

*   © 2009 Annals of Family Medicine, Inc.

## REFERENCES

1.  Stange KC, Miller WL, McLellan LA, et al. *Annals* Journal Club: it’s time to get RADICAL. Ann Fam Med. 2006;4(3):196–197. [http://annfammed.org/cgi/content/full/4/3/196](http://annfammed.org/cgi/content/full/4/3/196).
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNC8zLzE5NiI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vNy80L2lpaS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  National Heart, Lung and Blood Institute. *Guidelines for the Diagnosis and Management of Asthma (EPR-3)*. [http://www.nhlbi.nih.gov/guidelines/asthma](http://www.nhlbi.nih.gov/guidelines/asthma). Accessed Jun 1, 2009.
    
    

3.  Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician. 2004;69(3):548–556. [http://www.aafp.org/afp/20040201/548.html](http://www.aafp.org/afp/20040201/548.html). Accessed Jun 1, 2009.
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=14971837&link_type=MED&atom=%2Fannalsfm%2F7%2F4%2Fiii.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000188830200011&link_type=ISI) 

4.  Agency for Healthcare Quality and Research. Systems to rate the strength of scientific evidence. [http://www.ahrq.gov/clinic/epcsums/strengthsum.htm](http://www.ahrq.gov/clinic/epcsums/strengthsum.htm). Accessed Jun 1, 2009.