The use of Cochrane reviews to inform clinical recommendations in the Danish National Clinical Guideline development

Tags: Oral
Korfitsen CB1, Kirkegaard Mikkelsen M1, Händel MN1, Ussing A1, Walker C1, Rohde JF1, Andersen HK2, Tarp S1
1The Parker Institute, Bispebjerg and Frederiksberg Hospital and the Danish Health Authority, 2The Danish Health Authority

Background: The purpose of the guidelines from the Danish Health Authority is to support evidence-based clinical decision-making. This is done by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach with a maximum of 10 outcomes per question (between one and three critical outcomes). The GRADE approach recommends using systematic reviews as the base for the development of health-care recommendations. One of the main aims of the Cochrane collaboration is to inform clinical decision-making by developing independent and updated systematic reviews of high quality and relevance. Use of Cochrane reviews in guideline development depends on discrepancies between the aim of the review and the guideline. Especially in relation to the selection of outcomes.

Objectives: To explore the use of Cochrane reviews as a source of evidence to inform clinical recommendations in guideline development.

Methods: Guidelines published since 2014, available at the Danish Health Authority website, were reviewed. Firstly, recommendations based on evidence derived from Cochrane reviews and topic (using the Cochrane topic taxonomy) were noted. Secondly, these review-informed recommendations were categorized according to the extent the pre-specified clinical question outcomes were covered: 1) all, 2) all critical, 3) some critical or 4) any (non-critical).

Results: A total of 340 evidence-based recommendations and 211 expert consensus recommendations (no randomized controlled trials available) were published. Of the 340 recommendations, 104 (31%) included evidence partly or fully derived from Cochrane reviews. Among these, 27 (26%) had all critical and non-critical outcomes, 34 (33%) had all critical outcomes, 34 (33%) had some critical outcomes and nine (9%) had only some non-critical outcomes estimated with evidence from Cochrane reviews (fig. 1). Recommendations with evidence from Cochrane reviews varied from 0-75% across topics, where most topics had coverage of 20-40%. Pregnancy & Childbirth had the highest coverage of 75% of four recommendations whereas Skin disorders had the lowest with 0% of 10 recommendations (fig. 2).

Conclusions: One-third of the evidence-based recommendations used Cochrane reviews to inform the clinical recommendations and the coverage was similar across most topics. In 59% of these recommendations Cochrane reviews were used for all critical outcomes however, in 74% additional data extraction from primary studies was necessary because not all outcomes were informed by the Cochrane review. This evaluation should inform future Cochrane reviews to emphasize all outcomes important for clinical decision-making.

Patient or healthcare consumer involvement: Developing Danish clinical guidelines include involvement of patient organizations as part of the guideline-working group, patients reviewing clinical questions prior to searching the evidence base and patients are represented in the reference group reviewing and commenting on the final guidelines before publishing.