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

Transfer of Research into Practice

Answers to medical questions

• Clinical (randomised / controlled) studies

• Epidemiological (observational -) studies

. . . .

Evid

en

ce

ap

plic

atio

n

Evid

en

cd

pro

du

ctio

n

? • Practicing physicians

• Health authorities, sickness funds, insurances, institutions

• Clinical research

• Patients

50 %

Kn

ow

led

ge T

ran

sla

ton

1968 McMaster Univ.

Hamilton, Canada

1971 Archie Cochrane, UK

1993 Cochrane Collab.

1998 Cochrane Germany

The trial deluge

194 271 355 476 649 1241 1468

2071 2550

2855

3893 4535

5647

6762

7591 8261

9490

10382 10357

11530 11164

12257

13484

15199

17360

19087

20614

22510

25333

27445

29638

29131

0

5.000

10.000

15.000

20.000

25.000

30.000

35.00019

65

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

Overall: 419.020

September 2016

The truth

194 271 355 476 649 1241 1468

2071 2550

2855

3893 4535

5647

6762

7591 8261

9490

10382 10357

11530 11164

12257

13484

15199

17360

19087

20614

22510

25333

27445

29638

29131

0

5.000

10.000

15.000

20.000

25.000

30.000

35.000

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

Freiburg Ethics Board

2000-2002:

48% published until 2010

J. Simes (1986)

RCTs (Reports) in Medline (PubMed)

Overall: 419.020

September 2016

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)

Disease Clinical

Management Programs (DMPs) Pathways (CPs)

EB

M

glo

bal

local

The knowledge refinery

„All“ trials ?

Not published Not

identified identified

?

Review

Quality?

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!!

Produce unbiased view of “all” evidence

July 2011

Example

Thrombolysis after

acute myocardial

infarction

NEJM 1992

Forest Plot

Body of

Evidence

Cumulative Forest Plot:

Stop - Regel?

Thrombolysis (Streptokinase) after myocardial infarction NEJM 1992

Forest Plot:

Open questions

– No accepted stopping rule

– Have all relevant trials been identified and considered?

Need „all“ (!) relevant trials:

2016 no reliable method and procedure

RCTs of aprotinin in

cardiac surgery to

stop bleeding

Lancet 2005

Clinical Trials 2005

1987

2002

Cited

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

CT not WHO

Primary Registry

EU Clinical

Trials Register

Clinical

Trials.gov

DRKS

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

. . . . . . . .

Trusted evidence. Informed decisions. Better health

The Cochrane Collaboration (since 1993)

Independent network of 36000+ contributors

from science and health professions

Systematic Reviews

Leading principle: Minimizing bias

Risk of Bias

Cochrane Library

Counts

September 2016

7004 reviews

2516 protocols

Impact Factor 2015:

6.103 (vorläufig)

9520 9668

Today

992236

The Cochrane Library

- free searching and abstracts

- updating system

Cochrane is

- a charity under UK law

- member of WH assembly

- organized globally in entities

<20% von Cochrane

Knowledge accumulation: backfiring?

Systems of wrong incentives, agendas driven by science and scientists‘

careers, maldevelopment of journals . . .

Commentary

M. J. Page

D. Moher

Blog Pubmed

Commons

A new enemy?

Open access, data sharing . . .

Old: The poor can‘t read

New: The poor can‘t write

A strong barrier:

language

Most frequently visited SRs

1000 lay language summaries in German

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