Rapid and Living Guidance for COVID-19
Authors: Julian H. Elliott, Britta Tendal Jeppesen
Journal: Annals of Internal Medicine (2021)

Editorials25 May 2021Rapid and Living Guidance for COVID-19FREEJulian H. Elliott, MBBS, PhD and Britta Tendal Jeppesen, MSc, PhDJulian H. Elliott, MBBS, PhDCochrane Australia, School of Public Health and Preventive Medicine, Monash University Melbourne, AustraliaSearch for more papers by this author and Britta Tendal Jeppesen, MSc, PhDDanish Health Authority Copenhagen, DenmarkSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-2245 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The COVID-19 pandemic is stress testing our evidence systems (1). The tremendous output of COVID-19 research and the need for clinicians and other decision makers to have trusted, up-to-date sources of evidence and guidance during a time of great uncertainty have highlighted the limitations of conventional approaches. The pandemic has been a reminder that too often our decisions are informed either by guidance developed using rigorous scientific methods or by sources that are up to date with the latest research—but not both. Seldom do we find sources that are an accurate reflection of research knowledge by being both methodologically rigorous and current.Although the COVID-19 pandemic has highlighted many of the flaws in our evidence systems, it has also shown the value of novel approaches, including in examples where the rigor or currency tradeoff has been broken. Qaseem and colleagues at the American College of Physicians (ACP) responded to the urgent need for guidance during the pandemic by producing living, rapid practice points. They report their methods in this issue of Annals (2).The ACP team followed conventional processes for the development of recommendations, with 2 important modifications. First, their initial development was accelerated using methods for rapid reviews and recommendations. Second, these practice points are being maintained in a living, frequently updated state to incorporate new research as it becomes available.Methodological options for rapid review (3) and guideline (4) development are well established. One option is to increase the resources allocated to the process. An alternative is to adapt the development process, such as by narrowing the scope or modifying aspects of the methodology used. The quality of rapidly developed guidelines varies substantially (5), highlighting that not all shortcuts are created equal and it matters how you modify the methodology. Not doing a systematic review may save time, but the resulting guidance will not be as trustworthy because of higher risk of bias in the selection of the evidence underpinning the recommendations.The approach the ACP team took was to invest more resources and narrow the scope, avoiding the need to sacrifice important methodological steps, such as systematic review of the evidence, management of conflicts of interest, and use of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method, thereby ensuring both rapid and trustworthy guidance.Although the field of living evidence has developed more recently, it builds on the work of Iain Chalmers, who launched the Oxford Database of Perinatal Trials, the precursor to the Cochrane Collaboration, as a “library of trial overviews which will be updated when new data become available” (6). During the subsequent 35 years, achieving that vision has been hampered by ongoing growth in research output and increasing methodological expectations.However, in recent years, a renewed interest in achieving both rigor and currency (7), along with advances in supporting technologies and processes, has created the foundations for frequent or living approaches to updating (8).Before the COVID-19 pandemic, the first living systematic reviews were developed (Cochrane and non-Cochrane); the first version of relevant methods was documented; and the first national evidence-based guidelines (the Australian Clinical Guidelines for Stroke Management) were transitioned into “living mode,” reducing the time between updates from 7 years to 2 months (9).With the advent of the COVID-19 pandemic, it became clear that clinical practice guidelines needed to quickly and reliably address questions and keep pace with the explosion of COVID-19 research. In the first few months of the global response, there was a commensurate explosion of rapid evidence syntheses and rapid development of normative statements, including guidelines, position statements, protocols, and practice points. Unfortunately, much of this work was duplicative and of low quality—one of the key lessons the global evidence community must recognize when reflecting on our response to the pandemic. Furthermore, there was often no commitment to the updating of these rapid evidence products, leading to a rapid decay in currency and accuracy.In parallel, several groups used the foundational work on living approaches to launch COVID-19 living systematic reviews and living guidelines, including the publication of several living systematic reviews and ACP practice points in Annals. In Australia, we established the National COVID-19 Clinical Evidence Taskforce and have been updating national, living, GRADE-based guidelines weekly since March 2020. In France, the COVID-NMA group maintains several living network meta-analyses, and more recently, both the World Health Organization and the United Kingdom National Institute for Health and Care Excellence have transitioned their COVID-19 guidelines into living mode.Although rapid methods have been widely used during the pandemic, and living approaches have come of age, these approaches are still young, and several challenges and research questions remain. Qaseem and colleagues identified the important role strong project management plays in both rapid and living approaches, along with several methodological questions related to frequent updating and the need to ensure adequate resourcing. In our own work maintaining frequently updated living recommendations for over a year, we have seen substantial efficiencies achieved during the “maintenance” phase (analogous to walking along a plateau after the initial climb up a mountain). Overall, these challenges highlight the importance of carefully choosing topics for living guidance (sometimes embedded within a conventional guideline) and keeping in mind that “living guidelines are not a life sentence” and can be transitioned back to intermittent updating when appropriate.We agree with Qaseem and colleagues' conclusion that rapid and living development of trustworthy guidance has application beyond COVID-19. Rapid approaches are appropriate when decision makers require guidance quickly. A living approach should be considered for high-priority questions where new evidence is likely to emerge and to change recommendations (10). Used appropriately, these methods are important additions to the tools we have available to translate research and improve health outcomes. Put simply, what we know changes rapidly, and guidelines can now reflect this.References1. Pearson H. How COVID broke the evidence pipeline. Nature. 2021;593:182-185. [PMID: 33981057] doi:10.1038/d41586-021-01246-x CrossrefMedlineGoogle Scholar2. Qaseem A, Yost J, Forciea MA, et al. The development of living, rapid practice points: summary of methods from the Scientific Medical Policy Committee of the American College of Physicians. Ann Intern Med. 2021;174:1126-1132. doi:10.7326/M20-7641 Google Scholar3. Garritty C, Gartlehner G, Nussbaumer-Streit B, et al. Cochrane Rapid Reviews Methods Group offers evidence-informed guidance to conduct rapid reviews. J Clin Epidemiol. 2021;130:13-22. [PMID: 33068715] doi:10.1016/j.jclinepi.2020.10.007 CrossrefMedlineGoogle Scholar4. Morgan RL, Florez I, Falavigna M, et al. Development of rapid guidelines: 3. GIN-McMaster guideline development checklist extension for rapid recommendations. Health Res Policy Syst. 2018;16:63. [PMID: 30005679] doi:10.1186/s12961-018-0330-0 CrossrefMedlineGoogle Scholar5. Kowalski SC, Morgan RL, Falavigna M, et al. Development of rapid guidelines: 1. Systematic survey of current practices and methods. Health Res Policy Syst. 2018;16:61. [PMID: 30005712] doi:10.1186/s12961-018-0327-8 CrossrefMedlineGoogle Scholar6. Chalmers I. Electronic publications for updating controlled trial reviews. Lancet. 1986;328:287. Google Scholar7. Elliott JH, Turner T, Clavisi O, et al. Living systematic reviews: an emerging opportunity to narrow the evidence-practice gap. PLoS Med. 2014;11:e1001603. [PMID: 24558353] doi:10.1371/journal.pmed.1001603 CrossrefMedlineGoogle Scholar8. Elliott JH, Synnot A, Turner T, et al; Living Systematic Review Network. Living systematic review: 1. Introduction—the why, what, when, and how. J Clin Epidemiol. 2017;91:23-30. [PMID: 28912002] doi:10.1016/j.jclinepi.2017.08.010 CrossrefMedlineGoogle Scholar9. Stroke Foundation. Clinical guidelines for stroke management. Accessed at https://informme.org.au/en/Guidelines/Clinical-Guidelines-for-Stroke-Management on 19 May 2021. Google Scholar10. Akl EA, Meerpohl JJ, Elliott J, et al; Living Systematic Review Network. Living systematic reviews: 4. Living guideline recommendations. J Clin Epidemiol. 2017;91:47-53. [PMID: 28911999] doi:10.1016/j.jclinepi.2017.08.009 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Dr.Rajiv KumarFaculty, Department of Pharmacology, Government Medical College and Hospital Chandigarh-160030, India.25 August 2021 RE: Rapid and Living Guidance for COVID-19 I read with great interest the article by Julian H. Elliott, on “Rapid and Living Guidance for COVID-19”, In his editorial the author has pointed out the challenges and limitations of evidence-based medicine related to the COVID-19 pandemic. COVID-19 pandemic has broken the evidence pipeline and become the greatest challenges to the clinicians and researchers globally with regard to evidence-based medicine. Evidence-based medicine (EBM) has been defined by Sackett DL et al., as "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients" and EBM involves- published evidence, clinical judgement and the patients' values & preferences [1]. The pace of the COVID-19 pandemic poses a threat to traditional EBM approaches and knowledge translation and practice changes. Clinicians do not have the time to follow EBM approaches and there is need of expert advice or clinical judgment [2]. The pandemic requires globally to reach a new level of evidence-based medicine, characterized by skepticism, thoughtfulness, accountability and clinically agile in practice. It is time to strengthen the understanding of EBM and continue to apply its principles, albeit with more alertness and agility than usual. Regards, Dr.Rajiv Kumar, Faculty, Department of Pharmacology, Government Medical College and Hospital Chandigarh-160030, India. [email protected] Reference Sackett DL , Rosenberg WM , Gray JA , et al. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71–2.doi:10.1136/bmj.312.7023.71 2. Carley S, Horner D, Body R, et al., Evidence-based medicine and COVID-19: what to believe and when to change Emergency Medicine Journal 2020;37:572-575. Disclosures: No Conflict of Interest Author, Article, and Disclosure InformationAuthors: Julian H. Elliott, MBBS, PhD; Britta Tendal Jeppesen, MSc, PhDAffiliations: Cochrane Australia, School of Public Health and Preventive Medicine, Monash University Melbourne, AustraliaDanish Health Authority Copenhagen, DenmarkDisclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-2245.Corresponding Author: Julian H. Elliott, MBBS, PhD, Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, 553 St. Kilda Road, Melbourne, Victoria 3004, Australia; e-mail, julian.elliott@monash.edu.Current Author Addresses: Dr. Elliott: Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, 553 St. Kilda Road, Melbourne, Victoria 3004, Australia.This article was published at Annals.org on 25 May 2021. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoThe Development of Living, Rapid Practice Points: Summary of Methods From the Scientific Medical Policy Committee of the American College of Physicians Amir Qaseem , Jennifer Yost , Mary Ann Forciea , Janet A. Jokela , Matthew C. Miller , Adam Obley ,and Linda L. Humphrey , for the Scientific Medical Policy Committee of the American College of Physicians Metrics Cited byLiving Practice Guidelines Require Robust and Continuous Iteration and UptakeTianjing Li, MD, MHS, PhD and Maria Michaels, MBA, PMPComparative efficacy trials in inflammatory bowel disease: current and future implications for practiceMost published systematic reviews of remdesivir for COVID-19 were redundant and lacked currency August 2021Volume 174, Issue 8 Page: 1171-1172 Keywords COVID-19 Prevention, policy, and public health Research design Systematic reviews Treatment guidelines ePublished: 25 May 2021 Issue Published: August 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...