PURLs Methodology

Version 1.0

Priority Updates from the Research Literature (PURL) Methodology
Family Physicians Inquiries Network (FPIN)
Bernard Ewigman, MD MSPH
FPIN PURLs Editor in Chief
October 29, 2007

The purpose of the Priority Updates from the Research Literature (PURL) system is to identify original research studies, systematic reviews, and meta-analyses that report findings that, if implemented in practice, would be expected to improve patient outcomes. The PURL methodology includes primary literature surveillance, secondary literature surveillance, critical appraisal, review of the literature, peer review, editorial review, and clinical review. Each of these elements is described below.

The PURL system is expected to evolve as additional members of the FPIN Consortium, interested experts and practicing clinicians become engaged in the nomination, selection and dissemination of PURLs, the published end product of the PURL system. This methodology description will therefore be updated periodically to reflect the evolution of the system.

Primary literature surveillance

Journals that publish original research, systematic reviews, and meta-analyses relevant to family medicine and primary care are monitored regularly for potential PURLS. These include, among others, New England Journal of Medicine, Journal of the American Medical Association, British Medical Journal, Lancet, Annals of Internal Medicine, Pediatrics, Obstetrics & Gynecology, and Archives of Internal Medicine. The designated FPIN clinicians who monitor these sources nominate potential PURLS to FPIN PURLS Editors daily. Nominations for potential PURLs are also accepted from any FPIN clinician (eg, clinicians affiliated with departments of family medicine, family medicine residency programs, practice-based research networks, and other organizations that are members of the FPIN Consortium).

Secondary literature surveillance

Three secondary literature surveillance systems are also monitored regularly for potential PURLS: the BMJOnline Updates, DynaMed Weekly Update, and InfoPOEMS Daily Dose of Knowledge. These 3 surveillance systems monitor over 100 journals and other sources each. The designated FPIN clinicians who monitor these sources nominate potential PURLs to FPIN PURLs editors based on their judgment that the findings from the original research, systematic review or meta-analysis may meet the PURLs criteria for a change in practice; the evidence is true (internal validity), relevant (external validity), builds on prior research, and supports a new practice, not a current practice.

Critical appraisal and review of the literature

FPIN PURLs editors approve or reject nominated PURLs using the same criteria as the nominating clinician. Those studies approved as potential PURLs by FPIN PURLs editors are then assigned to potential PURL reviewer, who completes a formal critical appraisal using a standardized potential PURL review form for each type of study (randomized trials, meta-analyses and systematic reviews, cohort studies, etc). The potential PURL reviewer also completes a review of secondary literature on the topic in an effort to determine current practice (based on the published recommendations), ascertain whether the findings support current practice as reflected in published sources, or suggest a need to change practice.

The literature review begins with evaluating the entries in 3 electronic knowledge resources that are updated regularly, well-referenced, and attempt to be evidence-based: UpToDate, DynaMed, and PEPID PCP. Additional literature review is tailored to the topic, including past original research, systematic reviews, and meta-analysis, and identification of guidelines addressing the topic.

Peer review

The potential PURL reviewers present their critical appraisal and review of the literature to 4 to 6 PURLs clinician and/or peer reviewers and 1 or 2 FPIN PURLs editors. Peer reviewers are academic family physicians, psychologists, pharmacists, and/or methodologists who belong to the FPIN consortium. PURLs clinician reviewers are clinicians who practice at least half time. Following discussion, a decision is made as to whether the potential PURL is a PURL, an important reference that supports current practice, adds new evidence, or is neither a PURL nor an important reference. If consensus is not reached among the 4 to 6 peer reviewers, the FPIN PURLs editor makes the decision. Additional peer review from experts on the topic is sought once an article is selected as a PURL to be written for publication in The Journal of Family Practice.

Editorial review

As mentioned above, the FPIN PURLs editor approves nominated articles as potential PURLs, makes the decision about a potential PURL being reviewed when consensus is not reached among the peer reviewers, and acts as either the editor or as the co-author mentor on all PURLs to be published in The Journal of Family Practice. All PURLs are therefore edited by one FPIN PURLs editor and co-authored by a second FPIN PURLs editor. All PURLs selected by the FPIN PURLs editor are then forwarded to The Journal of Family Practice editor, who makes the final decision about whether to accept the topic as a PURL for publication in JFP, and subsequently whether to accept the completed PURLs manuscript for publication in JFP.

Clinical review

FPIN PURLs editors seek the review and opinions of practicing family physicians and other clinicians at each stage of the development of a PURL. Their input is sought on the relevance, usefulness and the potential challenges of implementing a change in practice that may be stimulated by a PURL. Specifically, 3 questions are of paramount importance that are best answered by practicing clinicians who are the ones who must decide if the new research findings will change their practice or not:

1. Is the recommendation in this PURL a practice that you already do?
2. If not, is this a practice that you will consider incorporating?
3. If so, or if not, what are the challenges to implementing this change into your practice?

The completed potential PURL review form is published at www.jfponline.com/purls for each PURL published in The Journal of Family Practice. FPIN maintains a database of all nominated potential PURLs, approved potential PURLs, and the potential PURL review form for each. Access to this database is available on request.

How to become a PURLs participant

For additional details about the PURL system methodology, or to learn how to become a participant in the PURL system, please contact Bernard Ewigman, MD, MSPH, FPIN PURLS Editor-in-Chief at be.editor@gmail.com or at 773-834-9852. Additional editorial and clinical participants are welcome. For more information about FPIN see www.fpin.org or contact Heather Stewart, FPIN Membership Coordinator at heather@fpin.org or at 573-256-2066.