Introduction to BMJ Rapid RecommendationsBMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i5191 (Published 28 September 2016) Cite this as: BMJ 2016;354:i5191
- Reed A Siemieniuk, methodologist1 2,
- Thomas Agoritsas, assistant professor1 3,
- Helen Macdonald, acting head of education section4,
- Gordon H Guyatt, distinguished professor1 5,
- Linn Brandt, methodologist6,
- Per O Vandvik, associate professor6 7
- 1Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- 2Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- 3Division of General Internal Medicine, and Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
- 4The BMJ, London WC1H 9JP, UK
- 5Department of Medicine, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- 6Institute of Health and Society, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway
- 7Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
- Correspondence to: P O Vandvik
Find a committee. Add evidence, opinion, politics, and money in varying measures, and a murky set of recommendations can emerge. To those on the outside, guideline production may seem like a black box, and, unless it is carefully and transparently managed, loss of trust, patient suffering, waste, and over and under treatment can occur. Clinicians and patients who implement recommendations may feel disenfranchised by the pronouncements of researchers, publishers, and guideline writers. In an era when clinicians and patients aim to discuss and select management options that seem right for them, it is clear that we can do better.1 An initiative from the MAGIC non-profit research and innovation programme—representing patients, front-line clinicians, researchers, and guideline experts (www.magicproject.org)—has resulted in a collaboration with The BMJ. We aim to promptly translate emerging research to user friendly and trustworthy recommendations, evidence summaries, and decision aids.
During the hiatus between new evidence and guideline publication, many patients receive outdated care; it can take years for evidence to filter into guidelines from specialty or government organisations, which face bureaucratic hurdles to updating. Some profit making organisations have capitalised on this gap in the market by providing rapid updates for doctors based on new evidence. But what is gained in speed may be sacrificed in quality if their recommendations are not underpinned by systematic reviews or have a quality process for developing recommendations.
We can all do better, especially when everyone is included and we use the many tools at our disposal. We have the technology and methodology to rapidly incorporate new data into the body of evidence in systematic reviews. We have systems and methodologies to rate and appraise our certainty in the evidence, such as GRADE.2 The guideline community has described what a trustworthy guideline is.3 We understand that, to discuss the options, users need the best absolute estimates of benefit and harm, knowledge of the quality of research, an honest offer on the limits of our knowledge, and detail on the resources needed.2 4 We hope that this project will address a partly characterised spectrum of problems with guidelines and their recommendations, including those mentioned in table 1⇓.
The Rapid Recommendations team from MAGIC, including The BMJ, will identify and confirm which studies that might change practice and are of interest to their readers. Researchers will then perform systematic reviews on the benefit and harm of the intervention, baseline risk of important outcomes, and the values and preferences of patients. In parallel a panel including researchers, patients, and doctors will choose the most important outcomes. They will consider the systematic reviews and evaluate the evidence using a GRADE approach, and produce recommendations for practice. The research and recommendations will be submitted to The BMJ for peer review and publication (fig 1⇓).
Those who have and will contribute to the project bring diverse experience and anticipate that in working together the sum of our efforts will equal more than our parts. We hope to translate current best evidence into formats that can enhance clinical judgement and discussions with patients.
We hope to demonstrate that state of the art systematic reviews and trustworthy guidelines can be created and published rapidly; that guideline panels need not have worrisome conflicts of interest; that patient, generalist, and allied health professional panellists improve guideline quality; and that recommendations used in guidelines can facilitate shared conversations and decision-making at an individual level. Each guideline panel will consider the expected spectrum in patient values and preferences, the quality of the evidence, the magnitude of benefits and harms, and other key practical issues (such as resources).5 6
Published here is the first batch of BMJ Rapid Recommendations, together with linked systematic reviews (box 1).7 8 9 10 Readers will find the recommendations, evidence summaries, and consultation decision aids in multilayered digital formats available on MagicApp for use at the point of care. Please read them, try them, and feed back if you find them helpful or if there is anything else that might be helpful. This project has just started and is designed to change as we go.
Box 1: Linked articles in this BMJ Rapid Recommendations cluster
Siemieniuk RA, Agoritsas T, Manja V, et al. Transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis at low and intermediate risk: systematic review and meta-analysis. BMJ 2016;354:i5130. doi:10.1136/bmj.i5130
Foroutan F, Guyatt GH, O’Brien K, et al. Prognosis after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: systematic review of observational studies. BMJ 2016;354:i5065. doi:10.1136/bmj.i5065
Lytvyn L, Guyatt GH, Manja V, et al. Patient values and preferences on transcatheter or surgical aortic valve replacement therapy for aortic stenosis: a systematic review. BMJ Open 2016;6:e014327. doi:10.1136/bmjopen-2016-014327
Vandvik PO, Otto CM, Siemieniuk RA, et al. Transcatheter or surgical aortic valve replacement for patients with severe, symptomatic, aortic stenosis at low to intermediate surgical risk: a clinical practice guideline. BMJ 2016;354:i5085. doi:10.1136/bmj.i5085
Summary of the results from the Rapid Recommendation process
Magic App (www.magicapp.org/public/guideline/aEeKpL)
Expanded version of the results with multilayered recommendations, evidence summaries, and decision aids for use on all devices
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare that POV, TA, LB, and GHG are founders and board members of the non-profit organisation MAGIC.