OTHER PROGRAM CHALLENGES

Keeping Reviews Up-to-Date

Systematic reviews are not only difficult and time consuming, they also must be kept up-to-date to ensure patient safety. Having an organization that exercises oversight on the production of systematic reviews, for example, the Cochrane Collaboration or professional societies that produce clinical practice guidelines, provides an infrastructure and chain of responsibility for the updating of reviews. There has been little research on updating, and the research that does exist indicates that not all organizations have mechanisms for systematically updating their reviews.

In 2001, Shekelle and colleagues (2001) examined how quickly the AHRQ guidelines went out of date. At the time of that study, they classified only 3 of the 17 guidelines in circulation at that time as still valid. About half of the guidelines were out of date in 5.8 years from the time of their release, and at 3.6 years, at least 10 percent were out of date. A more recent report examining a sample of 100 high-quality systematic reviews of interventions found that within 5.5 years, half of the reviews had new evidence that would substantively change the conclusions about the effectiveness of interventions, and within 2 years almost 25 percent had such evidence (Shojania et al., 2007). The frequency of updating was associated with the clinical topic area and the initial heterogeneity of the results.

Thus, it appears that the failure to update systematic reviews and guidelines within a few years could easily result in patient care that is not evidence based and, worse, care that is not as effective as possible or potentially dangerous.

New and Emerging Technologies

Although this chapter has focused on comprehensive, systematic reviews, the committee recognizes that some decision makers have a legitimate need for objective advisories on new and emerging technologies in order to respond to coverage requests when few, if any, high-quality studies or systematic reviews exist. In addition, patients and providers want information on new health care services as soon as the services become known, often because manufacturers are pressing them to adopt a product or because patients have read direct-to-consumer advertising and want answers from their physicians and other health care providers.

Private technology assessment organizations, such as the ECRI Institute and Hayes, Inc., have responded to the market demand for early reviews of new technologies (ECRI, 2006b; Hayes, Inc., 2007). These firms and other private, proprietary organizations offer clients brief reviews based on



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