Evidence-based Optometry Process

AOA's 14 steps to evidence-based clinical practice guideline development

1. Guideline Development Group (GDG): The Evidence-Based Optometry (EBO) Committee selects a multidisciplinary panel of experts, including patient and public representatives, to act as the Guideline Development Group (GDG). 
2. Transparency and COI: The GDG manages all conflict of interest (COI), which is documented by AOA staff and reviewed during face-to-face meetings.
3. Clinical questions*: The GDG defines the literature search criteria and identifies all clinical questions through a question formulation meeting.
4. Search for evidence: The AOA staff sends the search criteria and clinical questions for a systematic review of the literature (outside researchers) and provides all obtained papers to the Guideline Development Reading Group (GDRG). Systematic reviews, when available, are included in the guideline. There is no inclusion of systematic review writers in the GDG or GDRG.
   1. Inclusion criteria (must meet all): Scientific studies written in English that address the clinical question and that meet the patient population or age range being addressed.
   2. Exclusion criteria (meets any of the following): Scientific studies that are not in English, animal studies, studies outside the patient population or age range (if relevant), studies not addressing any topic of the clinical questions searched.
5. Grade evidence/quality: Two members from the GDRG are randomly selected to read and grade each paper. They separately grade the paper for quality of evidence, based on predetermined grading criteria and state the clinical recommendation(s).
6. Articulate clinical recommendations/strength*: The GDRG and GDG clinical experts review all clinical recommendations and articulate each for inclusion in the guideline during an "articulation of recommendations" meeting(s). There are single and/or aggregate recommendations made and a strength level is assigned. Potential benefits and harms, costs, and patient preferences are identified, as well as any gaps in research, and each is documented.
7. Write the draft: The AOA staff sends the articulation results to the writer to develop draft one.
8. Draft review and edits*: The GDG reads draft one, discusses and edits.
9. Rewrite/final drafts: The AOA staff sends the draft results to the writer for writing/revisions for draft two (peer review draft) and sends to the medical editor for copy editing. Additional reviews are completed as necessary.
10. Approval and posting for peer review: The AOA staff and/or EBO Committee chair sends the peer review draft to the AOA Board of Trustees for approval to post for peer and public review. The draft is posted on the AOA website, along with a comment form, and the review period is announced. Comments are solicited/collected to a separate email and comment authors are not made public.
11. Final document produced: The GDRG and GDG clinical experts review all peer comments and revise the final document. They may choose to include the peer review comment, not include the comment and/or identify further gaps to review when preparing the next edition. All comments are documented regarding actions taken/not taken and the final draft is produced.
12. Final draft approval and legal review: The final draft is reviewed by the AOA Board of Trustees and AOA Legal Counsel for approval and verification that the GDG followed the evidence-based process as outlined by the National Academies of Sciences, Engineering, and Medicine (NASEM) - Health and Medicine Division, previously the Institute of Medicine.
13. Post guidelines: The AOA staff posts the evidence-based guideline to the AOA website for public use.
14. Schedule reviews: The GDG schedules a review to meet the NASEM guideline development standards and reviews all previously identified gaps in medical research and any new evidence, and revises the evidence-based guideline every 2-5 years.

** Denotes face-to-face meeting

Download a copy of the 14 step process. 

What is evidence-based health care?

While definitions vary depending upon the area of application, all refer to the use of scientific research as a way to inform delivery of patient care. The Cochrane Collaboration states:

"Evidence-based health care is the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services. Current best evidence is up-to-date information from relevant, valid research about the effects of different forms of health care, the potential for harm from exposure to particular agents, the accuracy of diagnostic tests, and the predictive power of prognostic factor[1]."

The National Association of Social Workers (NASW) defines a broader process that encompasses the AOA's goals for evidence-based optometry. They define evidence-based practice as:

"A process involving creating an answerable question based on a client or organizational need, locating the best available evidence to answer the question, evaluating the quality of the evidence as well as its applicability, applying the evidence, and evaluating the effectiveness and efficiency of the solution." 

The AOA Evidence-based Optometry (EBO) Committee has undertaken the challenge of developing clinical practice guidelines and providing resources that will markedly improve health care quality by ensuring patients are diagnosed and treated based on the best available scientific research.

_{[1] Cochrane AL. Effectiveness and Efficiency : Random Reflections on Health Services. London: Nuffield Provincial Hospitals Trust, 1972. Reprinted in 1989 in association with the BMJ. Reprinted in 1999 for Nuffield Trust by the Royal Society of Medicine Press, London, ISBN 1-85315- 394-X. (temporarily out of print; new edition scheduled for early 2013)}

Role of NASEM - Health and Medicine Division (formerly IOM)

The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide independent, objective analysis and advice to the nation, and conduct other activities to solve complex problems and inform public policy decisions related to science, technology and medicine. The academies operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Abraham Lincoln.

The NASEM's aim is to help those in government and the private sector make informed health decisions by providing evidence upon which they can rely. Each year, more than 3,000 individuals volunteer their time, knowledge and expertise to advance the nation's health through the work of the NASEM.

The NASEM asks and answers the nation's most pressing questions about health and health care

When the U.S. Congress initiated the Medicare Improvements for Patients and Providers Act of 2008, they directed the NASEM/IOM to develop rigorous new standards for the development of evidence-based guidelines. The NASEM/IOM, through the AHRQ, issued two reports in March 2011: Clinical Practice Guidelines We Can Trust and Finding What Works in Health Care: Standards for Systematic Reviews.

In Clinical Practice Guidelines We Can Trust, the NASEM/IOM redefined CPGs as follows:

"Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of the evidence and an assessment of the benefits and harms of alternative care options."

According to the AHRQ and the NASEM/IOM, evidence-based guidelines must be:

• Based on a systematic review of the existing evidence.
• Developed by a knowledgeable, multidisciplinary panel of experts and representatives from key affected groups.
• Based on an explicit and transparent development process to minimize bias and conflicts of interest.
• Graded for both the quality of evidence and the strength of recommendations.
• Contain articulated and precise clinical recommendations, produced in a standardized form.
• Reviewed, completing an external and peer review process.
• Reviewed every 2-5 years and revised when new evidence warrants.