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Knowing what Works in Health Care: A Roadmap for the Nation
lished in the 1930s (American Academy of Pediatrics, 2007). The groups that were among the first to use systematic reviews to support clinical recommendations were the Canadian Task Force on the Periodic Health Examination and the U.S. Preventive Services Task Force (USPSTF) (Fielding and Briss, 2006). The Canadian task force was established in 1976 to make recommendations about the inclusion of preventive services in the periodic health examination; the USPSTF was established in 1984 and also provided prevention-related recommendations for health professionals (Woolf and Atkins, 2001). The American College of Physicians began to publish explicit recommendations based on systematic reviews in 1981 (Eddy, 2005).
In 1989, Congress established the Agency for Health Care Policy and Research (AHCPR) and tasked it with developing clinical practice guidelines, among its other responsibilities. The Institute of Medicine (IOM) noted that this effort was part of a cultural shift: a move away from an unexamined reliance on professional judgment and toward more structured support and accountability for these judgments (1990). Before the move toward evidence-based practice, medical textbooks and articles were filled with thousands of statements and care recommendations that were based solely on the belief of the author or at best a consensus of experts (Eddy, 2005). Evidence-based guidelines initiatives aim to base recommendations on empirical evidence.
Relationship to Systematic Reviews
Clinical guidelines go beyond systematic reviews by recommending what should and should not be done in specific clinical circumstances. Although systematic reviews produce findings about clinical effectiveness, transforming that evidence into specific care recommendations is often challenging. Given the gaps in information that frequently exist and the variable quality of the information that is available, a key component of guideline development is the establishment of a link between the strength of the clinical recommendation and the quality of the underlying evidence.
Guyatt and colleagues (2006a) argue that one of the first criteria of an effective guideline development process is having two separate grading systems: one for the quality of the evidence and another for the recommendations themselves. The quality of evidence grade reflects the level of confidence that, if the recommendation is followed, the anticipated outcomes will occur. The strength of the recommendation takes into account the balance of the benefits and the harms that are associated with the intervention and the guideline authors’ views about the importance of adhering to the recommendation.