ATTRACT was created in 1997 in response to a large needs assessment exercise carried out with members of the primary care team in Gwent, South Wales. Clinicians were keen to practice 'evidence-based medicine' but found that they didn't have the time and/or expertise in which to keep 'up to date'. What the clinicians wanted was rapid access to the literature via a mechanism that meant that they had minimum resource implication for them. Our findings were broadly in line with those published by McColl et al.
In order to meet these needs ATTRACT was created. In 2001 ATTRACT became an all Wales service. Since 1997 the basic principle has been the same - clinicians contact us, we rapidly search the evidence, appraise and summarise onto a side of A4 and then return it to the clinician via email - where available, fax or post -within 6 hours if necessary. In order to meet this timescale certain shortcuts need to be made. We do not claim to produce systematic reviews (in the EBM sense) for each answer - we basically do what we can within the timescale 'given' to us by the clinicians. We do take the quality of our answers very seriously and have taken part in a number of informal quality exercises. An internal quality control is regularly conducted.
As a result of these shortcuts we have been open to criticism. Perhaps the best place to see this is via the BMJ site which carried an evaluation of the ATTRACT project. The electronic responses, and our responses, sum things up fairly well. ImpAct also carried out a review of our service - ATTRACTing the right questions.
The ATTRACT Process
Clinicians send their query to ATTRACT. Researchers receive questions and seek clarification if necessary. Researchers analyse terms - looking for synonyms, general classifications and MeSH terms - then devise a search strategy. Researchers search abstracts of evidence based literature in accordance with the following hierarchy of sources:
1. TRIP Database (including Cochrane Library, Clinical Evidence)
2. Guidelines (including CKS, SIGN and NICE)
3. PubMed
4. Professional organisations
If a recent (less than 2 yrs old) systematic review is found, that answers the query, the search will terminate here. If no recent evidence is found from the core sources then PubMed is searched. The research literature is appraised,summarised and returned to the clinician via email (preferred option), fax or post. The summary will be uploaded on to the ATTRACT website as an answer to the question. A scoring system has been devised to help guide clinicians in using any particular answer published by ATTRACT. This scoring system uses three variables:
Search
• Strong will be as good, or close, to a systematic review.
• Moderate will be a search carried out using multiple databases and carried out by experienced searches
• Weak will be one carried out on only a single database and/or carried out by an inexperienced searcher.
Appraisal
• Strong will be as good, or close, to a systematic review.
• Moderate will be a critical appraisal ‘light’ and this will often rely on just the abstracts. Appropriate methodologies, sample size et can be considered, although issues such as appropriate randomisation, intention to treat analysis may be overlooked.
• Weak is anything less than moderate and may well include no appraisal.
Confidence
This has proved the most difficult for us to utilise and are aware of potential deficiencies. Is this variable to do with evidence, confidence, robustness? We struggled, but have gone with confidence. We sought the opinion of numerous information specialists with experience in answering clinical questions.
• Strong, where the question is answered well by secondary review articles
• Moderate, where the question is answered by primary research of eTextbooks
• Poor is where there is little research or the primary and secondary literature highlights great uncertainty.
We currently employ two members of staff, Eleri Tyler and Lynne Hockey, who are our main query answerers.
In 2003 ATTRACT became part of the Welsh National Public Health Service
For further information contact me via the e-mail below.
Jon Brassey (jon.brassey@nphs.wales.nhs.uk)
Director