research (CER), both for setting priorities among individual CER studies and for appropriately focusing studies during their design. The committee recognizes that fully implementing all of the SR standards proposed in this report will be costly, resource intensive, and time consuming. Further, as previous chapters make clear, the evidence base supporting many elements of SRs is incomplete and, for some steps, nonexistent. Finally, the committee is fully aware that there is little direct evidence linking high-quality SRs to clinical guidance that then leads to improved health. Nonetheless, designing and conducting new comparative effectiveness studies without first being fully informed about the state of the evidence from an SR risks even higher costs and waste by conducting studies that are poorly designed or redundant. Research organizations such as the Agency for Healthcare Research and Quality (AHRQ) Effective Health Care Program, Centre for Reviews and Dissemination (CRD) (University of York), and the Cochrane Collaboration have published standards, but none of these are generally accepted and consistently applied during planning, conducting, reporting, and peer reviewing of SRs. Furthermore, the environment supporting development of a robust SR enterprise in the United States lacks both adequate funding and coordination; many organizations conduct SRs, but do not typically work together. Thus the committee concludes that improving the quality of SRs will require advancing not only the science supporting the steps in the SR process and linking SRs to improved health, but also providing a more supportive environment for the conduct of SRs. In this chapter the committee outlines some of the principal issues that must be addressed in both of these domains.

Throughout the chapter and in its final recommendations, the committee refers to the newly established Patient-Centered Outcomes Research Institute (PCORI) and, in particular, its Methodology Committee, as a potentially appropriate organization to provide comprehensive oversight and coordination of the development of the science and to promote the environment for SRs in support of CER in the United States. The committee views PCORI as an unusually timely development—albeit untested—that should help advance the field of SRs as an essential component of its overall mission, building on the strengths of well-established programs in the United States (e.g., AHRQ, National Institutes of Health [NIH]) and internationally (e.g., Cochrane Collaboration, National Institute for Health and Clinical Excellence in the United Kingdom), that either produce or rely on SRs for policy purposes. Nonetheless, while the committee views PCORI as relevant and promising, PCORI is by no means the only way to achieve the stated aims. Other agencies, working

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