When we seek care for sickness or injury, we count on doctors and health care professionals to know what treatment will work best for us. The field of evidence-based practice research is devoted to reviewing and analyzing the body of scientific evidence to inform the decisions of health care practitioners.
Since 1997 we have served as leader of what is known as the RTI International-University of North Carolina Evidence-based Practice Center (RTI-UNC EPC), conducting what are known as evidence syntheses—systematic reviews that are distillations of evidence in scientific literature—that improve clinical practice, health policy, and research.
One of 14 EPCs sponsored by the Agency for Healthcare Research and Quality (AHRQ), the RTI-UNC EPC is led by RTI In collaboration with the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. The EPC conducts systematic reviews on drugs, devices, and interventions on a variety of health topics. Patients, health care providers, insurers, professional societies, advocates, and policymakers use our reviews to support patient and provider decisions, insurance coverage decisions, clinical practice guidelines, and the direction of future health research.
Consistent, Transparent, and Rigorous Reviews in Support of the United States Preventive Services Task Force (USPSTF)
Our EPC reviews support the USPSTF by informing its recommendations for primary care clinicians regarding the effectiveness of preventive clinical services such as screening, behavioral counseling, and preventive interventions.
Under the Affordable Care Act, recommended services must be covered at no cost to patients, meaning our reviews carry significant policy weight. In recognition of the high stakes of applying our review results, we institute and maintain quality processes to ensure consistency, transparency, and rigor across multiple concurrent reviews.
Specifically, we follow national and international standards endorsed by the Institute of Medicine, the Cochrane Collaboration, the USPSTF, and AHRQ in conducting systematic reviews. Among other quality measures, we
- Vet investigators for financial and nonfinancial conflicts of interest to ensure a well-balanced and unbiased review team.
- Develop a review protocol in consultation with methodologists and clinical and content experts and post it on the USPSTF website for review and public comment.
- Search multiple databases and grey literature sources and hand-search references from key citations.
- Develop and test forms for title and abstract review, full-text review, risk-of-bias evaluation, and data abstraction.
- Conduct strength of evidence (GRADE) assessments dually and independently with third-person adjudication for conflicts.
- Post draft reports for public comment, distribute them widely for peer review, and revise the report based on feedback.
To ensure that these evidence-based recommendations benefit patients by making their way into clinical practice, we disseminate and translate our findings through multiple venues—including conference presentations, peer-reviewed publications, materials for continuing medical education, and clinical practice guidelines.
Changing Clinical Practice and Policy
Since its founding, the RTI-UNC EPC has delivered recommendations that have resulted in significant changes in health care practice.
One well-known example is our systematic review on routine episiotomy in delivery, which received international exposure and led to revisions in the American College of Obstetrics and Gynecology guidelines. These changes in guidelines cascaded, driving changes in medical education and training for new obstetricians. Owing to these changes, episiotomy rates have declined in the past decade, as found in one study that saw rates drop from 17.3% in 2006 to 11.6% in 2012.
In other recent examples, our reviews on screening on childhood depression helped support the USPSTF’s recommendation to screen for depression in adolescents—an essential first step to addressing suicide risk. In the context of recent evidence pointing to steady increases over the past 15 years in the rates of suicide among adolescents and young adults, our work can potentially contribute solutions to this emerging national concern.
We also conducted a review of the use of antidepressants for major depressive disorders, providing a basis for practice guidelines by the American College of Physicians. And our review of gestational weight gain factored heavily in revisions to Institute of Medicine guidelines on weight gain during pregnancy.
Driving Future Health Research
Our efforts have changed and continue to change research in many ways.
Perhaps most significantly, our syntheses help identify gaps in the evidence that can then serve as the basis for future funding initiatives. For example, building on our evidence synthesis that showed a paucity of information on management of uterine fibroids, the Patient-Centered Outcomes Research Institute funded a multi-million dollar network to create robust evidence on treatment for uterine fibroids.
Additional evidence of the influence of EPC systematic reviews and synthesis of methodological approaches include incorporation of reviews into federal requests for applications and the frequency with which reviews are cited in the literature.
Advancing Methods for Conducting Systematic Reviews
In the course of generating this body of research, the EPC has been in the forefront of several methodological advances for systematic reviews, such as
- Assessing risk of bias
- Establishing and validating standards for assessing strength of evidence
- Reviewing complex interventions
- Conducting network meta-analyses
- Distinguishing efficacy from effectiveness
- Exploring the nature of heterogeneity
- Creating reporting standards for assessing nonfinancial conflicts of interests.
We continue to develop and disseminate new methods such as qualitative comparative analysis and new guidance for choosing methods and reporting systematic reviews of complex interventions. We are also actively involved in conducting methods work in collaboration with methodologists from international institutions such as the Cochrane Collaboration and GRADE.