First, we need to prioritise effectively and reduce avoidable waste in the production and reporting of research evidence 
. This has implications for trials as well as systematic reviews. Some funders and others will now not consider supporting a trial unless a systematic review has shown the trial to be necessary 
. It is essential that this requirement be more widely adopted. And it is essential that reviews address questions that are relevant to patients, clinicians and policymakers.
Second, we may need to choose between elaborate reviews of a quarter of the questions clinicians and patients have or “leaner” reviews of most of what we want to know. The methodological standards for systematic reviewing have been increasing over time 
, and the evolution of standards in the Cochrane Collaboration and in HTA has been remarkable. The increase in steps and reporting required is reflected in the length of reviews. Early Cochrane reviews could typically be printed out in 10 or 20 pages, even when they incorporated several trials. Today, it is not unusual for a review by a health technology agency to run to several hundred pages. Often the reviews are longer than the combined length of the reports of all the included trials.
A contributing factor here is the increasing expectation for reviews to include study types other than randomised trials. This will often be essential for detecting less common adverse effects. However, the inclusion of all study types to answer all questions about the effects of treatments would not necessarily provide better quality information in every instance – while it would unquestionably increase the time and resource requirement for reviews. While it is vital that reviews are scientifically defensible, burdening those preparing them with excessive requirements could result in having valid answers to relatively few questions.
In particular, we need leaner and more efficient methods of staying up-to-date with the evidence. Using current methods, the Cochrane Collaboration has not been able to keep even half of its reviews up-to-date 
, and other organisations are in a similar predicament 
. We need to develop innovative methods to reduce the labour of updating, and provide what clinicians and patients need: an assurance that a conclusion is not out of date, even if not every later trial is included within every analysis. It is also the responsibility of reviewer authors and journal editors to ensure that every new systematic review places itself clearly in context of other systematic reviews and HTAs. It will be to little avail to the average clinician, patient, and information provider, however, if the resulting knowledge is not comprehensible and openly accessible.
Finally, although more funding for evaluative clinical research internationally remains a priority, more international collaboration could result in better use being made of resources for systematic reviewing and HTAs. While multiple reviews on topics can provide a rounded picture of an area as well as a de facto form of updating when the reviews are conducted several years apart, there is also considerable duplication of review effort.
In November 2009, an international meeting in Cologne formed a new collaboration called “KEEP Up,” which will aim to harmonise updating standards and aggregate updating results. This should reduce the workload and enable organisations to be alerted when there are important shifts in evidence. Initiated and coordinated by the German Institute for Quality and Efficiency in Health Care (IQWiG) and involving key systematic reviewing and guidelines organisations such as the Cochrane Collaboration, Duodecim, the Scottish Intercollegiate Guidelines Network (SIGN), and the National Institute for Health and Clinical Excellence (NICE), this effort will provide a platform for tackling practical and methodological issues involved in keeping up-to-date.
There is nevertheless a risk that the increasing burdens placed on the methods of systematic reviewing could make the goal of keeping up-to-date with the knowledge won from trials recede ever more quickly into the distance. Perhaps one of the first questions we should ask whenever an additional process or more demanding methodology for systematic reviewing is proposed is this: Will this development serve or hinder our ability to better understand and communicate enough results from trials? In 1979, when Archie Cochrane argued that we needed critical summaries to keep up with the crucial knowledge those trials were generating, there were perhaps 14 trials a day being published. Thirty years later, it would be just as hard to keep up with the systematic reviews. Every day there are now 11 systematic reviews and 75 trials, and there are no signs of this slowing down: but there are still only 24 hours in a day.