Editorial Process

To identify new evidence and guidance, the DynaMed Editorial Team monitors over 450 medical journals and guideline organizations publishing the most clinically-relevant research and clinical practice guidelines across 45 specialties. DynaMed’s team of practicing physicians and methodologists identify, objectively appraise, and summarize clinical trials and clinical practice guidelines that impact patient care.

The Systematic Literature Surveillance (SLS) Team supports DynaMed’s evidence-based methodology by continually monitoring medical research as it is published. To select the best available evidence, the SLS team works with over 50 medical specialists who screen published research and clinical practice guidelines for relevance and potential impact on clinical decision-making and patient care. In order to optimize its literature surveillance, DynaMed has partnered with McMaster University. DynaMed utilizes PubMed searching and filtering strategies from McMaster University’s Health Information Research Unit to identify studies and systematic reviews that are scientifically sound. In addition, DynaMed uses McMaster’s PLUS database, which provides ratings and comments on newly published articles from their global network of more than 8,000 frontline clinicians through the McMaster Online Rating of Evidence (MORE™) system.

As part of DynaMed’s evidence-based methodology, the Editorial Team continually monitors clinical practice guidelines as they are released by American and International guideline organizations. DynaMed’s guideline monitoring process includes a novel automated website surveillance for guideline organizations developed in partnership with McMaster University. Practicing physicians and methodologists in the Editorial Team critically appraise and summarize clinical practice guidelines for integration into DynaMed topics across 45 specialties.

Every study identified and selected for inclusion in DynaMed is rigorously and objectively appraised by an editorial team trained in evidence-based medicine. Each study undergoes a process of critical appraisal, which assesses the research to evaluate its trustworthiness, relevance, and clinical value. The appraisal process enables the application of research into practice. 

DynaMed’s critical appraisal process involves systematic identification of potential sources of bias in order to objectively communicate the relevant clinical takeaway in the context of a study’s limitations. A team of practicing physicians and methodologists objectively appraise the most valid clinical trials and clinical practice guidelines and integrate the findings into DynaMed. 

A simple Level of Evidence rating system makes it easy 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 evidence, 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 Clinical practice guideline group has explicitly deliberated on making a similar 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 topics in DynaMed are developed under the direction of a Deputy Editor and Topic Editor. There is a rigorous writing and review process that includes clinical experts and methodologists. The editorial team performs subject area-specific targeted queries across the over 5,000 journals indexed in PubMed. The topic development process leverages DynaMed’s methodology to identify and select the best available evidence which is then critically appraised.

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 question. 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 topics are updated regularly as new evidence is identified through the systematic literature surveillance process. In addition, topics undergo updating and review by the editorial team. This process includes performing subject area-specific targeted queries across the over 5,000 journals indexed in PubMed. This ensures that DynaMed includes the most current evidence for use at the point of care.