Past research and findings offer valuable insights if you know where to look and how to synthesize and apply the evidence. These evidence syntheses, either as standalone products or in support of guidelines, are critical to supporting decisions now and for identifying priorities for additional research to allow even better decisions in the future.
The Duke Evidence Synthesis Group produces comparative effectiveness reviews on medications, devices, and other health care services with the goal of helping patients, physicians, and policymakers make better decisions about treatments. Depending on the uncertainty that exists, one or more methods may be used.
Prioritize Research
Uncertainties
- Where should we focus future data acquisition?
- What future research is of most value to different decision-makers?
Methods
- Value-of-information analyses
- Stakeholder engagement
- Future research needs prioritization
- Horizon scans
Synthesize Evidence
Uncertainties
- What do we know about the comparative safety and effectiveness of alternative strategies?
- What are the benefits and harms of available strategies?
- What are the limitations of existing evidence?
Methods
- Systematic reviews of the evidence
- Individual patient data analysis
- Meta-analysis
Improve Decision-Making
Uncertainties
- How do we trade off possible benefits and harms?
- How can we make our decision-making process transparent and understandable?
- How can we inform decision-making from diverse perspectives?
- What healthcare interventions are the best value given limited resources?
- How do alternative payment models affect the implementation and or value of interventions?
Methods
- Decision modeling
- Cost-effectiveness analysis
- Benefit-harm acceptability curves
- Shared decision making
- Guideline development
Duke Evidence-Based Practice Center
Duke ESG is proud to once again serve as the Duke Evidence-based Practice Center (EPC) for the Agency for Healthcare Research and Quality (AHRQ).
The Duke Evidence-based Practice Center brings together the expertise necessary to develop state of the art systematic reviews and meta-analyses. The EPC advances understanding of clinical topics through 1) a thorough ascertainment of available scientific research, 2) a scientifically-driven process for evaluating available evidence, and 3) a methodologically sophisticated analysis designed to demonstrate and estimate bias. The goal of such projects is to aid in the development of clinical practice guidelines or practice improvement projects. The center is one of 13 Evidence-based Practice Centers (EPCs) nationwide designated and funded by the Agency for Healthcare Research and Quality (AHRQ).
Case Studies
Situation
- Evidence that mammography reduces breast cancer mortality, but with potential harms (e.g., false positives, overdiagnosis)
- Balance of benefits and harms may vary (e.g., age, screening interval)
- American Cancer Society (ACS) sought to consider both observational and RCT evidence
Solution
- Systematic review of 93 studies
- Quality rating of the evidence (GRADE)
- Benefit/harm framework to enable ACS to translate evidence into guideline recommendations
- Primary outcomes: breast cancer mortality, overdiagnosis, false positive biopsy findings, life expectancy, QALY
Findings and Impact
- For women of all ages at average risk, mammography screening was associated with a reduction in breast cancer mortality, but a reduction from more frequent intervals or younger ages is uncertain.
- Formed the underlying evidence for revised breast cancer screening guidelines from the ACS
Situation
- PCOR was unsure of the possible role of decision models in informing trial design decisions
- Methods project using as an example PCORI’s ADAPTABLE study (81 mg vs 325mg aspirin in coronary artery disease patients)
Solution
- Development of a full disease state model for value of information analysis of ADAPTABLE
- Explored how optimal strategy changes based on outcome (composite, LY, QALE)
Findings and Impact
- Considerable uncertainty about optimal dosage
| Outcome | Low Dose Optimal | High Dose Optimal |
|---|---|---|
| QALYs | 88% |
12% |
| Unadjusted Life Years | 46% | 54% |
| Composite Endpoint | 56% | 41% (3% no difference) |
Duke ESG Leadership
