1
|
Ghozy S, Kobeissi H, Amoukhteh M, Kadirvel R, Brinjikji W, Rabinstein AA, Carpenter CR, Kallmes DF. The Utilization of Systematic Reviews and Meta-Analyses in Stroke Guidelines. Brain Sci 2024; 14:728. [PMID: 39061468 PMCID: PMC11274449 DOI: 10.3390/brainsci14070728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/13/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Stroke guideline statements are important references for clinicians due to the rapidly evolving nature of treatments. Guideline statements should be informed by up-to-date systematic reviews (SRs) and meta-analyses (MAs) because they provide the highest level of evidence. To investigate the utilization of SRs/MAs in stroke management guidelines, we conducted a literature review of guidelines and extracted relevant information regarding SRs/MAs. METHODS A literature review was conducted in PubMed with supplementation using the Trip medical database with the term "stroke" as the target population, followed by using the filter "guidelines". We extracted the number of included SRs/MAs, the years of publication, the country of origin, and other characteristics of interest. Descriptive statistics were generated using the R software version 4.2.1. RESULTS We included 27 guideline statements. The median number of overall SRs or MAs within the guidelines was 4.0 (interquartile range [IQR] = 2-9). For MAs only, the median number included in the guidelines was 3.0 (IQR = 2.0-5.5). Canadian guidelines had the oldest citations, with a median gap of 12.0 (IQR = 5.2-18.0) years for the oldest citation, followed by European (median = 12; IQR = 9.5-13.5) and US (median = 10.0; IQR = 5.2-16) guidelines. CONCLUSIONS Stroke guideline writing groups and issuing bodies should devote greater effort to the inclusion of up-to-date SRs/MAs in their guideline statements so that clinicians can reference recent data with the highest level of evidence.
Collapse
Affiliation(s)
- Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (H.K.); (M.A.); (R.K.); (W.B.); (D.F.K.)
| | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (H.K.); (M.A.); (R.K.); (W.B.); (D.F.K.)
| | - Melika Amoukhteh
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (H.K.); (M.A.); (R.K.); (W.B.); (D.F.K.)
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (H.K.); (M.A.); (R.K.); (W.B.); (D.F.K.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (H.K.); (M.A.); (R.K.); (W.B.); (D.F.K.)
| | | | | | - David F. Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (H.K.); (M.A.); (R.K.); (W.B.); (D.F.K.)
| |
Collapse
|
2
|
Martin FC, Quinn TJ, Straus SE, Anand S, van der Velde N, Harwood RH. New horizons in clinical practice guidelines for use with older people. Age Ageing 2024; 53:afae158. [PMID: 39046117 PMCID: PMC11267466 DOI: 10.1093/ageing/afae158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 03/12/2024] [Accepted: 07/12/2024] [Indexed: 07/25/2024] Open
Abstract
Globally, more people are living into advanced old age, with age-associated frailty, disability and multimorbidity. Achieving equity for all ages necessitates adapting healthcare systems. Clinical practice guidelines (CPGs) have an important place in adapting evidence-based medicine and clinical care to reflect these changing needs. CPGs can facilitate better and more systematic care for older people. But they can also present a challenge to patient-centred care and shared decision-making when clinical and/or socioeconomic heterogeneity or personal priorities are not reflected in recommendations or in their application. Indeed, evidence is often lacking to enable this variability to be reflected in guidance. Evidence is more likely to be lacking about some sections of the population. Many older adults are at the intersection of many factors associated with exclusion from traditional clinical evidence sources with higher incidence of multimorbidity and disability compounded by poorer healthcare access and ultimately worse outcomes. We describe these challenges and illustrate how they can adversely affect CPG scope, the evidence available and its summation, the content of CPG recommendations and their patient-centred implementation. In all of this, we take older adults as our focus, but much of what we say will be applicable to other marginalised groups. Then, using the established process of formulating a CPG as a framework, we consider how these challenges can be mitigated, with particular attention to applicability and implementation. We consider why CPG recommendations on the same clinical areas may be inconsistent and describe approaches to ensuring that CPGs remain up to date.
Collapse
Affiliation(s)
- Finbarr C Martin
- Population Health Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Terence J Quinn
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Sharon E Straus
- Department of Medicine, University of Toronto and Li Ka Shing Knowledge Institute of St. Michael’s, Toronto, Ontario, Canada
| | - Sonia Anand
- Departments of Medicine and Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Nathalie van der Velde
- Department of Internal Medicine, Section of Geriatric Medicine, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute (Aging and Later Life), Amsterdam, The Netherlands
| | - Rowan H Harwood
- School of Health Sciences, University of Nottingham, Nottingham, UK
| |
Collapse
|
3
|
Wiles L, Hibbert PD, Zurynski Y, Smith CL, Arnolda G, Ellis LA, Lake R, Easpaig BNG, Molloy C, Middleton S, Braithwaite J, Hill K, Turner T. Is it possible to make 'living' guidelines? An evaluation of the Australian Living Stroke Guidelines. BMC Health Serv Res 2024; 24:419. [PMID: 38570788 PMCID: PMC10988967 DOI: 10.1186/s12913-024-10795-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/28/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Keeping best practice guidelines up-to-date with rapidly emerging research evidence is challenging. 'Living guidelines' approaches enable continual incorporation of new research, assisting healthcare professionals to apply the latest evidence to their clinical practice. However, information about how living guidelines are developed, maintained and applied is limited. The Stroke Foundation in Australia was one of the first organisations to apply living guideline development methods for their Living Stroke Guidelines (LSGs), presenting a unique opportunity to evaluate the process and impact of this novel approach. METHODS A mixed-methods study was conducted to understand the experience of LSGs developers and end-users. We used thematic analysis of one-on-one semi-structured interview and online survey data to determine the feasibility, acceptability, and facilitators and barriers of the LSGs. Website analytics data were also reviewed to understand usage. RESULTS Overall, the living guidelines approach was both feasible and acceptable to developers and users. Facilitators to use included collaboration with multidisciplinary clinicians and stroke survivors or carers. Increased workload for developers, workload unpredictability, and limited information sharing, and interoperability of technological platforms were identified as barriers. Users indicated increased trust in the LSGs (69%), likelihood of following the LSGs (66%), and frequency of access (58%), compared with previous static versions. Web analytics data showed individual access by 16,517 users in 2016 rising to 53,154 users in 2020, a threefold increase. There was also a fourfold increase in unique LSG pageviews from 2016 to 2020. CONCLUSIONS This study, the first evaluation of living guidelines, demonstrates that this approach to stroke guideline development is feasible and acceptable, that these approaches may add value to developers and users, and may increase guideline use. Future evaluations should be embedded along with guideline implementation to capture data prospectively.
Collapse
Affiliation(s)
- Louise Wiles
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
- Innovation, Implementation & Clinical Translation (IIMPACT) in Health, University of South Australia, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Peter D Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia.
- Innovation, Implementation & Clinical Translation (IIMPACT) in Health, University of South Australia, Adelaide, Australia.
- South Australian Health and Medical Research Institute, Adelaide, Australia.
| | - Yvonne Zurynski
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
- NHMRC Partnership Centre for Health System Sustainability, Sydney, Australia
| | - Carolynn L Smith
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
- NHMRC Partnership Centre for Health System Sustainability, Sydney, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Louise A Ellis
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
- NHMRC Partnership Centre for Health System Sustainability, Sydney, Australia
| | - Rebecca Lake
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | | | - Charlotte Molloy
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
- Innovation, Implementation & Clinical Translation (IIMPACT) in Health, University of South Australia, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney and Australian Catholic University, Sydney, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
- NHMRC Partnership Centre for Health System Sustainability, Sydney, Australia
| | | | - Tari Turner
- School of Population Health and Preventive Medicine, Monash University, Melbourne, Australia
| |
Collapse
|
4
|
Millard T, Elliott JH, Green S, McGloughlin S, Turner T. Exploring the use and impact of the Australian living guidelines for the clinical care of people with COVID-19: where to from here? J Clin Epidemiol 2024; 166:111234. [PMID: 38072175 DOI: 10.1016/j.jclinepi.2023.111234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVES The Australian National COVID-19 Clinical Evidence Taskforce has been developing, maintaining, and disseminating living guidelines and decision support tools (clinical flowcharts) for the care of people with suspected or confirmed COVID-19 since 2020. Living guidelines, a form of living evidence, are a relatively new approach; hence, more work is required to determine how to optimize their use to inform practice, policy, and decision-making and to explore implementation, uptake, and impact implications. An update of an earlier impact evaluation was conducted to understand sustained awareness and use of the guidelines; the factors that facilitate the widespread adoption of the guidelines and to explore the perceived strengths and opportunities for improvement of the guidelines. STUDY DESIGN AND SETTING A mixed-methods impact evaluation was conducted. Surveys collected both quantitative and qualitative data and were supplemented with qualitative interviews. Participants included Australian healthcare practitioners providing care to individuals with suspected or confirmed COVID-19 and people involved in policy-making. Data were collected on awareness, use, impact, strengths, and opportunities for improvement of the guidelines and flow charts. RESULTS A total of 148 participants completed the survey and 21 people were interviewed between January and March 2022. Awareness of the work of the Taskforce was high and more than 75% of participants reported that the guidelines were used within their workplace. Participants described the Taskforce website and guidelines as trustworthy, valuable, and reliable sources of up-to-date evidence-based information. The evaluation highlighted the varied ways the guidelines were being used across a range of settings and the diverse impacts they have from those at a clinical level to impacts at a policy level. Barriers to and enablers of impact and uptake of the guideline were explored. CONCLUSION This evaluation highlights the value of living guidelines during a pandemic when the evidence base is rapidly changing and expanding. It presents useful understanding of the ways clinicians and others use living evidence to inform their clinical practice and decision-making and the diverse impacts the guidelines are having around Australia.
Collapse
Affiliation(s)
- Tanya Millard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Julian H Elliott
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sally Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Steve McGloughlin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Tari Turner
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| |
Collapse
|
5
|
Meteku BT, Quigley M, Turner T, Green SE. Barriers to and facilitators of living guidelines use in low-income and middle-income countries: a scoping review. BMJ Open 2024; 14:e074311. [PMID: 38233061 PMCID: PMC10806715 DOI: 10.1136/bmjopen-2023-074311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 11/22/2023] [Indexed: 01/19/2024] Open
Abstract
INTRODUCTION Living guidelines provide reliable, ongoing evidence surveillance and regularly updated recommendations for healthcare decision-making. As a relatively new concept, most of the initial application of living approaches has been undertaken in high-income countries. However, in this scoping review, we looked at what is currently known about how living guidelines were developed, used and applied in low-income and middle-income countries. METHODS Searches for published literature were conducted in Medline, Global Health, Cochrane Library and Embase. Grey literature was identified using Google Scholar and the WHO website. In addition, the reference lists of included studies were checked for missing studies. Studies were included if they described or reflected on the development, application or utility of living guideline approaches for low-income and middle-income countries. RESULTS After a full-text review, 21 studies were included in the review, reporting on the development and application of living recommendations in low-income and middle-income countries. Most studies reported living guideline activities conducted by the WHO (15, 71.4%), followed by China (4, 19%), Chile (1, 4.8%) and Lebanon (1, 4.8%). All studies based on WHO reports relate to living COVID-19 management guidelines. CONCLUSIONS Most of the studies in this review were WHO-reported studies focusing solely on COVID-19 disease treatment living guidelines. However, there was no clear explanation of how living guidelines were used nor information on the prospects for and obstacles to the implementation of living guidelines in low-income and middle-income countries.
Collapse
Affiliation(s)
- Bekele Tesfaye Meteku
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Nursing, College of Health Science, Debre Markos University, Debre Markos, Amhara, Ethiopia
| | - Matthew Quigley
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Tari Turner
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cochrane Australia, Melbourne, Victoria, Australia
| | - Sally E Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cochrane Australia, Melbourne, Victoria, Australia
| |
Collapse
|
6
|
Rajit D, Johnson A, Callander E, Teede H, Enticott J. Learning health systems and evidence ecosystems: a perspective on the future of evidence-based medicine and evidence-based guideline development. Health Res Policy Syst 2024; 22:4. [PMID: 38178086 PMCID: PMC10768258 DOI: 10.1186/s12961-023-01095-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 12/14/2023] [Indexed: 01/06/2024] Open
Abstract
Despite forming the cornerstone of modern clinical practice for decades, implementation of evidence-based medicine at scale remains a crucial challenge for health systems. As a result, there has been a growing need for conceptual models to better contextualise and pragmatize the use of evidence-based medicine, particularly in tandem with patient-centred care. In this commentary, we highlight the emergence of the learning health system as one such model and analyse its potential role in pragmatizing both evidence-based medicine and patient-centred care. We apply the learning health system lens to contextualise the key activity of evidence-based guideline development and implementation, and highlight how current inefficiencies and bottlenecks in the evidence synthesis phase of evidence-based guideline development threaten downstream adherence. Lastly, we introduce the evidence ecosystem as a complementary model to learning health systems, and propose how innovative developments from the evidence ecosystem may be integrated with learning health systems to better enable health impact at speed and scale.
Collapse
Affiliation(s)
- D Rajit
- Monash Centre for Health Research and Implementation, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Level 1, 43-51 Kanooka Grove, Melbourne, VIC, 3168, Australia
| | - A Johnson
- Monash Partners Academic Health Sciences Centre, Melbourne, VIC, Australia
| | - E Callander
- Monash Centre for Health Research and Implementation, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Level 1, 43-51 Kanooka Grove, Melbourne, VIC, 3168, Australia
- Monash Partners Academic Health Sciences Centre, Melbourne, VIC, Australia
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - H Teede
- Monash Centre for Health Research and Implementation, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Level 1, 43-51 Kanooka Grove, Melbourne, VIC, 3168, Australia
- Monash Partners Academic Health Sciences Centre, Melbourne, VIC, Australia
- Monash Health Endocrinology and Diabetes Departments, Melbourne, Australia
| | - J Enticott
- Monash Centre for Health Research and Implementation, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Level 1, 43-51 Kanooka Grove, Melbourne, VIC, 3168, Australia.
- Monash Partners Academic Health Sciences Centre, Melbourne, VIC, Australia.
| |
Collapse
|
7
|
Hodder RK, Vogel JP, Wolfenden L, Turner T. Living Systematic Reviews and Living Guidelines to Maintain the Currency of Public Health Guidelines. Am J Public Health 2024; 114:21-26. [PMID: 38091567 PMCID: PMC10726929 DOI: 10.2105/ajph.2023.307450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Rebecca K Hodder
- Rebecca K. Hodder is with the College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, Australia and Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia. Luke Wolfenden is with the College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, Australia and Cochrane Public Health, The University of Newcastle, Callaghan, Australia. Joshua P. Vogel is with the School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia, and the Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia. Tari Turner is with the School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Joshua P Vogel
- Rebecca K. Hodder is with the College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, Australia and Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia. Luke Wolfenden is with the College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, Australia and Cochrane Public Health, The University of Newcastle, Callaghan, Australia. Joshua P. Vogel is with the School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia, and the Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia. Tari Turner is with the School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Luke Wolfenden
- Rebecca K. Hodder is with the College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, Australia and Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia. Luke Wolfenden is with the College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, Australia and Cochrane Public Health, The University of Newcastle, Callaghan, Australia. Joshua P. Vogel is with the School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia, and the Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia. Tari Turner is with the School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Tari Turner
- Rebecca K. Hodder is with the College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, Australia and Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia. Luke Wolfenden is with the College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, Australia and Cochrane Public Health, The University of Newcastle, Callaghan, Australia. Joshua P. Vogel is with the School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia, and the Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia. Tari Turner is with the School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| |
Collapse
|
8
|
Turner T, Lavis JN, Grimshaw JM, Green S, Elliott J. Living evidence and adaptive policy: perfect partners? Health Res Policy Syst 2023; 21:135. [PMID: 38111030 PMCID: PMC10726516 DOI: 10.1186/s12961-023-01085-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/27/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND While there has been widespread global acceptance of the importance of evidence-informed policy, many opportunities to inform health policy with research are missed, often because of a mismatch between when and where reliable evidence is needed, and when and where it is available. 'Living evidence' is an approach where systematic evidence syntheses (e.g. living reviews, living guidelines, living policy briefs, etc.) are continually updated to incorporate new relevant evidence as it becomes available. Living evidence approaches have the potential to overcome a major barrier to evidence-informed policy, making up-to-date systematic summaries of policy-relevant research available at any time that policy-makers need them. These approaches are likely to be particularly beneficial given increasing calls for policy that is responsive, and rapidly adaptive to changes in the policy context. We describe the opportunities presented by living evidence for evidence-informed policy-making and highlight areas for further exploration. DISCUSSION There are several elements of living approaches to evidence synthesis that might support increased and improved use of evidence to inform policy. Reviews are explicitly prioritised to be 'living' by partnerships between policy-makers and researchers based on relevance to decision-making, as well as uncertainty of existing evidence, and likelihood that new evidence will arise. The ongoing nature of the work means evidence synthesis teams can be dynamic and engage with policy-makers in a variety of ways over time; and synthesis topics, questions and methods can be adapted as policy interests or contextual factors shift. Policy-makers can sign-up to be notified when relevant new evidence is found, and can be confident that living syntheses are up-to-date and contain all research whenever they access them. The always up-to-date nature of living evidence syntheses means producers can rapidly demonstrate availability of relevant, reliable evidence when it is needed, addressing a frequently cited barrier to evidence-informed policymaking. CONCLUSIONS While there are challenges to be overcome, living evidence provides opportunities to enable policy-makers to access up-to-date evidence whenever they need it and also enable researchers to respond to the issues of the day with up-to-date research; and update policy-makers on changes in the evidence base as they arise. It also provides an opportunity to build flexible partnerships between researchers and policy-makers to ensure that evidence syntheses reflect the changing needs of policy-makers.
Collapse
Affiliation(s)
- Tari Turner
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - John N Lavis
- McMaster Health Forum, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L6, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
- Health Policy PhD Program, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
- Department of Political Science, McMaster University, Hamilton, Canada
- Africa Centre for Evidence, University of Johannesburg, Johannesburg, South Africa
| | - Jeremy M Grimshaw
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Population and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sally Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Julian Elliott
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| |
Collapse
|
9
|
McDonald S, Hill K, Li HZ, Turner T. Evidence surveillance for a living clinical guideline: Case study of the Australian stroke guidelines. Health Info Libr J 2023. [PMID: 37942888 DOI: 10.1111/hir.12515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/26/2023] [Accepted: 10/26/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Continual evidence surveillance is an integral feature of living guidelines. The Australian Stroke Guidelines include recommendations on 100 clinical topics and have been 'living' since 2018. OBJECTIVES To describe the approach for establishing and evaluating an evidence surveillance system for the living Australian Stroke Guidelines. METHODS We developed a pragmatic surveillance system based on an analysis of the searches for the 2017 Stroke Guidelines and evaluated its reliability by assessing the potential impact on guideline recommendations. Search retrieval and screening workload are monitored monthly, together with the frequency of changes to the guideline recommendations. RESULTS Evidence surveillance was guided by practical considerations of efficiency and sustainability. A single PubMed search covering all guideline topics, limited to systematic reviews and randomised trials, is run monthly. The search retrieves about 400 records a month of which a sixth are triaged to the guideline panels for further consideration. Evaluations with Epistemonikos and the Cochrane Stroke Trials Register demonstrated the robustness of adopting this more restrictive approach. Collaborating with the guideline team in designing, implementing and evaluating the surveillance is essential for optimising the approach. CONCLUSION Monthly evidence surveillance for a large living guideline is feasible and sustainable when applying a pragmatic approach.
Collapse
Affiliation(s)
- Steve McDonald
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Kelvin Hill
- Stroke Services, Stroke Foundation, Melbourne, Australia
| | - Heidi Z Li
- Stroke Services, Stroke Foundation, Melbourne, Australia
| | - Tari Turner
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| |
Collapse
|
10
|
Cooper N, Germeni E, Freeman SC, Jaiswal N, Nevill CR, Sutton AJ, Taylor-Rowan M, Quinn TJ. New horizons in evidence synthesis for older adults. Age Ageing 2023; 52:afad211. [PMID: 37955937 DOI: 10.1093/ageing/afad211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Indexed: 11/14/2023] Open
Abstract
Evidence synthesis, embedded within a systematic review of the literature, is a well-established approach for collating and combining all the relevant information on a particular research question. A robust synthesis can establish the evidence base, which underpins best practice guidance. Such endeavours are frequently used by policymakers and practitioners to inform their decision making. Traditionally, an evidence synthesis of interventions consisted of a meta-analysis of quantitative data comparing two treatment alternatives addressing a specific and focussed clinical question. However, as the methods in the field have evolved, especially in response to the increasingly complex healthcare questions, more advanced evidence synthesis techniques have been developed. These can deal with extended data structures considering more than two treatment alternatives (network meta-analysis) and complex multicomponent interventions. The array of questions capable of being answered has also increased with specific approaches being developed for different evidence types including diagnostic, prognostic and qualitative data. Furthermore, driven by a desire for increasingly up-to-date evidence summaries, living systematic reviews have emerged. All of these methods can potentially have a role in informing older adult healthcare decisions. The aim of this review is to increase awareness and uptake of the increasingly comprehensive array of newer synthesis methods available and highlight their utility for answering clinically relevant questions in the context of older adult research, giving examples of where such techniques have already been effectively applied within the field. Their strengths and limitations are discussed, and we suggest user-friendly software options to implement the methods described.
Collapse
Affiliation(s)
- Nicola Cooper
- NIHR Evidence Synthesis Group @Complex Review Support Unit
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Evi Germeni
- NIHR Evidence Synthesis Group @Complex Review Support Unit
- Health Economics and Health Technology Assessment (HEHTA), School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Suzanne C Freeman
- NIHR Evidence Synthesis Group @Complex Review Support Unit
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Nishant Jaiswal
- NIHR Evidence Synthesis Group @Complex Review Support Unit
- Health Economics and Health Technology Assessment (HEHTA), School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Clareece R Nevill
- NIHR Evidence Synthesis Group @Complex Review Support Unit
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- NIHR Evidence Synthesis Group @Complex Review Support Unit
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Martin Taylor-Rowan
- NIHR Evidence Synthesis Group @Complex Review Support Unit
- Health Economics and Health Technology Assessment (HEHTA), School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Terence J Quinn
- NIHR Evidence Synthesis Group @Complex Review Support Unit
- School of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| |
Collapse
|
11
|
Cheyne S, Chakraborty S, Lewis S, Campbell S, Turner T, Norris S. What could health technology assessment learn from living clinical practice guidelines? Front Pharmacol 2023; 14:1234414. [PMID: 37693902 PMCID: PMC10484706 DOI: 10.3389/fphar.2023.1234414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023] Open
Abstract
A "living" approach to clinical practice guidelines is when the identification, appraisal and synthesis of evidence is maintained and repeated at an agreed frequency, with a clear process for when and how new evidence is to be incorporated. The value of a living approach to guidelines was emphasised during the COVID-19 pandemic when health professionals and policymakers needed to make decisions regarding patient care in the context of a nascent but rapidly evolving evidence base. In this perspective, we draw on our recent experience developing Australian and international living guidelines and reflect on the feasibility of applying living guideline methods and processes to a lifecycle approach to health technology assessment (HTA). We believe the opportunities and challenges of adopting a living approach in HTA fall into five key themes: identification, appraisal and synthesis of evidence; optimising the frequency of updates; embedding ongoing multi-stakeholder engagement; linking the emergence of new evidence to reimbursement; and system capacity to support a living approach. We acknowledge that the suitability of specific living approaches to HTA will be heavily influenced by the type of health technology, its intended use in the health system, local reimbursement pathways, and other policy settings. But we believe that the methods and processes applied successfully to guideline development to manage evidentiary uncertainty could be applied in the context of HTA and reimbursement decision-making to help manage similar sources of uncertainty.
Collapse
Affiliation(s)
- Saskia Cheyne
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Australian Living Evidence Consortium, Cochrane Australia, Monash University, Melbourne, VIC, Australia
| | - Samantha Chakraborty
- Australian Living Evidence Consortium, Cochrane Australia, Monash University, Melbourne, VIC, Australia
| | | | | | - Tari Turner
- Australian Living Evidence Consortium, Cochrane Australia, Monash University, Melbourne, VIC, Australia
| | - Sarah Norris
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Hereco, Sydney, NSW, Australia
| |
Collapse
|
12
|
Shaikh F, Wynne R, Castelino RL, Inglis SC, Davidson PM, Ferguson C. Practices, beliefs, and attitudes of clinicians in prescribing direct oral anticoagulants for obese adults with atrial fibrillation: a qualitative study. Int J Clin Pharm 2023; 45:962-969. [PMID: 37253952 PMCID: PMC10228882 DOI: 10.1007/s11096-023-01583-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 03/24/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) and obesity affect over 60 and 650 million people, respectively. AIM This study aimed to explore clinician practices, beliefs, and attitudes towards the use of direct oral anticoagulants (DOACs) in obese adults (BMI ≥ 30 kg/m2) with AF. METHOD Semi-structured interviews via video conference were conducted with multidisciplinary clinicians from across Australia, with expertise in DOAC use in adults with AF. Clinicians were invited to participate using purposive and snowball sampling techniques. Data were analysed in NVIVO using thematic analysis. RESULTS Fifteen clinicians including cardiologists (n = 5), hospital and academic pharmacists (n = 5), general practitioners (n = 2), a haematologist, a neurologist and a clinical pharmacologist participated. Interviews were on average 31 ± 9 min. Key themes identified were: Health system factors in decision-making Disparities between rural and metropolitan geographic areas, availability of health services, and time limitations for in-patient decision-making, were described; Condition-related factors in decision-making Clinicians questioned the significance of obesity as part of decision-making due to the practical limitations of dose modification, and the rarity of the extremely obese cohort; Decision-making in the context of uncertainty Clinicians reported limited availability, reliability and awareness of primary evidence including limited guidance from clinical guidelines for DOAC use in obesity. CONCLUSION This study highlights the complexity of decision-making for clinicians, due to the limited availability, reliability and awareness of evidence, the intrinsic complexity of the obese cohort and limited guidance from clinical guidelines. This highlights the urgent need for contemporary research to improve the quality of evidence to guide informed shared decision-making.
Collapse
Affiliation(s)
- Fahad Shaikh
- School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Wollongong, NSW, Australia.
| | - Rochelle Wynne
- School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Wollongong, NSW, Australia
- The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Ronald L Castelino
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pharmacy Department, Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, Australia
| | - Sally C Inglis
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Sydney, NSW, Australia
| | | | - Caleb Ferguson
- School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Wollongong, NSW, Australia
| |
Collapse
|
13
|
Choi M, Lee HJ, Yu SY, Kim J, Park J, Ryoo S, Kim I, Park DA, Yoon YK, Joh JS, Park S, Yun KW, Choi CH, Kim JS, Shin S, Kim H, Huh K, Jeong IS, Choi SH, Hwang SH, Lee H, Lee DK, Yong HS, Yum HK. Two Years of Experience and Methodology of Korean COVID-19 Living Clinical Practice Guideline Development. J Korean Med Sci 2023; 38:e195. [PMID: 37309700 DOI: 10.3346/jkms.2023.38.e195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/11/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND In Korea, during the early phase of the coronavirus disease 2019 (COVID-19) pandemic, we responded to the uncertainty of treatments under various conditions, consistently playing catch up with the speed of evidence updates. Therefore, there was high demand for national-level evidence-based clinical practice guidelines for clinicians in a timely manner. We developed evidence-based and updated living recommendations for clinicians through a transparent development process and multidisciplinary expert collaboration. METHODS The National Evidence-based Healthcare Collaborating Agency (NECA) and the Korean Academy of Medical Sciences (KAMS) collaborated to develop trustworthy Korean living guidelines. The NECA-supported methodological sections and 8 professional medical societies of the KAMS worked with clinical experts, and 31 clinicians were involved annually. We developed a total of 35 clinical questions, including medications, respiratory/critical care, pediatric care, emergency care, diagnostic tests, and radiological examinations. RESULTS An evidence-based search for treatments began in March 2021 and monthly updates were performed. It was expanded to other areas, and the search interval was organized by a steering committee owing to priority changes. Evidence synthesis and recommendation review was performed by researchers, and living recommendations were updated within 3-4 months. CONCLUSION We provided timely recommendations on living schemes and disseminated them to the public, policymakers and various stakeholders using webpages and social media. Although the output was successful, there were some limitations. The rigor of development issues, urgent timelines for public dissemination, education for new developers, and spread of several new COVID-19 variants have worked as barriers. Therefore, we must prepare systematic processes and funding for future pandemics.
Collapse
Affiliation(s)
- Miyoung Choi
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Hyeon-Jeong Lee
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Su-Yeon Yu
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
- Department of Medical Information, College of Nursing and Health, Kongju National University, Gongju, Korea
| | - Jimin Kim
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Jungeun Park
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Seungeun Ryoo
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Inho Kim
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Dong Ah Park
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Joon-Sung Joh
- Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ki Wook Yun
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Chi-Hoon Choi
- Department of Radiology, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Jae-Seok Kim
- Department of Laboratory Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Sue Shin
- Department of Laboratory Medicine, Seoul National University-Seoul Metropolitan Government Boramae Hospital, Seoul, Korea
| | - Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kyungmin Huh
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - In-Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, Korea
| | - Soo-Han Choi
- Department of Pediatrics, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Sung Ho Hwang
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hyukmin Lee
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Keon Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hwan Seok Yong
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.
| | - Ho Kee Yum
- Department of Respiratory and Critical Care Medicine, Inje University Seoul Paik Hospital, Seoul, Korea.
| |
Collapse
|
14
|
Hewitt J, McDonald S, Poole A, White H, Turner S, Turner T. Weekly updating of guideline recommendations was feasible: the Australian National COVID-19 clinical evidence Taskforce. J Clin Epidemiol 2023; 155:131-136. [PMID: 36813003 PMCID: PMC9939393 DOI: 10.1016/j.jclinepi.2023.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 02/08/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023]
Abstract
OBJECTIVES To investigate how quickly evidence was incorporated into the Australian living guidelines for COVID-19 during the first 12 months of the pandemic. STUDY DESIGN AND SETTING For each study concerning drug therapies included in the guideline from April 3, 2020 to April 1, 2021, we extracted the publication date of the study, and the guideline version the study was included in. We analyzed two subgroups of studies as follows: those published in high impact factor journals and those with 100 or more participants. RESULTS In the first year, we published 37 major versions of the guidelines, incorporating 129 studies that investigated 48 drug therapies informing 115 recommendations. The median time from first publication of a study to incorporation in the guideline was 27 days (interquartile range [IQR], 16 to 44), ranging from 9 to 234 days. For the 53 studies in the highest impact factor journals, the median was 20 days (IQR 15 to 30), and for the 71 studies with 100 or more participants the median was 22 days (IQR 15 to 36). CONCLUSION Developing and sustaining living guidelines where evidence is rapidly incorporated is a resource- and time-intensive undertaking; however, this study demonstrates that it is feasible, even over a long period.
Collapse
Affiliation(s)
- Jessie Hewitt
- School of Public Health and Preventive Medicine, Monash University, 553 Street Kilda Road, Melbourne, VIC 3004, Australia
| | - Steve McDonald
- School of Public Health and Preventive Medicine, Monash University, 553 Street Kilda Road, Melbourne, VIC 3004, Australia
| | - Alex Poole
- School of Public Health and Preventive Medicine, Monash University, 553 Street Kilda Road, Melbourne, VIC 3004, Australia; Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA 5000, Australia
| | - Heath White
- School of Public Health and Preventive Medicine, Monash University, 553 Street Kilda Road, Melbourne, VIC 3004, Australia
| | - Simon Turner
- Biostatistics Unit, School of Public Health and Preventive Medicine, Monash University, 553 Street Kilda Road, Melbourne, VIC 3004, Australia
| | - Tari Turner
- School of Public Health and Preventive Medicine, Monash University, 553 Street Kilda Road, Melbourne, VIC 3004, Australia.
| |
Collapse
|
15
|
McDonald S, Sharp S, Morgan RL, Murad MH, Fraile Navarro D. Paper 4: Search methods and approaches for living guidelines. J Clin Epidemiol 2023; 155:108-117. [PMID: 36642347 DOI: 10.1016/j.jclinepi.2022.12.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/15/2022] [Accepted: 12/21/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To describe the key features of a continual evidence surveillance process that can be implemented for living guidelines and to outline the considerations and trade-offs in adopting different approaches. STUDY DESIGN AND SETTING Members of the Australian Living Evidence Consortium (ALEC), National Institute of Health and Care Excellence (NICE), and the US GRADE Network (USGN) shared their practical experiences of and approaches to establishing surveillance systems for living guidelines. We identified several common components of evidence surveillance and listed the key features and considerations for each component drawn from case studies, highlighting differences with standard guidelines. RESULTS We developed guidance that covers the initial information needed to support decisions around suitability for living mode and the practical considerations in setting up continual search surveillance systems (search frequency, sources to search, use of automation, reporting the search, ongoing resources, and evaluation). The case studies draw on our experiences with developing guidelines for COVID-19, as well as for other conditions such as stroke and diabetes, and cover a range of practical approaches, including the use of automation. CONCLUSION This paper highlights different approaches to continual evidence surveillance that can be implemented in living guidelines.
Collapse
Affiliation(s)
- Steve McDonald
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Steve Sharp
- National Institute for Health and Care Excellence (NICE), Manchester, UK
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - M Hassan Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - David Fraile Navarro
- Australian Living Evidence Consortium, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | | |
Collapse
|
16
|
Cheyne S, Fraile Navarro D, Hill K, McDonald S, Tunnicliffe D, White H, Whittle S, Karpusheff J, Mustafa R, Morgan RL, Sultan S, Turner T. Methods for living guidelines: early guidance based on practical experience. J Clin Epidemiol 2023; 155:84-96. [PMID: 36639038 DOI: 10.1016/j.jclinepi.2022.12.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 12/13/2022] [Accepted: 12/21/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To introduce methods for living guidelines based on practical experiences by the Australian Living Evidence Consortium (ALEC), the National Institute of Health and Care Excellence (NICE), and the Infectious Diseases Society of America (IDSA), with methodological support from the US Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Network. STUDY DESIGN AND SETTING Members of ALEC, NICE, and the US GRADE Network, convened a working group to share experiences of the methods used to develop living guidelines and outline the key differences between traditional and living guidelines methods. RESULTS The guidance includes the following steps: 1) deciding if the guideline is a priority for a living approach, 2) preparing for living guideline development, 3) literature surveillance and frequency of searching, 4) assessment and synthesis of the evidence, 5) publication and dissemination, and 6) transitioning recommendations out of living mode. CONCLUSION This paper introduces methods for living guidelines and provides examples of the similarities and differences in approach across multiple organizations conducting living guidelines. It also introduces a series of papers exploring methods for living guidelines based on our practical experiences, including consumer involvement, selecting and prioritizing questions, search decisions, and methods decisions.
Collapse
Affiliation(s)
- Saskia Cheyne
- Australian Living Evidence Consortium, Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia; NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia.
| | - David Fraile Navarro
- Australian Living Evidence Consortium, Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia; Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | | | - Steve McDonald
- Australian Living Evidence Consortium, Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - David Tunnicliffe
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Heath White
- Australian Living Evidence Consortium, Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Samuel Whittle
- Australia and New Zealand Musculoskeletal Clinical Trials Network, Melbourne, Australia; The Queen Elizabeth Hospital, South Australia, Australia; Department of Epidemiology and Preventive Medicine, School of Preventive Medicine and Public Health, Monash University, Melbourne, Australia
| | | | - Reem Mustafa
- University of Kansas Medical Center, KS, USA; The Evidence Foundation, Cleveland Heights, OH, USA
| | - Rebecca L Morgan
- The Evidence Foundation, Cleveland Heights, OH, USA; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Shahnaz Sultan
- The Evidence Foundation, Cleveland Heights, OH, USA; Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Tari Turner
- Australian Living Evidence Consortium, Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | | |
Collapse
|
17
|
Fraile Navarro D, Cheyne S, Hill K, McFarlane E, Morgan RL, Murad MH, Mustafa RA, Sultan S, Tunnicliffe DJ, Vogel JP, White H, Turner T. Methods for living guidelines: early guidance based on practical experience. Article 5: decisions on methods for evidence synthesis and recommendation development for living guidelines. J Clin Epidemiol 2023; 155:118-128. [PMID: 36608720 DOI: 10.1016/j.jclinepi.2022.12.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 12/15/2022] [Accepted: 12/21/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Producing living guidelines requires making important decisions about methods for evidence identification, appraisal, and integration to allow the living mode to function. Clarifying what these decisions are and the trade-offs between options is necessary. This article provides living guideline developers with a framework to enable them to choose the most suitable model for their living guideline topic, question, or context. STUDY DESIGN AND SETTING We developed this guidance through an iterative process informed by interviews, feedback, and a consensus process with an international group of living guideline developers. RESULTS Several key decisions need to be made both before commencing and throughout the continual process of living guideline development and maintenance. These include deciding what approach is taken to the systematic review process; decisions about methods to be applied for the evidence appraisal process, including the use of unpublished data; and selection of "triggers" to incorporate new studies into living guideline recommendations. In each case, there are multiple options and trade-offs. CONCLUSION We identify trade-offs and important decisions to be considered throughout the living guideline development process. The most appropriate, and most sustainable, mode of development and updating will be dependent on the choices made in each of these areas.
Collapse
Affiliation(s)
- David Fraile Navarro
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Saskia Cheyne
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kelvin Hill
- Stroke Foundation, Melbourne, Victoria, Australia
| | - Emma McFarlane
- National Institute for Health and care Excellence, Manchester, UK
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - M Hassan Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Shahnaz Sultan
- University of Minnesota, Minneapolis Veterans Affairs Healthcare System, MN, USA
| | - David J Tunnicliffe
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia
| | - Heath White
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Tari Turner
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
18
|
Turner T, McDonald S, Wiles L, English C, Hill K. How frequently should "living" guidelines be updated? Insights from the Australian Living Stroke Guidelines. Health Res Policy Syst 2022; 20:73. [PMID: 35725548 PMCID: PMC9207845 DOI: 10.1186/s12961-022-00866-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 05/11/2022] [Indexed: 12/03/2022] Open
Abstract
Background “Living guidelines” are guidelines which are continually kept up to date as new evidence emerges. Living guideline methods are evolving. The aim of this study was to determine how frequently searches for new evidence should be undertaken for the Australian Living Stroke Guidelines. Methods Members of the Living Stroke Guidelines Development Group were invited to complete an online survey. Participants nominated one or more recommendation topics from the Living Stroke Guidelines with which they had been involved and answered questions about that topic, assessing whether it met criteria for living evidence synthesis, and how frequently searches for new evidence should be undertaken and why. For each topic we also determined how many studies had been assessed and included, and whether recommendations had been changed. Results Fifty-seven assessments were received from 33 respondents, covering half of the 88 guideline topic areas. Nearly all assessments (49, 86%) were that the continual updating process should be maintained. Only three assessments (5%) deemed that searches should be conducted monthly; 3-monthly (14, 25%), 6-monthly (13, 23%) and yearly (17, 30%) searches were far more frequently recommended. Rarely (9, 16%) were topics deemed to meet all three criteria for living review. The vast majority of assessments (45, 79%) deemed the topic a priority for decision-making. Nearly half indicated that there was uncertainty in the available evidence or that new evidence was likely to be available soon. Since 2017, all but four of the assessed topic areas have had additional studies included in the evidence summary. For eight topics, there have been changes in recommendations, and revisions are underway for an additional six topics. Clinical importance was the most common reason given for why continual evidence surveillance should be undertaken. Workload for reviewers was a concern, particularly for topics where there is a steady flow of publication of small trials. Conclusions Our study found that participants felt that the vast majority of topics assessed in the Living Stroke Guidelines should be continually updated. However, only a fifth of topic areas were assessed as conclusively meeting all three criteria for living review, and the definition of “continual” differed widely. This work has informed decisions about search frequency for the Living Stroke Guidelines and form the basis of further research on methods for frequent updating of guidelines.
Collapse
Affiliation(s)
- Tari Turner
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Level 4 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
| | - Steve McDonald
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Level 4 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Louise Wiles
- IIMPACT in Health, UniSA Allied Health & Human Performance, The University of South Australia, Adelaide, Australia.,Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.,South Australian Health and Medical Research Institute, Adelaide, South, Australia
| | - Coralie English
- School of Health Sciences, and Priority Research Centre for Stroke and Brain Injury, The University of Newcastle, Newcastle, Australia
| | | |
Collapse
|
19
|
English C, Hill K, Cadilhac DA, Hackett ML, Lannin NA, Middleton S, Ranta A, Stocks NP, Davey J, Faux SG, Godecke E, Campbell BCV. Living clinical guidelines for stroke: updates, challenges and opportunities. Med J Aust 2022; 216:510-514. [PMID: 35569098 PMCID: PMC9542680 DOI: 10.5694/mja2.51520] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Dominique A Cadilhac
- Monash University Melbourne VIC
- Florey Institute of Neuroscience and Mental Health Melbourne VIC
| | - Maree L Hackett
- The George Institute for Global Health, Faculty of Medicine University of NSW Sydney NSW
- University of Central Lancashire Preston UK
| | | | - Sandy Middleton
- Nursing Research Institute Australian Catholic University and St Vincent’s Health Australia Sydney NSW
- Australian Catholic University Sydney NSW
| | | | | | | | - Steven G Faux
- St Vincent's Hospital Sydney NSW
- University of NSW Sydney NSW
| | - Erin Godecke
- Edith Cowan University Perth WA
- Sir Charles Gairdner Hospital Perth WA
| | - Bruce CV Campbell
- Melbourne Brain Centre at Royal Melbourne Hospital Melbourne VIC
- University of Melbourne Melbourne VIC
| |
Collapse
|