Level 1 EBM Expedited Review

A recent poll of Canadian researchers identified the top 3 factors that influence where they send their own manuscripts: 1) ensuring methodologic soundness by peer review, 2) journal reputation, and 3) fast publication.¹ The AJNR (independent of this poll) has recognized these important factors, as well as the competitive nature of scientific publishing, by the introduction of a Level 1 Evidence-Based Medicine Expedited Program. The details of this significant program are defined on the AJNR Web site (see the “Author Info” section). Briefly, the program entails a very fast peer review time of 5–7 days, followed by an immediate editorial decision. The length of time from acceptance of the final revision to electronic publication would be 4 weeks. Other perks of this program include the waiving of various fees, such as the open access, color, and over-the-limit word count charges.

What is level 1 evidence? That depends. Levels of evidence were initially defined in 1979 by the Canadian Task Force on Periodic Health Examination.² Sackett³ further defined this in 1989 in an article looking at the evidence for antithrombotic agents. This seminal paper was barely 2 pages in length. Since that time, interest in this subject has exploded, and there are now multiple stakeholders eyeing evidence-based medicine ranging from individual patients to the Federal government. Multiple excellent reviews are available for the intrepid reader of this complex and controversial topic.^4,5

For the purpose of classification for the AJNR, the Oxford Centre for Evidence-Based Medicine Levels of Evidence (2009) is used (also on the AJNR Web site).⁶ For neuroradiologists, the questions to be answered primarily involve therapy and diagnosis. Therapy level 1 studies include systematic reviews of randomized controlled trials, and randomized controlled trials with narrow confidence limits. Diagnosis level 1 studies include systematic reviews of level 1 studies, a validating cohort study with good reference standards, or a clinical decision rule tested within 1 clinical center. For reference, a nonconsecutive study is level 3, a case series is level 4, and expert opinion is level 5 (ouch).

Evidence-based medicine defines a hierarchy of clinically relevant information; however, this information is by no means absolute.⁷ Certain therapies and treatments may be so effective or dramatic that they will never experience a randomized controlled trial. The oft-cited tongue-in-cheek manuscript evaluating randomized controlled trials in parachute use is a case in point.⁸ In our specialty, with its emphasis on technologic advancement, there will be seminal articles that advance the field and which provide important contributions to patient care, but do not achieve level 1–2 status (such as the initial diffusion imaging papers).

Despite its flaws and increasing complexity, the sorting and weighting of manuscripts that define high quality and minimal bias is an important foundation upon which evidence-based medicine is built. This journal will do its part to bring such manuscripts to readers.

• © 2014 by American Journal of Neuroradiology