Paper summarized: Jaramillo A, Welch V, Ueffing E, Gruen RL, Bragge P, Lyddiatt A, Tugwell P. Prevention and self-management interventions are top priorities for osteoarthritis systematic reviews; JCE 2013;66:503-510.e4
Summary of the Paper by Alejandra Jaramillo
The Cochrane Collaboration has produced more than 4,000 systematic reviews of the evidence but estimates that at least 10,000 are required to summarize the healthcare information produced to date. Given that resources are limited, selecting and prioritizing the research topics to work on next has become a difficult but very important task. Cochrane Review Groups are faced with two key questions when prioritizing topics.
First, they need to decide who should be involved in selecting the research topics. Historically, Cochrane Review Groups involved clinicians, researchers, and other influential players, such as funding organizations, in the decision-making process. Patients were not a major player in the decision-making process. Furthermore, their input was not systematically included by all Cochrane Review Groups.
Second, the Cochrane Review Groups need to decide the scope of the topics to cover in the priority exercise. Recent evidence suggests that health is impacted by more than just clinical factors; social determinants, such as the income of a person, may impact his/her level of health. By acting on social determinants of health (SDH), unfair avoidable health differences can be addressed and health equity promoted.
The authors propose a priority setting method for Cochrane Review Groups to identify 10 research questions to work on next. The methods can be conducted once a year for a particular condition and place an emphasis on the patient perspective, the SDH and health equity. The methods were piloted with the Cochrane Musculoskeletal Group to identify systematic review topics for osteoarthritis.
The methods included 5 main steps:
1. First, the research team searched 5 electronic databases (including Cochrane’s) to identify existing systematic reviews on osteoarthritis and classified the topics by stage of the condition (e.g. prevention, early or advanced stages) and by type of intervention (e.g. pharmacological).
2. Second, with the help of a facilitator, the research team conducted two workshops (one with 8 patients only and another with 5 clinicians, 4 researchers and 12 patients) to identify top priority research topics.
The facilitator started with a brainstorming session to identify (in the view of the workshop participants) the top research topics that are needed to prevent, treat and manage osteoarthritis. The initial discussion included a dialogue on SDH and health equity and their impact on the progression of osteoarthritis.
Throughout the brainstorming session, workshop participants wrote down on post-it notes all the research topics that they considered important and put them up on the wall where everybody could read them. Then, with assistance of the facilitator, participants discussed the importance of each research topic and (when needed) added information to the post-it notes to clarify the scope of each topic.
Finally, each participant was given 5 red dots to place them on the 5 topics that he/she considered were the most important ones. The research team counted and documented the number of red dots assigned to each topic to identify the top broad research topics.
3. Third, the research team developed detailed research questions from the top broad research topics that were identified in the workshop.
4. Fourth, the research team identified the top 10 research questions using the criteria of those interventions with “9 or more” red dots.
5. Fifth, another group of patients completed an online survey to prioritize the top 10 research questions. The survey asked patients to rank the 10 questions from top to lowest priority on two dimensions: importance and health equity.
1. Identifying existing evidence: The research team identified 174 preexisting systematic reviews on osteoarthritis and classified them using the Map of Evidence for Osteoarthritis.
2. Identifying broad research topics: The two workshops produced 371 topics related to osteoarthritis. Twelve research topics had the highest number of red dots (between 4 and 10 red dots) and where therefore identified as top priority.
3. Converting broad topics into research questions: 43 research questions were produced from the 12 broad research topics, and 50% of the research questions were relevant to social determinants of health.
4. Identifying the top research questions: From the 43 research questions, 10 were identified as the top priorities: 4 questions related to self-management approaches, 2 related to the level and quality of communication between the patient and clinicians, 2 concerning the reduction of decisional conflict about timing for joint replacement, 1 about reducing the risk in the well community and 1 regarding the reduction of inequities in waiting times for osteoarthritis surgery.
5. Ranking the top 10 research questions: Research questions related to prevention and self-management interventions were ranked as the top priorities for osteoarthritis systematic reviews.
1. Supporting a holistic approach in managing and treating patients with osteoarthritis, the resulting research questions included clinical and non-clinical interventions, and SDH that impact the progression of osteoarthritis.
2. The methods do not limit the scope of topics to a particular Cochrane Review Group. They are aligned with patient needs and with the needs of users of information outside of the Cochrane system.
3. The method seems feasible if conducted annually.
1. The methodology lacked a process to verify whether patients that participated in the online survey understood the concept of health equity. If the patients did not understand the concept, the results could potentially be inaccurate.
2. Lack of involvement of patients from disadvantaged groups of the population and from low-and middle-income countries. This was mainly due to lack of contacts in those groups and lack of resources from the patients to travel and participate in the workshops. Virtual workshops may be a way to engage patients with less resources or unable to travel.
3. There were marked gaps in the topics. For example, no high-priority topics were identified for access to care until the patients had advanced disease. We do not have a good understanding of what these gaps represent.
4. There is a risk that there will be little evidence to address the top 10 research questions, mainly for two reasons: 1) It is unlikely that randomized controlled trials will be able to address the questions that relate to SDH. Only recently Cochrane created a methods group focusing on developing methodologies that will incorporate the best study design (beyond RCTs) to address the question in hand. Furthermore, given that the topic on SDH is relatively new, there might be few underlying studies that combine clinical and social aspects. Funding in those areas needs to be encouraged.
5. Because SDH crosses different review groups, the list of topics requires work from more than one group. However, those other groups felt that the research questions had to be modified to make them consistent with their scope of work. Thus, a risk exists that the top research questions may not be addressed in their entirety.
The priority setting method could be used by all Cochrane Review Groups to set priorities for systematic reviews on a continuous basis. The proposed method effectively incorporates SDH considerations. Further testing is needed to validate that health equity is effectively incorporated and increase the involvement of disadvantaged people.