Systematic Reviews and American College of Physicians Clinical Practice Guidelines

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Systematic Reviews and American College of Physicians Clinical Practice Guidelines

Amir Qaseem, MD, PhD, MHA, FACP
Director, Clinical Policy
American College of Physicians (ACP)

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Who We Are

• Largest medical specialty organization in the U.S.
• 132,000 members:
  • Internists.
  • Internal Medicine sub-specialists.
  • Residents/fellows training in Internal Medicine or its subspecialties.
  • Medical students.
• Headquarters in Philadelphia and an office in Washington, D.C.

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History of ACP Clinical Guidelines

• Program was established in 1981.
• Developed by Clinical Guidelines Committee.
• Screening, Dx, and Rx to help clinicians in making health care decisions.

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ACP's Guidelines Coverage

• Top 3 most valued product.
• Most common reason to visit ACP's Web site.
• 25 of the top 100 most read articles ever in the Annals of Internal Medicine.
• Top most read article in Internal Medicine on Medscape.
• All ACP Guidelines are regularly covered by print, TV, radio, and online stories.

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ACP Guidelines Coverage

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ACP and Systematic Reviews

• Clinical Policies:
  • Clinical Guidelines.
  • Guidance Statements.
  • High-Value Cost Conscious Care Advice.
• Performance measurement.
• Gaps.

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ACP Membership Feedback

• High quality guidelines.
• Based on scientific evidence.
• Helpful source of advice.
• Not rigid or difficult to apply.
• Not difficult to understand or use.

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The Need for a Good Systematic Review?

• Medical literature is expanding at an extremely fast rate.
• RCTs in MEDLINE (5,000 per yr from 1978-1985 to 25,000 per year in 1994-2001).
• 15 million citations on MEDLINE and 10,000-20,000 added per week.
• Evidence → Clinical Guidelines.

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ACP and Systematic Reviews

• Systematic Reviews:
  • ACP sponsored.
  • Collaboration with other societies.
  • AHRQ's Evidence-based Practice Centers:
    • Working together since1999.
    • EPC & EHC.
    • 66% of our guidelines based on EPC evidence reports.
• Available Systematic Reviews.

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Issues with Systematic Reviews

• Major variation in quality.
• COI.
• Multidisciplinary.
• Scope not clearly defined or followed.
• Key Questions not well-formulated.

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Issues with Systematic Reviews

• Poor methods or poorly documented methods.
• Lack of a standard reporting system.
• Lack of a grading system.
• Do not address all outcomes.

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Relationship between Guideline Developers & Systematic Review Developers

• What is the purpose of a Systematic Review (SR)?
• Balance inappropriate influence with critical input.
• Develop a line of communication with guideline group.
• Include a rep in TEP [Technical Expert Panel].
• Responsiveness to the questions of guideline group.

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Relationship between Guideline Developers & Systematic Review Developers

• Registry of systematic reviews:
  • GINDER (Guidelines International Network).
  • PROSPERO (National Institute for Health Research).

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Clinical Practice Guidelines

"Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options."

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Summary

• SR are the backbone of a guideline.
• A good and well-developed SR is costly, resource intensive, and time consuming.
• Some of us underestimate the resources and expertise needed and the result is variability in quality of SRs.
• A good SR is a collaborative effort and guideline developers should be able to provide their expertise among the contributors.

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Questions