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Cochrane reviews and guideline development: Is there anything new under the sun?

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Professor Cindy Farquhar ...

Professor Cindy Farquhar
Cochrane Menstrual Disorders & Subfertility Group
NZ Cochrane Branch of the Australasian Cochrane Centre
New Zealand Guidelines Group
National Women’s Health
University of Auckland

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  •  Contents 2About this Catalogue 4How to obtain NZGG Publications 4Cancer 5Bowel cancer 5Breast cancer 5Melanoma 5Prostate cancer 5Cancer investigation, referral and reduction of disparities 6
  • Competitive marketplace for health knowledgeAwareness amongst health professionals and public should be betterUsage should be betterSome criticisms

Cochrane reviews and guideline development: Is there anything new under the sun? Cochrane reviews and guideline development: Is there anything new under the sun? Presentation Transcript

  • Cochrane reviews and guideline development: is there anything new under the sun?
    Professor Cindy Farquhar
    Cochrane Menstrual Disorders & Subfertility Group
    NZ Cochrane Branch of the Australasian Cochrane Centre
    New Zealand Guidelines Group
    National Women’s Health
    University of Auckland
  • There’s been a culture change
    Reasoning based on patho-physiology
    Randomised controlled trials
    Guidelines
    Improved health care
    Reasoning based on observational studies
    Systematic reviews
  • Why systematic reviews?
    Too many studies to consider individually
    Assists in identifying gaps and planning new research
    Identifies effective and ineffective treatments
    Better quality than traditional reviews which tend to be haphazard, biased and contradictory
    Reduced bias - explicit about inclusion and exclusions, study quality is assessed, more generalisable and greater power
  • Using evidence to improve care?
    Failure to translate research finding into clinical practice means:
    30-40% patients do not get treatments of proven effectiveness
    20-25% patients get care that is not needed or potentially harmful
    Schuster et al 1998 Milbank Memorial Quarterly
    R Grol (2001) Med Care
  • The Cochrane Collaboration
    Preparing, maintaining and disseminating systematic reviews of the effects of health care
  • Cochrane Collaboration: mission
    an international not-for-profit organisation which aims to help people makewell-informed decisions about healthcare by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of health care interventions
  • Scope
    Questions of clinical intervention
    Reviews of diagnostic test accuracy
    Effective practice and organisation of care reviews (eg workforce, quality improvement)
    Consumer and communication reviews (eg effective methods of consent, ways of involving consumers in research and policy)
    Public health reviews (eg prevention of childhood obesity, school based interventions)
  • The Cochrane Collaboration in 2011
    22,000 contributors in 100+ countries
    52 Cochrane Review Groups
    13 Cochrane Centres (and branches)*
    4100 completed reviews
    1900 protocols for reviews underway
    600,000 references to completed and ongoing trials in Cochrane Controlled Trials Register
  • Better quality reviews
    “..we observed far superior reporting standards of Cochrane reviews compared to non-Cochrane therapeutic ones.”
    “For therapeutic reviews, all the Cochrane ones reported assessing the quality of included studies whereas only half of the non-Cochrane did (43/87 [49.4%]).”
    “The seven industry supported reviewsthat had conclusions recommended the experimental drug withoutreservations, compared with none of the Cochrane reviews (P= 0.02), although the estimated treatment effect was similaron average (z = 0.46, P = 0.64).”
  • IOM report
    Overall endorsement of Cochrane Standards
    Risk of “cutting corners”
    Reporting bias & unpublished studies
    Importance of licensing agency data
    Observational studies
    Knowledge translation and implementation
    Relevance, applicability and timeliness
  • The rise and rise in the number of systematic reviews
  • 12
    Year-on-year total Abstracts & Full Text downloads (Wiley data only)
  • Cochrane Library and National Licence
  • New Zealander’s use of Cochrane Library
  • Clinicians
    reliable summary of research
    inform practice
    inform patient
  • Podcast feature
    16
  • Consumers
  • Policy makers
  • So what is new …..under the sun?
  • So, what’s next?
    Content development
    Improved presentation
    Flexible delivery
    Partnerships with stakeholders
  • Content development
    Ensure consistent high quality
    Improve timeliness
    Improve accessibility
    More SoF tables
    Shorter reviews
    Different types of review
    Overviews/Multiple comparison reviews
    Diagnostic test accuracy reviews
    Health systems / qualitative reviews
  • GRADE and Summary of Findings table
  • Benefits of GRADE
    Outcome focussed
    Provides a summary of key findings
    Direction and magnitude of any effect
    Confidence in effect
    Flexible, intuitive
    Transparent
    www.gradeworkinggroup.org
  • Improved presentation
  • Plain language summaries
  • Flexible delivery
  • Accessibility
  • The Cochrane Library on IPAD
  • www.cochranelearning.com password: drcochrane
  • Cochrane Partnerships
    WHO
    January 2011 awarded The Cochrane Collaboration a seat on the World Health Assembly allowing the Collaboration to provide input on WHO health resolutions
    Guidelines Groups
    Guideline International Network partners with Cochrane
  • And now for guidelines
  • The problem : the ‘know-do’ gap
    ‘There is a gap between today’s scientific advances and their application: between what we know and what is actually being done. Health work teaches us with great rigour that action without knowledge is wasted effort, just as knowledge without action is wasted resource’.
    LEE Jong-Wook, past WHO Director General
  • The New Zealand Guidelines Group
    NZGG is funded by government but is an independent incorporated society
    Vision
    Reduce inequalities and improve health outcomes for all New Zealanders
    Mission
    Lead the health and disability sectors in driving the effective use of reliable evidence
  • NZGG record in evidence …..
    Guidelines – 30 reports including 5 explicit evidenced based reports
    Evidence and technical reports - 30
    Consumer work – 1 major report on development of a consumer forum
    Complementary and alternative medicine reports – 16
    In process – implementation projects, 2 guidelines projects, rapid reviews
  • Cancer topics
    Breast cancer (2009)
    Melanoma (2009)
    Cancer investigation, referral & reduction of disparities (2009)
    Prostate cancer (2010)
    Bowel cancer (underway)
    National Cancer Network (for protocols for chemotherapy)
  • Cardiovascular guidelines: all in one place
    Cardiovascular Risk assessment and diabetes screening
    Cardiac risk factor management
    Smoking cessation
    Atrial fibrillation and flutter
    Coronary heart disease
    Stroke and transient ischaemic heart disease
    Rheumatic heart disease
    Prevention of infective endocarditis
    Heart failure
  • Mental Health Topics
    Suicide and self harm prevention guidelines (2004)
    Depression guidelines (2008)
    Autism Spectrum Disorders (2008)
  • Other topics
    Gynaecology
    Heavy menstrual bleeding
    Fibroids
    Fertility treatments (ICSI and assisted hatching)
    Obstetrics
    Vaginal birth after caesarean section
    Breech management
    Injuries
    Hip fractures
    Knee injuries
    Shoulder injuries
    Management of burns
    Fluoride for communities
  • But.......
    We are not complacent......There are challenges ahead!
  • Some of the challenges
    Our guidelines are big (and costly)
    Tension between quality, affordability and usefulness
    Lack of knowledge about where the true evidence-practice gaps are
    Lack of national data
    Lack of insight into the bigger/national practice issues
    Electronic platforms for guidelines
    Many available
    But costly….
  • The opportunities
    New Zealand has a well developed primary care sector
    “better, sooner, more convenient health care” – connecting primary and secondary health care
    Newly established Health Quality and Safety Commission
    We have a focus on new initiatives and innovations…
  • Can we use our electronic connections...
    NZ Primary Care Doctors use electronic patient medical records
  • 48
    Doctor Routinely Receives Reminders for Guideline-Based Interventions or Screening Tests
    73
    72
    54
    49
    47
    39
    27
    21
    16
    16
    10
    Percentages may not sum to totals because of rounding.
    Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
  • NZGG: what’s new ….
    Smaller more focused guidelines
    Prioritised clinical questions
    More partnerships
    clinicians, health care organisations, researchers, patient groups
    More implementation*
  • NZGG’s Implementation Approach
    Identify key themes to promote
    Identify the range of audiences – and find out how they want to learn about the messages
    Primary care, Specialists, Allied health practitioners
    Consumers and the media
    Policy makers and funders
    Software vendors
  • Then we consider…
    Barriers to implementation
    Workforce requirements
    Cost implications
    Identify incentives that could encourage uptake of the guideline
  • NZGG recent implementation examples
    Whakawhanuatanga– implementing the suicide and self harm guidelines in emergency departments
    Autistic spectrum guidelines -
    Rapid E for priority change area
  • What is a Priority Change Area?
    It’s an area where there are problems with current practice or service delivery,
    Examples - where one or more of the following apply:
    high degree of variation from evidence-based best practice or service delivery
    Potential for high impact on patient outcomes if practice or service delivery were to become evidence-based
    Potential for this impact to occur for Maori, Pacific or Asian populations
    Potential for patients to reach critical points in the care pathway more quickly
    An area of important or worrying uncertainty about what is best practice.
  • ‘Rapid – E’ is a combination of…
    Tight and limited topics
    Clinical evidence review (from existing high quality guidance or from new review)
    Implementation evidence review
    Implementation plan
    Production of media / resources / change tools for active sector engagement
    Measurement
  • Rapid E
    Diabetes
    tools will be launched at the College of GP conference
    a package of algorithms
    CME and promotion/education
  • Making it work
    Stroke guidelines
    Collaboration between Australian and New Zealand, Stroke Foundation, Colleges
    347 pages long
    10 chapters
  • From the guideline to the local clinical pathway……
  • Summary
    Evidence is at the heart of health strategy
    Evidence needs to be highest possible quality
    Cochrane groups and New Zealand Guidelines Group are well positioned to deliver high quality evidence to inform decision making
    Your support and constructive feedback are crucial
  • Thank you