Cochrane Consumer Activities and Access to Medical Libraries

Tamara Rader

Cochrane Musculoskeletal Group

January 12, 2008

What are we going to talk about today?

Evidence-based health care

Systematic reviews

Cochrane Collaboration

Access to information for all (NNLH)

How consumers fit in

Evidence-Based Health Care

Evidence/Information Expertise or experience

Values, preferences, needs

What is “evidence”?

Cohort studies Case control studies Cross sectional surveys Case reports Clinical trials Randomized controlled trials Reviews Systematic reviews

Why don’t doctors use research results in practice?

Lack of information management Individual studies may be misleadingNeed to put results into context

Problem of information management

Over 20,000 medical journals published per year

Published research of variable quality and relevance

Health care professionals often poorly trained in critical appraisal skills

Average time professionals have available to read = <1 hour/week

Need to put results into context

The results of individual studies need to be interpreted alongside the totality of evidence (systematic reviews)

Emphasis on individual studies may distract us

Individual studies may be misleading

Analyzed 115 articles published in 1990-2003 in the 3 major general medical journals (NEJM, JAMA, Lancet) and specialty journals that had received over 1000 citations each by August 2004

49 reported evaluations of health care interventions; 45 claimed that the interventions were effective.

By 2004 5/6 non randomised studies and 9/39 randomised trials were already contradicted or found to be exaggerated

Ioannidis JP. JAMA 2005

What do we need to manage the flow of information, keep it in context, and not be mislead by individual studies?

Reviews!

Reviews

Are a collection of material on a given subjectLooks at all studies on a specific topic (treatment,

correct way to diagnose, prevention)Two ways to review literature: Narrative or Systematic

Narrative Reviews of the Literature

Concerns:- Not focused- Studies excluded or missed- Inappropriate assessment of studies- Inappropriate comparison of studies- Author bias

What is a systematic review?

Systematic reviews are a way of synthesizing research evidence from many studies

Systematic reviews are a basic building block for planning future research

NARRATIVE VS SYSTEMATIC

equal weight of studies High quality studies and weighted

General overview Focused question

?Search strategy Methodical and reproducible search

?assessment of studies Quality & relevance assessed

?bias Impartial and relevant results

What can systematic reviews tell us?

Systematic reviews (including meta-analysis) generic method for addressing different questions –− Epidemiological reviews of observational data− Reviews of diagnostic test performance− Reviews of effectiveness of interventions− Reviews of efficiency of interventions− Reviews of qualitative research− Reviews of research methods− Reviews of theories and models

Meta-analysis

The use of statistical techniques in a systematic review to integrate the results of included studies.

Cochrane Collaboration (2005) Glossary of Terms in The Cochrane Collaboration

What is the Cochrane Collaboration?

Cochrane Collaboration is a unique worldwide organization producing and disseminating systematic reviews on the effects of health care interventions

The Cochrane Collaboration is an international organisation that aims to help people make well informed decisions about health care by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of healthcare interventions. It is a not for profit organisation, established as a company, limited by guarantee, and registered as a charity in the UK .

Mission Statement

Cochrane Collaboration’s vision:

Healthcare decision-making throughout the world will be informed by high quality, timely research evidence.

The Cochrane Collaboration will play a pivotal role in the production and dissemination of this evidence across all areas of health care.

Organization of Cochrane

International Steering GroupInternational Steering Group--Governs the Cochrane CollaborationGoverns the Cochrane Collaboration-Comprised of a group of elected -Comprised of a group of elected representatives from the 5 types of Cochrane representatives from the 5 types of Cochrane Groups (entities)Groups (entities)

Fields/NetworksFields/Networks

1313

CollaborativeCollaborativeReview GroupsReview Groups(CRG)(CRG)

5050

Methods Methods Groups Groups (MG)(MG)

10 10

CentresCentres

1212

Writing Reviews

Commenting on Reviews

Editing Reviews

Disseminating Reviews

Searching for good studies

Management

Who Does What?

Collaborative Review Groups (CRG) - develop and maintain systematic reviews relevant to a

particular health area

- groups are coordinated by an editorial team who edit and assemble completed reviews into modules for inclusion in The Cochrane Library

- examples: Musculoskeletal, Effective Practice & Organization of Care, Back, Breast Cancer, Infectious Diseases, Tobacco Addiction Group

6 review groups based in Canada

• Back Review Group- Toronto• Effective Practice and Organisation of Care Review Group - Ottawa• Hypertension Review Group - Vancouver• Inflammatory Bowel Disease Review Group - London• Musculoskeletal Review Group - Ottawa• Neonatal Review Group - Hamilton

Who Does What?

Consumer Network - International network that facilitates the dissemination of

information to patients, their families, friends and advocates

- Ensures consumer needs and interests are incorporated into the operation of the Collaboration

- Provides input to all activities of the Collaboration- Helps set priorities for review topics- Helps with translation of reviews

Affiliate Organizations

• Representatives from 20 healthcare professional organizations and consumer groups

• Purposes:• Advise on future directions and activities• Promote the awareness, appreciation,

distribution and use of Cochrane systematic reviews among their members

Affiliate Organizations

• L’Agence de L’Agence de éévaluation des technologies et des modes valuation des technologies et des modes d’intervention en santd’intervention en santéé

• Arthritis SocietyArthritis Society• Canadian Association of Occupational TherapistsCanadian Association of Occupational Therapists• Canadian Association of Speech-Language, Pathologists Canadian Association of Speech-Language, Pathologists

and Audiologistsand Audiologists• Canadian Cancer SocietyCanadian Cancer Society• Canadian Chiropractic AssociationCanadian Chiropractic Association• Canadian Coordinating Office for Health Technology Canadian Coordinating Office for Health Technology

AssessmentAssessment• Canadian Dental AssociationCanadian Dental Association• Canadian Health Libraries AssociationCanadian Health Libraries Association• Canadian Institute for Health InformationCanadian Institute for Health Information• Canadian Institute for the Relief of Pain and DisabilityCanadian Institute for the Relief of Pain and Disability

Affiliate Organizations

• Canadian Medical AssociationCanadian Medical Association• Canadian Nurses AssociationCanadian Nurses Association• Canadian Pharmacists AssociationCanadian Pharmacists Association• Canadian Physiotherapy AssociationCanadian Physiotherapy Association• Canadian Task Force on Preventive Health CareCanadian Task Force on Preventive Health Care• Canadian Women’s Health NetworkCanadian Women’s Health Network• College of Family Physicians of CanadaCollege of Family Physicians of Canada• Dietitians of CanadaDietitians of Canada• Institute for Clinical Evaluative SciencesInstitute for Clinical Evaluative Sciences• Royal College of Physicians and Surgeons of CanadaRoyal College of Physicians and Surgeons of Canada

People in Cochrane

Over 10,000 involved internationally About 80 countries Mostly volunteers Diverse backgrounds, experience and

expertise

People in Cochrane

Epidemiologists/Statisticians

Healthcare professionals

Consumers

Librarians

What is found in a Cochrane Review?

Consumer summary (Synopses, Plain Language Summary)

Abstract Background Objectives Selection Criteria for studies Search strategy Methods of the review Description of studies Methodological qualities of included studies Results Summary of analyses Conclusions Potential conflict of interest Acknowledgements

Steps in Production

Identify and prioritise topics

to synthesise

TITLE PROTOCOL REVIEW

Plan how to synthesise the studies

Identify why important to do this synthesis

Identify special groups to look at, benefits & harms to report, factors that might change the results

Write the protocol

Send protocol for comment

Edit protocol

Find, analyse and synthesise the studies

Interpret results and determine impact of findings

Write review

Send review for comment

Edit review

Publish Cochrane review

Preparing a Title

TITLE

• evidence of value in identifying primary research topics• show the difference in what is done and what would like to see done

Challenges• not an emphasis• reviewer driven• individual bias or public consensus not known

Preparing a Protocol

PROTOCOLValue in recognizing all factors in studies that are relevant and important to people making health care decisions

•Background, Participants, Interventions, Outcomes

Examples:• peer review of protocols• working with reviewers

Preparing the review

REVIEW • value of consumers to determine meaning of the results to other consumers and put results in context

Challenges• knowledge of methods, analysis, limitations • time commitment (mutual) and recruitment• feedback and recognition• timelines

The Cochrane Library

The main output of The Cochrane Collaboration, Cochrane Reviews, is contained in The Cochrane Database of Systematic Reviews, published electronically by John Wiley and Sons as part of The Cochrane Library.

The Cochrane Library

All of the Cochrane systematic reviews are on the Internet

In some countries such as the UK and Australia you can access it for free,

Other countries you need to pay for a password to view them

Most universities and some hospitals have the Library for their staff

Where is the “evidence”?

Health Journals Databases Web sites

Libraries Government departments Professional associations Private companies

What’s wrong with that?

Access to evidence is inequitable.

Not all evidence is free Not all evidence is accessible to those who

need it Not all evidence is easy to find Not easy to tell if evidence is valid

National Network of Libraries for Health

NNLH A network of existing health libraries and

information services Will provide equal access to the best

information for patient care Including databases, journals, books,

reports, and web resources.

Why the need for NNLH?

Focus groups in 2001-2002 revealed gaps in access to information for health professionals.

growing demand by health professionals for health information;

the myth that either someone is taking care of making the literature accessible, or that "it's all on the web".

• High quality health care requires evidence-based decisions

• In the absence of a national network with equitable and coordinated access to information for health professionals……

Why a National Network?

• Many health care providers have little or no access to information resources and services

• Others have access from a variety of providers – in some cases with significant duplication

• Lack of access impacts significantly on health care practices and costs

• Simply providing access to resources without support does not adequately meet needs of front line care providers

How can NNLH help consumers?

To inform their preferences and decisions

To filter out unreliable informationTo make access to information more

fair and equitable to all Canadian consumers

Where do consumers get information?

Currently;TV and print media Individual doctor or health care

professionalFriends and familyPublic library or hospital library Internet websites of unknown quality

What’s wrong with that?

Contradictory or inaccurate research results reported in the media

Doctors, friends and family may or may not have current information

Individual libraries have limited collections

Web sites are of variable quality

Canadian Health Network

Providing health and lifestyle information in French and English since 1999.

Collaboration of 26 major health organizations, universities, hospitals, and libraries.

Was mandated with providing access to information to Canadian consumers.

What’s the solution?

Journalists being clear on the quality of the evidence

Emphasizing results of systematic reviews over individual studies

Access to high quality information to doctors and patients and family members alike

Creating a network of libraries so consumers can benefit from the collection of all the libraries in the network

NNLH Vision

The National Network of Libraries for Health (NNLH) will ensure that all health care providers in Canada will have equal access to the best information for patient care. It is designed to fit the Canadian health care model and fill in the information gaps inherent in a complex health delivery system.

Activities 2006-2007

Spring 2006 – CoO RFP Summer 2006 – CoO completed

Thank-you: CISTI, PHAC, CAN, CMA February 2007 – NNLH Task Force meeting May 2007 – CMAJ letter June 2007 – development of VHL Phase 0 with

Canada Health Infoways Fall 2007 – Canadian Health Network funding

cancelled

Benefits of this model

Coordinates and leverages the existing base of resources, services and expertise

Builds on available infrastructure and develops opportunities for local and regional libraries to improve and expand unique services

Provides a virtual platform to facilitate knowledge transfer and exchange at a national level

Preserves and provides access to key Canadian health care resources

Effectively identifies and addresses service and resource gaps

Services

Virtual Help Desk Training & Education Broader linkages (e.g. e-health records,

patient safety, later linkages, emergency response, surveillance data, consumer health info, biotech sources, CHI)

Consumer Involvement

Participating in research studies Advising on research priorities through

Cochrane or other associations Commenting on Cochrane protocols and

reviews Supporting the work of the National

Network of Libraries of Health.

Thank you!

Tamara Rader613-562-5800

Ext. 2397

trader@uottawa.ca