In recent posts, we’ve discussed how living systematic reviews (LSRs) can help improve the currency of our understanding of the evidence, as well as the efficiency with which the evidence is identified and synthesized through novel crowdsourcing and machine learning techniques. In the fourth and final installment of the 2017 series on LSRs, Akl and colleagues apply the LSR approach to the concept of a living clinical practice guideline.
As the figure below from the paper demonstrates, while simply updating an entire guideline more frequently (Panel B) reduces the number of out-of-date recommendations (symbolized by red stars) at any given time, it comes with a serious trade-off: namely, the high amount of effort and time required to continuously update the entire guideline. Turning certain recommendations into "living" models helps solve this dilemma between currency and efficiency.
Rather than a full update of an entire guideline and all of the recommendations therein, a living guideline uses each recommendation as a separate unit of update. Recommendations that are eligible to make the transition from “traditionally updated” to “living” include those that are a current priority for healthcare decision-making, for which the emergence of new evidence may change clinical practice, and for which new evidence is being generated at a quick rate.
The Living Guideline Starter Pack
Each step of a recommendation’s formation must make the transition to “living,” including:
- A living systematic review
- Living summary tables, such as Evidence Profiles and Evidence-to-Decision tables
- Online collaborative table-generating software such as GRADEpro can be used to keep these up-to-date with the emergence of newly relevant evidence
- A living guideline panel who can remain “on-call” to contribute to updates of recommendations with relatively short notice when warranted
- A living pool of peer-reviewers who can review and provide feedback on updates with a quick turnaround time
- A living publication platform, such as an online version that links back to archived versions, as well as “pushes” new versions to practice tools at the point of care.
Further information and support for the development of LSRs, including updated official guidance, is provided on the Cochrane website.
Akl, E.A., Meerpohl, J. J., Elliott, J., Kahale, L. A., Schünemann, H.J., and the Living Sysematic Review Network. Living systematic reviews: 4. Living guideline recommendations. J Clin Epidemiol, 2017; 91: 47-53.
Manuscript available from the publisher's website here.