Let 1000 flowers bloom: Support for the current “system”
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The current system for evidence assessment in the United States is uncoordinated, with no single agency setting priorities and different organizations having varying objectives. Several initiatives have evolved to fill needs, such as the Drug Effectiveness Review Project which conducts reviews for state Medicaid programs. Prioritizing topics for systematic reviews is important due to scarce resources but major increases in funding and capacity may diminish the importance of prioritization in the future. The measure of success for any prioritization scheme is its usefulness to its intended audience.
Let 1000 flowers bloom: Support for the current “system”
- 1. Let 1000 Flowers Bloom: Support for the current “system” Douglas C. McCrory, MD, MHS Duke University Center for Clinical Health Policy Research Duke Evidence-based Practice Center, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center Durham, NC
- 2. What is the current “system”? Uncoordinated No one agency or organization sets priorities Diverse Each organization has different objectives and target audiences for evidence assessment Adaptive Initiatives have evolved to fill “needs” e.g. DERP
- 3. Commissioned SRs in US, 2006 14 20 86 Private technology assessors -BCBS TEC -ECRI -Hayes 9 3 3 Other Federal Pgms -CMS -DERP -NIH Consensus Dev’p Pgm 4 22 6 AHRQ -Effective Health Care -EPC -USPSTF # full reviews Organization
- 4. Commissioned SRs in US, 2006 Cochrane 867 14 20 86 Private technology assessors -BCBS TEC -ECRI -Hayes 9 3 3 Other Federal Pgms -CMS -DERP -NIH Consensus Dev’p Pgm 4 22 6 AHRQ -Effective Health Care -EPC -USPSTF # full reviews Organization
- 5. Nominators of EPC topics 2005-06 Health Care Professional organizations or consortia Federal agencies Health care industry groups Single Health care institution State/local government agencies
- 6. Systems for identifying topics/questions Active solicitation of nominations from constituents Stakeholders public Subscribers or members Internal processes for gathering suggestions from staff or outside advisors
- 7. An anecdote: Probiotic use in ICU Duke hospital formulary decision Used existing published SR Critical appraisal found fatal flaw post hoc subgroup analysis presented as primary in most influential positive study Reanalysis of existing data allowed a timely decision to be made
- 8. DERP - Filling a need Consortium of state Medicaid directors and a couple of Canadian provinces Reviews geared toward formulary decision-making Focusing on comparative drug trials
- 9. Grassroots Cochrane collaboration 51 discipline-specific review groups set their own agendas Relies on volunteer researchers to conduct reviews Little central influence from steering group on prioritization Little central funding
- 10. Functions of The Program increased funding for CERs developing increased capacity for SR improvements in methods for SR, CCR developing standards for quality developing process for prioritizing topics
- 11. A few predictions Scarcity of resources and manpower to perform SRs has made prioritization important Major increases in funding and capacity will diminish the importance of prioritization New problems will become paramount such as lack of good quality unbiased evidence particularly for CERs
- 12. Other approaches to improve efficiency of SR production Clearinghouse for systematic reviews? Improve coordination among diverse organization and participants Coordinating function? Leverage scarce funds through cooperation/consortia Standard setting and quality assessment
- 13. What’s the measure of success of a prioritization scheme? Usefulness to intended audience Anecdotes and case studies Return on investment Opportunity costs
- 15. Criteria for Priority Setting for SRs burden of disease (prevalence, severity) cost unexplained variation in use public controversy (ethical, legal issues) potential impact on outcomes, costs new evidence adequacy of existing evidence
- 16. Consumers have highly specific needs Topic selections and nominations are often too vague research questions inadequately specified for review Decision context also influences approach and ultimately influences its usefulness to consumers
- 17. Is duplication in SRs wasted effort? Updates Reproducibility Different questions Different decision contexts