Upgrading the tools to guide practice: IOM issues new standards for systematic reviews and clinical guidelines
Thousands of systematic reviews about maternal and newborn care have been published, and more and more are released every week. We clearly have guidance for many important questions related to safe effective practice, so why don’t we have a high-quality, high-value maternity care system? The trustworthy evidence must be translated in practice, a tall order. Also, we cannot improve practice, without first doing a good job of interpreting the research evidence.
Two much-needed recent companion reports from the Institute of Medicine will help us interpret the evidence. The first report sets a high bar for standards used to carry out systematic reviews. Some systematic review producers, such as the Cochrane Collaboration, have established and continually improve processes to minimize bias and error in systematic reviews. Most systematic reviews, however, are produced by individuals using their own voluntary nonstandardized processes. The new standards from the high-caliber committees convened by the Institute of Medicine have great potential for improving the quality of these essential resources. In addition to the classic systematic review phases of a detailed protocol, comprehensive search for relevant studies, critical appraisal of the relevant studies, and synthesis of better quality studies, standards in the new report that can upgrade the quality and integrity of many reviews include:
- review teams should exclude those with financial conflicts of interest
- review teams should exclude those with intellectual or professional conflicts of interest (e.g., gain revenue from practices covered in the review) that would diminish users’ confidence in the independence and integrity of the review
- review teams should gather meaningful input from consumers and other end users
- protocols, or detailed plans for reviews, should be publicly available and any deviations in carrying them out should be noted
- teams should post both protocols and full draft reviews, invite public comment, take feedback into consideration, and post information about disposition of the comments
- reviews should include a summary for the lay public
Who needs access to results of systematic reviews and can benefit from their upgraded quality? These reviews are essential resources for all stakeholders, including health care professionals, facilities, plans, policy makers, purchasers, researchers, and journalists, along with people who themselves face care decisions or those making decisions on their behalf. Drawing the right conclusions from systematic reviews also enables the health care quality community to develop high-quality tools to foster delivery of safe, effective care, including performance measures, consumer decision aids, professional decision support tools, and clinical practice guidelines.
The second Institute of Medicine report sets a similarly high bar for the standards used to develop clinical practice guidelines. Adopting the standards in that report would lead to great leaps in improving the quality of national guidelines for pregnancy and childbirth as well as in other health areas. Notable standards in the new report that are not implemented widely or at all in present processes for developing national maternity care guidelines include:
- guidelines should disclose the source of funding; the process of development (which should minimize bias and conflicts of interest); and the identity, experience and potential conflicts of interest of individual members of guideline development groups
- guideline development groups should be multi-disciplinary and should include input from patients and the public and support their participation
- guideline development group members should have no financial, intellectual, institutional or other conflicts of interest when possible, and the majority should always have no conflicts of interest
- guideline recommendations should be based upon systematic reviews that meet the standards identified in the companion report, which may require carrying out the needed reviews to develop the professional guidance
- guideline recommendations should include ratings of the quality of the supporting evidence and the strength of the recommendation
- draft guidelines should be externally reviewed by the full spectrum of stakeholders, including patient and public representatives, and should be posted for public comment
At a recent implementation workshop in Washington DC, I joined national and international leaders as they embraced the new standards for systematic reviews and guidelines and discussed their uptake. Despite the widespread call for improvement, all voluntary standards face political and economic challenges and general resistance to change. To effectively adopt measures that will improve these essential tools for care of mothers and babies, it is critical to foster growing awareness of the opportunities for improvement and for champions to lead the way.
The Transforming Maternity Care website brings together the growing riches for getting the abundant maternity care evidence into practice and improving care, health outcomes, and value. We’re working hard, and there are many opportunities for you to join this work, too, or expand your efforts. Why not work with or start a maternity care quality collaborative, emulate a successful quality improvement program, implement a toolkit, or take a quality and safety course with your team? High-quality, high-value maternity care is within reach!