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ing sections. The ACP is working with the British Medical Association (BMA) to publish a companion product for all areas of medicine. The new journal, called Evidence-Based Medicine, will supplement a core of J Club articles with abstracts of studies from psychiatry, surgery, obstetrics and gynecology, family medicine, public health, and pediatrics. A sample issue has appeared in September 1995 and full production begins in January 1996. Systematic Overviews Another rapidly maturing subset of the medical literature is secondary publications that summarize original research appearing in primary journal articles. Good quality overviews help clinicians by doing much of the work of critical appraisal pertaining to specific health conditions. The NLM helps clinicians by publishing its Bibliography of Review Articles at in the front of each volume of Index Medicus and by indexing different types of reviews with specific “publication type” tags in MEDLINE. Standards are emerging for evidence-based systematic overviews of evidence and meta-analyses of data from multiple studies (Mulrow, 1987). Meta-analysis was developed in the humanities and education fields in the early 1970s (Glass, McGaw, & Smith, 198 1) and has been embraced by medicine as a strategy for extending the power and applicability of results from large numbers of primary studies. Overviews and meta-analyses start with a clearly articulated question, then gather and appraise all relevant published and unpublished evidence before combining and analyzing data and exploring the experience of subsets of patients. For example, the Antiplatelet Trialists’ Collaboration ( 1994a, 1994b. 1994~) group’s study of antiplatelet agents (aspirin and other similar drugs) identified and analyzed data from 145 studies with 70,000 high-risk and 30,000 low-risk patients. They found that patients with unstable angina, myocardial infarction, stroke, transient ischemic attack, peripheral vascular disease, and patients scheduled for vascular procedures had substantially decreased risks for death, stroke, myocardial infarction, leg and lung clots, and arterial occlusion if they were receiving antiplatelet agents. Properly conducted and reported, evidence-based overviews provide readers with the information they need to ascertain biases that might have distorted the selection and analysis of evidence from multiple sources. One of the most important features of a good meta-analysis is the description of how primary data sources were identified. Many journal editors now insist that the search strategies (including databases searched, search terms used, and other information gathering processes such as contact with important authors and drug manufacturers) and the assessment of evidence quality appear in the abstract with full description in the methods section of the report. HIRU has promoted structured abstracts for review articles (systematic reviews and meta-analyses) (Mulrow et al., 1988) and guides to using them effectively (Oxman et al., 1994). Cochrane Collaboration The Cochrane Collaboration represents an international effort to build, gather, catalogue, and disseminate systematic overviews and meta-analyses about the effects of health interventions in man. Archie Cochrane ( 1972)) an inspirational epidemiologist in the United Kingdom, lamented: “it is surely a great criticism of our profession that we have not organized a critical summary, by specialty or subspecialty, adapted periodically of all relevant randomized controlled trials.” The Cochrane Collaboration is now a worldwide network of more than 1,000 health care professionals working together in disease and methods-focused groups to meet Archie Cochrane’s challenge. HIRU is the home to the Canadian Cochrane Centre (E-mail: cochrane@mcmaster.ca), with special interests in the dissemination of Cochrane Collaboration reviews in print, online, and CD-ROM format (the Cochrane Database of Systematic Reviews, CDSR) . Evidence-Based Guidelines Overviews can help clinicians systematically gathering, selecting, and combining evidence that links practice options to health outcomes. Clinical decision analyses can help by exploring the trade-offs between competing benefits and harms. Economic analyses can help by tallying the costs associated with different options. However, none of these secondary literatures synthesizes information about evidence, values, and patient circumstances in a way that directly supports specific clinical choices. Clinical practice guidelines, which have been defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances,” represent an attempt to distill a large body of medical knowledge into a convenient, readily useable format (Committee to Advise, 1980). Like overviews, they gather, appraise, and combine evidence. Guidelines, however, go beyond most overviews in attempting to address all the issues relevant to a clinical decision and all the values that might sway a clinical recommendation, Evidence-based guidelines start with a sound systematic review or meta-analysis pertaining to a particular health problem. In addition, they must apply a systematic process for considering the relative importance of alternative outcomes and applying values when formulating recommendations. An example of a systematic review (Grady et al., 1992) with a corresponding clinical review guideline comes from the ACP ( 1992). The committee concluded that for asymptomatic postmenopausal women using long-term estrogen therapy, the risks for breast cancer and endometrial cancer are increased and the risks for coronary heart disease and fracture are decreased, but individual women must take into account their family history and preferences before deciding to take postmenopausal hormones. HIRU has contributed to the development, reporting, and dissemination of evidence-based guidelines by studying clinician attitudes and preferences about guidelines (Tunis, Hayward, Wilson, et al., 1994)) developing a format for standardized abstracts of guidelines (Hayward et al., 1993)) and promoting users’ guides to practice guidelines (Hayward et al., 1995).

The Medical Literature as a Resource for Health Care Practice