Resource-tiered checklist
Resource-tiered reviews – A provisional reporting checklist
Van Hoving DJ, Chipps J, Jacquet G
Errors in research are perniciously unavoidable. These errors, both knowingly and unknowingly, span from initial fundamental data collection mishaps all the way through to reporting blunders. Avoiding them is an illusion best admitted early on in your research career. Attempting to work harder to avoid these “minor” slip-ups in today’s ever increasingly critical scientific environment is neither effective, nor efficient. Atul Gawande (author of ‘The checklist manifesto’) explains that we are up against two things when either performing a high volume of simple tasks or performing a variety of complex tasks. Firstly, human memory and attention is fallible; and secondly we tend to skip tasks even when we remember them simply because we think that the specific step does not matter. A basic checklist helps us to perform complex tasks not only correctly, but also consistently and safely. A large number of checklists are currently available to help report and/or critically appraise nearly every type of research design. To name only a few, the AGREE II tool for clinical guidelines;2 and AMSTAR, PRISMA and CASP for systematic reviews. It is not so much the specific checklist used, but rather the use of a validated checklist that ensures that reporting happens consistently and includes all relevant information.
Or so we thought, until we started to commission systematic reviews for AFJEM. It soon became clear that simply reporting on current international best practice was not always appropriate in African acute care settings; in fact it was often quite the opposite. Various resource restrictions ranging from cost-restrictions, to non-availability of essential drugs or equipment, to lack of local expertise exist in the African acute care setting. To illustrate, say a middle aged patient presents with gripping chest pain to a scantily-resourced emergency centre. Besides history and examination, none of the diagnostic tests required to work up a suspected acute coronary syndrome (electrocardiogram, cardiac enzymes, etc.) are available. What does current literature recommend in this setting if an electrocardiogram or cardiac enzymes are not readily available? Who knows? Even if acute care staff were able to diagnose a ST-elevated myocardial infarction (STEMI), best practice treatment might not be offered locally; or transport to a centre which can provide best practice treatment may be inadequate or lacking. Connecting best evidence to available resources is thus of vital importance in the African acute care context.
AFJEM is committed to publishing review articles that will benefit acute care providers, independent of the resources available to them. As a result we have compiled a checklist aimed specifically at best evidence in the resource-restricted setting (Table 1). The aim is to guide authors in producing a report which is a combination between a clinical guideline and a systematic review. Best available evidence, using a transparent and systematic approach to find and evaluate relevant studies, is still key; but with additional focus on resource availability. In effect it will be more rigorous than a narrative review but less time-consuming than a systematic review or meta-analysis. In order to apply the content to different resource levels, authors are advised to start by describing the very best evidence available; then assume the resources for this level are not available and describe the next tier of evidence until all options are exhausted. For example, if we return to our patient with chest pain: the recommended treatment for a patient with STEMI is primary percutaneous coronary intervention; if this treatment is not available, then thrombolytics should be considered; if that is not available then antiplatelet therapy and anticoagulation should be used, and so on and so forth.
Van Hoving DJ, Chipps J, Jacquet G
Errors in research are perniciously unavoidable. These errors, both knowingly and unknowingly, span from initial fundamental data collection mishaps all the way through to reporting blunders. Avoiding them is an illusion best admitted early on in your research career. Attempting to work harder to avoid these “minor” slip-ups in today’s ever increasingly critical scientific environment is neither effective, nor efficient. Atul Gawande (author of ‘The checklist manifesto’) explains that we are up against two things when either performing a high volume of simple tasks or performing a variety of complex tasks. Firstly, human memory and attention is fallible; and secondly we tend to skip tasks even when we remember them simply because we think that the specific step does not matter. A basic checklist helps us to perform complex tasks not only correctly, but also consistently and safely. A large number of checklists are currently available to help report and/or critically appraise nearly every type of research design. To name only a few, the AGREE II tool for clinical guidelines;2 and AMSTAR, PRISMA and CASP for systematic reviews. It is not so much the specific checklist used, but rather the use of a validated checklist that ensures that reporting happens consistently and includes all relevant information.
Or so we thought, until we started to commission systematic reviews for AFJEM. It soon became clear that simply reporting on current international best practice was not always appropriate in African acute care settings; in fact it was often quite the opposite. Various resource restrictions ranging from cost-restrictions, to non-availability of essential drugs or equipment, to lack of local expertise exist in the African acute care setting. To illustrate, say a middle aged patient presents with gripping chest pain to a scantily-resourced emergency centre. Besides history and examination, none of the diagnostic tests required to work up a suspected acute coronary syndrome (electrocardiogram, cardiac enzymes, etc.) are available. What does current literature recommend in this setting if an electrocardiogram or cardiac enzymes are not readily available? Who knows? Even if acute care staff were able to diagnose a ST-elevated myocardial infarction (STEMI), best practice treatment might not be offered locally; or transport to a centre which can provide best practice treatment may be inadequate or lacking. Connecting best evidence to available resources is thus of vital importance in the African acute care context.
AFJEM is committed to publishing review articles that will benefit acute care providers, independent of the resources available to them. As a result we have compiled a checklist aimed specifically at best evidence in the resource-restricted setting (Table 1). The aim is to guide authors in producing a report which is a combination between a clinical guideline and a systematic review. Best available evidence, using a transparent and systematic approach to find and evaluate relevant studies, is still key; but with additional focus on resource availability. In effect it will be more rigorous than a narrative review but less time-consuming than a systematic review or meta-analysis. In order to apply the content to different resource levels, authors are advised to start by describing the very best evidence available; then assume the resources for this level are not available and describe the next tier of evidence until all options are exhausted. For example, if we return to our patient with chest pain: the recommended treatment for a patient with STEMI is primary percutaneous coronary intervention; if this treatment is not available, then thrombolytics should be considered; if that is not available then antiplatelet therapy and anticoagulation should be used, and so on and so forth.
