An Introduction to Cochrane Collaboration and its Impact on Medical Practices Gerd Antes Cochrane Germany (www.cochrane.de) University Medical Center Freiburg REHA-Kolloquium Frankfurt 20. März 2017
Conflicts of interest The Cochrane Germany is a central unit of the University Medical Centre Freiburg G. Antes is 100% employed by the University Hospital Potential conflict: Long-lasting commitment to Evidence and Systematic Reviews
Contents Evidence to answer the crucial question: What works? Systematic reviews as key technology for knowledge synthesis Cochrane as host for global knowledge and rigorous methology
Knowledge Translaton Transfer of Research into Practice Answers to medical questions Clinical (randomised / controlled) studies Epidemiological (observational -) studies.... Practicing physicians? Health authorities, sickness funds, insurances, institutions Clinical research Patients 50 % Evidencd production 1968 McMaster Univ. Hamilton, Canada 1971 Archie Cochrane, UK 1993 Cochrane Collab. 1998 Cochrane Germany Evidence application
The trial deluge
1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 September 2016 35.000 30.000 RCTs (Reports) in Medline Overall: 419.020 27445 29638 29131 25.000 20.000 25333 22510 20614 19087 17360 15.000 10.000 5.000 0 194 271 355 476 649 1241 1468 2071 2550 2855 3893 6762 5647 4535 8261 7591 10382 10357 9490 13484 11530 11164 12257 15199
The truth
1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 RCTs (Reports) in Medline (PubMed) Overall: 419.020 35.000 September 2016 30.000 29638 29131 25.000 20.000 Freiburg Ethics Board 2000-2002: 48% published until 2010 J. Simes (1986) 27445 25333 22510 20614 19087 17360 15.000 10.000 5.000 0 194 271 355 476 649 1241 1468 2071 2550 2855 3893 6762 5647 4535 8261 7591 10382 10357 9490 13484 11530 11164 12257 15199
EBM Transfer of Research into Practice Clinical studies (experimental, randomised, controlled, prospective) Epidemiological studies (observational, retrospective) Systematic Reviews Health Technology Clinical Guidelines Patient Information Assessment (HTA) global local Disease Management Programs (DMPs) Clinical Pathways (CPs)
The knowledge refinery
All trials? identified Not identified? Not published Quality? Review
1. Framing the question (PICO) 2. Systematic search for evidence from relevant trials and studies 3. Critical appraisal of trials - inclusion 4. Summary and quantivative synthesis (if possible) 5. Interpreting and putting in context Updating!! July 2011 Produce unbiased view of all evidence
Example Thrombolysis after acute myocardial infarction NEJM 1992 Body of Evidence Forest Plot
Thrombolysis (Streptokinase) after myocardial infarction NEJM 1992 Forest Plot: Cumulative Forest Plot: Stop - Regel?
Open questions No accepted stopping rule Have all relevant trials been identified and considered? Need all (!) relevant trials: 2016 no reliable method and procedure
1987 RCTs of aprotinin in cardiac surgery to stop bleeding Lancet 2005 Clinical Trials 2005 Cited 2002
Benefit? Harm? Costs?
Research in context
Leaving things out Selective reporting = 1. Hiding whole trials (classical publication bias) 2. Hiding (or distorting) information from trials which are published 3. Spin: Interpretations which have nothing to do with the trial results
Striving for quality: Trial registration as basis for transparency
WHO Register Network ICTRP www.who.int/ictrp Urology ANZCTR DRKS EU Clinical Trials Register Clinical Trials.gov CT not WHO Primary Registry
Declaration of Helsinki 2013 Research Registration and Publication and Dissemination of Results 35.Every research study involving human subjects must be registered in a publicly accessible database before recruitment of the first subject. 36.Researchers, authors, sponsors, editors and publishers all have ethical obligations with regard to the publication and dissemination of the results of research. Researchers have a duty........
The Cochrane Collaboration (since 1993) Trusted evidence. Informed decisions. Better health Independent network of 36000+ contributors from science and health professions
Systematic Reviews Leading principle: Minimizing bias Risk of Bias
The Cochrane Library - free searching and abstracts - updating system 9520 9668 992236 Today Cochrane is - a charity under UK law - member of WH assembly - organized globally in entities Cochrane Library Counts September 2016 7004 reviews 2516 protocols Impact Factor 2015: 6.103 (vorläufig)
<20% von Cochrane
Knowledge accumulation: backfiring?
Commentary M. J. Page D. Moher Blog Pubmed Commons Systems of wrong incentives, agendas driven by science and scientists careers, maldevelopment of journals...
A new enemy? Open access, data sharing...
Old: The poor can t read New: The poor can t write
A strong barrier: language
1000 lay language summaries in German Most frequently visited SRs
The biggest challenge: Updating
The solution? Living Systematic Reviews: An Emerging Opportunity to Narrow the Evidence-Practice Gap
Summary Systematic reviews as key technology knowledge accumulation to provide evidence for medical decisions Cochrane is an international network to support the production of systematic reviews and to develop rigorous methodology
www.globalevidencesummit.org