The Cochrane BJMT Group approach to priority setting: 2018 to 2020

Date published: 19 September 2019 (version 1)

The need for explicit prioritisation

From inception, the Cochrane BJMT Group has had a strong record of identifying and publishing reviews that are important to decision-makers. This is illustrated in an account of the work of the Group, produced in celebration of the 20 year landmark reached by Cochrane in 2013 [1]. This describes the strategies the Group had taken to deliver on key areas within its broad and diverse scope, including a purposeful focus on common injuries, such as fragility fractures in older people. The article also gives insights of the challenges the Group, and indeed all Cochrane Review Groups (CRGs), increasingly face. For example, a major challenge for well-established CRGs with a large portfolio of reviews is the scale and complexity of updating already large multiple comparison reviews, together with implementing demanding methodological standards (MECIR) that require an updated protocol and reassessment of all previously included trials. Throughout Cochrane, there has been recognition of the need for a major change in approach with a strong emphasis on prioritisation to meet Goal 1 of Cochrane’s Strategy to 2020.

To produce high-quality, relevant, up-to-date systematic reviews, and other synthesized research evidence to inform health decision making.

Linked with this is the imperative for greater transparency and engagement of stakeholders in the decision making of Cochrane. Particularly, in the second aspect, the BJMT Group builds on strong foundations [1]. Notably, this included the delivery of a Cochrane-funded priority setting project on hip fracture rehabilitation that included a formal consultation with an array of stakeholders drawn from a Cochrane Field [2].

 Aim of this document

The aim of this document is to make explicit the BJMT Group’s current approaches to priority setting and to share the list of priority reviews that we have been/are aiming to deliver in the years 2018 to 2020. This document will be kept under review, with a formal update intended in April 2020. Under development is a second ‘living’ document, intended for publication in late 2020, which will describe our prioritisation strategy from 2020 onwards. This will adhere to contemporary standards as described in Cochrane’s ‘Guidance note for Cochrane Groups to define systematic review priorities’; current version October 2018.

 Summary of approaches 2018 to 2020

The BJMT Group’s current approaches to priority setting are multifaceted. Much of our focus in this period continues to be on the delivery of a suite of reviews, each identified through a formal process of engagement with stakeholders, on two top priority areas: prevention of falls in older people and the management of hip fracture. Both of these internationally-recognised priority areas are strongly linked with the updating of NICE guidelines [3,4].

Other priority setting has related to individual reviews on specific interventions and/or injuries. As well as consultation with our team of multidisciplinary editors, which also includes a consumer editor, we consider evidence for impact (e.g. use in guidelines and newsworthiness), the results of other external priority setting exercises such as those conducted by the James Lind Alliance (e.g.[5]), disease burden, research activity including the potential identification of important research gaps and the existence of ongoing or recently completed, usually publicly-funded, large multicentre trials.

All single topic reviews listed on the priority list are topics that are strongly endorsed, albeit indirectly, via stakeholder consultation. For example, extensive stakeholder consultation and engagement are integral to both the identification of topics for both primary and secondary research projects funded by the NIHR (UK) and the development and production of NICE guidelines. Thus, the topics selected in these ways can be considered a proxy endorsement for selection of a similar topic for a Cochrane review. This is exemplified by the selection of the single topic review update on ‘Interventions for treating proximal humeral fractures in adults’. This injury features in the NICE guideline on non-complex fracture management (Fractures (non-complex): assessment and management. NICE guidelines [NG38]; 2016); it is the focus of two multicentre NIHR-funded RCTs, one of which is ongoing; and includes one of the top 10 priority topics for shoulder problems identified via a James Lind Alliance priority setting exercise [5].

We will continue to ensure that all priority reviews are promoted on publication, including engaging with Cochrane Knowledge Translation through completion of the Cochrane Knowledge Translation dissemination brief.

Prevention of falls in older people reviews

A formal and extended consultation in 2014 with stakeholders, all of whom were active falls-prevention researchers and many of whom were Cochrane-review contributors, in this area was orientated towards the future updating of two major, high impact, reviews [6,7]. A comprehensive scoping document was prepared by two BJMT editors, and the process was co-ordinated by the BJMT Managing Editor. The three-stage consultation on the draft proposal, which evolved in the light of stakeholder feedback, concluded with a meeting between stakeholder attendees at the 6th Biennial Australasian Falls Prevention Conference to finalise the document in November 2014. The main thrust of the consultation was on the splitting of the large (159 trials) and comprehensive [all] ‘Interventions for preventing falls in older people living in the community review’ [6] by major intervention category: five new titles were agreed. Consensus was achieved also on the need for a consistent and collaborative approach in the production of these 5 new reviews, which draw on the established classification system for interventions in this area [8]. Similar considerations of consistency applied to the updating of the smaller review (60 trials) on ‘Interventions for preventing falls in older people in care facilities and hospitals’ [7], whose splitting was deferred by at least one update but will eventually be by setting. Lastly, the consultation identified that priority should be given to the production of a review that focused on psychological / behavioural interventions for reducing fear of falling in older people. The priority reviews identified during this consultation process are included in the table below; work on these reviews is ongoing.

Management of hip fracture in older people

As evident from the project title of our Cochrane programme grant [9], the Group is aiming to deliver on a series of high priority Cochrane Reviews for the management of patients with hip fracture that can inform healthcare policy guidance. Stakeholder consultation centred on a one-day workshop, held in January 2018, that engaged stakeholders from a range of disciplines with direct experience of and/or strong interest in the evidence-based management of fragility hip fractures [11]. Informed by a scoping document, produced by the project management team and BJMT editorial base members, including summaries of pre-existing Cochrane Reviews, the workshop attendees explored a range of issues. The insights gained from this consultation helped guide the core-team decision-making in terms of the overall scope of the programme, and scopes of individual reviews. Based on these and subsequent stakeholder discussions, with input from the editorial team, commissioning briefs were generated for 7 priority BJMT reviews, including 4 newly started surgical intervention reviews, 1 updated surgical intervention review, 2 rehabilitation review updates and 1 overview on blood management.  These are shown in the Priority List table below.

BJMT Group Priority list for 2018 to 2020

[N] = New review; [U] = updated review
^# This list and status will be kept under review and updated on a 6-monthly basis

Other topic areas

The primary emphasis over the 2018 to 2020 period in terms of priority setting is on falls in older people and on the treatment of fractures, mainly hip, in older people. However, another strong theme in our work is the prevention and treatment of acute and overuse soft-tissue injuries that occur mainly in physically-active people. Evidence is accruing of the considerable health benefits of engaging physical activity at all ages [e.g. 15]. However, participation comes with the increased risk of musculoskeletal injury. Particularly given the increased promotion and popularity of running, a specific focus of the Group is on key interventions to prevent lower-limb running injuries. Another focus of the Group continues to be on muscle soreness which, while time-limited, is painful and disabling and can be counterproductive to the long term participation in sufficient physical activity. This prioritisation is supported also by the considerable and enduring public and media interest in our reviews on various interventions (antioxidants, cold water immersion, stretching, and whole body cryotherapy) for preventing and reducing muscle soreness after exercise. 

A generic prioritisation process aimed at these and other topics in association with the Acute and Emergency Care Network is under consideration; any developments will be described in the next update of this document.

 Acceptance of other review topics, including unsolicited proposals

This establishment of a list of priority reviews does not preclude acceptance of new titles nor pursuit of updates. These will be judged on the merits of individual cases and consideration of the capacity of the editorial base to support the extra review. When circulating title proposals, including unsolicited proposals, to the Group’s Editors, the following questions are asked. 

Title proposers are asked to provide a list of eligible studies and other related reviews in their form. Additionally, the editorial base usually runs a search checking for research volume and recently published reviews. This helps assess the viability of the review – other considerations, particularly the experience of the review team and involvement of consumers also form part of this assessment – and also whether there is a potential for excessive overlap in research effort. Central to prioritisation is the importance of avoiding research waste. 

Finally, although reviews or review updates accepted for support by the Group may not be listed formally as priority topics, all topics supported by the Group are of importance according to one or more of the following: disease burden, topicality, areas of controversy and treatment differences, evolving treatment, key evidence gap and potential or established impact. The status of title proposals for new reviews, not featured in the priority list, which have been accepted from 1^st January 2018 are listed below. 

As evidenced from the above list, titles can and will be removed if there is lack of progress or other strong reasons for discontinuation. Timely delivery of quality submissions is an integral part of prioritisation.

References

[1] Handoll H. Work of the Cochrane Bone, Joint and Muscle Trauma Review Group: making sense of complexity. Journal of Evidence-Based Medicine 2013:6: 208–212. doi: 10.1111/jebm.12064 https://onlinelibrary.wiley.com/doi/full/10.1111/jebm.12064

[2] Handoll HH, Stott DJ, Elstub LJ, Elliott JC, Kavanagh AL, Madhok R. A framework for effective collaboration between specialist and broad-spectrum groups for delivering priority Cochrane reviews. Journal of Clinical Epidemiology 2013; 66(5):490-495

[3] Falls in older people: assessing risk and prevention. NICE Clinical guideline [CG161]. Published date: June 2013 https://www.nice.org.uk/Guidance/cg161

[4] Hip fracture: management. NICE Clinical guideline [CG124]. Published date: June 2011 Last updated: May 2017. https://www.nice.org.uk/guidance/cg124

[5] Surgery for Common Shoulder Problems Top 10. www.jla.nihr.ac.uk/priority-setting-partnerships/surgery-for-common-shoulder-problems/top-10-priorities/ (accessed 11/09/19)

[6] Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9 . Art. No.: CD007146. DOI: 10.1002/14651858.CD007146.pub3

[7] Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD005465. DOI: 10.1002/14651858.CD005465.pub3 .

[8] Lamb SE, Becker C, Gillespie LD, Smith JL, Finnegan S, Potter R, et al. Reporting of complex interventions in clinical trials: development of a taxonomy to classify and describe fall-prevention interventions. Trials 2011;12:125. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127768/

[9] Griffin X et al. SRPG Project: 16/114/15 - A programme of high priority Reviews for the management of patients with hip fracture: a collaboration which can inform future healthcare policy guidance. https://www.journalslibrary.nihr.ac.uk/programmes/sr/1611415/#/

[10] Sreekanta A, Felix L, Handoll H, Grant R, Cook JA, Elliott J, Griffin XL. Optimising stakeholder engagement for informing direction and scope of a programme of Cochrane Reviews on hip fracture management (Poster 301). Abstracts of the 25th Cochrane Colloquium, Edinburgh, UK. Cochrane Database of Systematic Reviews 2018;(9 Suppl 1). https://doi.org/10.1002/14651858.CD201801

https://colloquium2019.cochrane.org/sites/2018.colloquium.cochrane.org/files/uploads/users/u11165/CC2018%20Abstract%20Submission_0.pdf

[11] Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michaleff ZA, Howard K, Clemson L, Hopewell S, Lamb SE. Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD012424. DOI: 10.1002/14651858.CD012424.pub2.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012424.pub2/full

[12] Hopewell S, Adedire O, Copsey BJ, Boniface GJ, Sherrington C, Clemson L, Close JCT, Lamb SE. Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2018, Issue 7 . Art. No.: CD012221. DOI: 10.1002/14651858.CD012221.pub2
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012221.pub2/full

[13] Cameron ID, Dyer SM, Panagoda CE, Murray GR, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews 2018, Issue 9 . Art. No.: CD005465. DOI: 10.1002/14651858.CD005465.pub4 . Interventions for preventing falls in older people in care facilities and hospitals
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005465.pub4/full

 [14] Handoll HHG, Elliott J, Iheozor-Ejiofor Z, Hunter J, Karantana A. Interventions for treating wrist fractures in children. Cochrane Database of Systematic Reviews 2018, Issue 12. Art. No.: CD012470. DOI: 10.1002/14651858.CD012470.pub2

[15] Mok A, Khaw KT, Luben R, Wareham N, Brage S. Physical activity trajectories and mortality: population based cohort study. BMJ. 2019 Jun 26;365:l2323. doi: 10.1136/bmj.l2323.

Document prepared by Dr Helen Handoll, Co-ordinating Editor, Cochrane Bone, Joint and Muscle Trauma Group. With thanks for critical feedback from Dr Joanne Elliott, Managing Editor, BJMT Group and Mrs Sharon Lewis, Network Support Fellow, Acute and Emergency Care Network