1. Systematic Reviews and American College of Physicians Clinical Practice Guidelines Amir Qaseem, MD, PhD, MHA, FACP Director, Clinical Policy American College of Physicians

2. Who We Are Largest medical specialty organization in the US 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.

3. 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

4. ACP’s Guidelines Coverage Top 3 most valued product Most common reason to visit ACP’s website 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

5. ACP Guidelines Coverage ACP GuidelinePrint/ Internet TV Coverage DownloadsTotal Audience ED (11/2009)121N/A18,50052 Million Rx of Depression (11/2008) 1411776,00027 Million Rx of Osteoporosis (9/2008) 65N/A95,00010 Million Screening for Osteoporosis (5/2008) 16715347,00032 Million Rx of Dementia (3/2008) 92N/A86,50017 Million Palliative Care (1/2008) 140N/A102,5007 Million COPD (11/2007)166102113,00048 Million

6. ACP and Systematic Reviews Clinical Policies  Clinical Guidelines  Guidance Statements  High-Value Cost Conscious Care Advice Performance measurement Gaps

7. 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

8. 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

9. 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

10. Issues with Systematic Reviews Major variation in quality COI Multidisciplinary Scope not clearly defined or followed Key Questions not well-formulated

11. 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

12. Relationship between Guideline Developers & Systematic Review Developers What is the purpose of a SR? Balance inappropriate influence with critical input Develop a line of communication with guideline group Include a rep in TEP Responsiveness to the questions of guideline group

13. Registry of systematic reviews  GINDER (Guidelines International Network)  PROSPERO (National Institute for Health Research) Relationship between Guideline Developers & Systematic Review Developers

14. 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”

15. 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

16. Questions