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Cochrane Present Tech - Cochrane Future Tech

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Ida Sim, from #CochraneTech Symposium, Québec 2013

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Cochrane Present Tech - Cochrane Future Tech

  1. 1. Cochrane Present Tech Cochrane Future Tech Ida Sim, MD, PhD University of California San Francisco Open mHealth September 17, 2013
  2. 2. • In 2003, estimate of 10-45,000 reviews needed to cover existing evidence as of 2003 – projected Cochrane to hit 10,000 reviews between 2010 and 2015 Mallet and Clarke, EBM 2003(8):100-1 Total Protocols Total Reviews Total Updated Reviews1000th Cochrane review 5665 total reviews today
  3. 3. How can we better leverage technology and knowledge to both help us prepare systematic reviews more efficiently but also deliver the outputs better to our end-users?
  4. 4. Setting the Stage: PICOT P opulation I ntervention C omparison O utcome T ime frame
  5. 5. Intervention P I Synthesized evidence, the "Cochrane Way" C O T
  6. 6. (Target) Population P Health care systems, clinicians I Synthesized evidence, the Cochrane Way C O T
  7. 7. Outcome P Health care systems, clinicians I Synthesized evidence, the Cochrane Way C O Population-level health outcomes & costs T
  8. 8. Comparison P Health care systems, clinicians I Synthesized evidence, the Cochrane Way C Eminence-based medicine O Population-level health outcomes & costs T
  9. 9. Time frame P Health care systems, clinicians I Synthesized evidence from the Cochrane Way C Eminence-based medicine O Population-level improvement in health, costs T Too many yearsT
  10. 10. Setting the Present Stage Cochrane Present P health systems, clinicians I Cochrane Way C eminence-based med O pop-level health & cost T too many Cochrane Future P I C O T
  11. 11. Cochrane Way: Workflow
  12. 12. Technology for Pain Points
  13. 13. Setting the Future Stage Cochrane Present P health systems, clinicians I Cochrane Way C eminence-based med O pop-level health & cost T too many years Cochrane Future P I Cochrane Way C O T
  14. 14. Additional Outcomes Cochrane Present P health systems, clinicians I Cochrane Way C eminence-based med O pop-level health & cost T too many years Cochrane Future P I Cochrane Way C O cost T
  15. 15. Chronic Diseases Drive Cost • 46% of morbidity and 59% mortality worldwide due to chronic diseases1 • Health systems targeting chronic care – 1/3 of deaths due to poor health behaviors – need to engage patients in self-care • Patients expect personalized medicine – want evidence at the individual-patient level WHO | Facts related to Chronic Disease http://www.who.int/dietphysicalactivity/publications/facts/chronic/en/
  16. 16. Additional Outcomes and Population Cochrane Present P health systems, clinicians I Cochrane Way C eminence-based med O pop-level health & cost T too many years Cochrane Future P add patients & families I Cochrane Way C O add ind-level health T
  17. 17. Time Frame • Personal digital technologies will play large role in chronic disease and transforming health – 20,000 health apps on iTunes, 8,000 on Google Play – technologies evolve rapidly • US Institute of Medicine goal of a continuous Learning Health System Riley et al. Clinical and Translational Medicine 2013, 2:10
  18. 18. New Time Frame Cochrane Present P health systems, clinicians I Cochrane Way C eminence-based med O pop-level health & cost T too many years Cochrane Future P add patients & families I Cochrane Way C O add ind-level health T continuous
  19. 19. New Comparison Intervention Cochrane Present P health systems, clinicians I Cochrane Way C eminence-based med O pop-level health & cost T too many years Cochrane Future P add patients & families I Cochrane Way C Big Data O add ind-level health T continuous
  20. 20. Three Illustrative Projects • N-of-1 studies for chronic pain • Kaiser: Diabetes and depression management • Health eHeart virtual cohort
  21. 21. PREEMPT Project • Chronic Pain is highly prevalent (>100 million Americans) and difficult to treat • Few studies on comparative effectiveness of analgesics, yielding only average population-level estimates R01-NR013938, PI R. Kravitz 50 people 100 people oxycodone Pain frequency, intensity 50 people hydrocodone population Pain frequency, intensity
  22. 22. none of us are average hydrocodone betteroxycodone better
  23. 23. which works better for you? N-of-1 study design: within-subject crossover design Kravitz, et al. Contemp Clin Trials 2009; 30:436-445 BPI individual pain intensity You pain intensity oxycodone hydrocodone hydrocodone oxycodone oxycodone hydrocodone
  24. 24. there you are! hydrocodone betteroxycodone better
  25. 25. n = 1
  26. 26. (n 1).N
  27. 27. Zucker DR et al. J Clin Epidemiol. 2010;63(12):1312-23. (n 1).N Σ
  28. 28. flip direction of research inference population
  29. 29. Differences from Traditional Research • Occurs in the course of clinical care • Patient participation, addresses patient questions • Patient choice in outcomes measured • Individual treatment effect • Aggregate to population-level effect
  30. 30. S. California Kaiser Complete Care Improving self-management of diabetes in patients with depression
  31. 31. Continuous Evaluation • eHealth interventions will play a substantial role in chronic care management and in shaping health care systems • Evaluations need to occur while they are being designed, developed, and deployed. Catwell and Sheikhl, PLoS Med 2009; 6(8):e1000126 Usability Studies Preliminary effectiveness User Requirements Pilot Field Testing Rigorous effectiveness
  32. 32. Differences from Traditional Research • Evidence is needed on intermediate non- clinical outcomes (e.g., effective design features) as well as end clinical effectiveness • Many of these evaluations will not be published in academic journals
  33. 33. • Enrolling 1,000,000 patients, capturing – self report data: food intake, mood – sensor data: weight, BP, activity – social data: Facebook – EHR data: including text mining for CV events – biospecimens and CV tests for San Francisco area patients • Trades precise data on fewer patients for messier data on 1000x more patients – will be supplemented with targeted data collection for specific studies
  34. 34. Future Cochrane Way? Cochrane Present P health systems, clinicians I Cochrane Way C eminence-based med O pop-level health & cost T too many years Cochrane Future P add patients & families I Cochrane Way? C Big Data O add ind-level health T continuous
  35. 35. "A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be." Wayne Gretsky, Edmonton Oilers
  36. 36. Where the Puck is Today Studies in PDF Forest plots in PDF Cochrane Way Draws the most sound inference from the totality of the available evidence
  37. 37. Where the Puck will be Evidence = study protocol + results Synthesized evidence continuous, multi- modal, personal data more personalized questions large, less controlled studies individual-level evidence range of acceptable rigor continuous release schedule Cochrane Way Drawing the most sound inference from the totality of the available evidence
  38. 38. Build to Basic Principles • Data sciences • Operational • Methodological
  39. 39. Data Sciences • Beyond PDF reports of study results – embrace data publishing • publish protocols as computable models • publish all results as open computable data – text mining to extract meaning from prose • No data silos: linked open data • Describe the data: metadata and ontologies for – study questions – study design (Ontology of Clinical Research) – systematic reviews (Cochrane Ontology)
  40. 40. Data Sciences Goal • Capture open data in clearly described computable form that can be re-purposed for multiple needs today, and unknown needs tomorrow
  41. 41. Operational • Pursue hybrid semi-automated approaches – seek out and work with the best designers of human-computer interaction • Support distributed, collaborative knowledge work, tapping into crowds
  42. 42. Methods Needed • Heterogeneity of treatment effect • Continuous evaluation methods • Large-scale assessment of biases and confounders • Better decision support for assessing biases and confounders • ...many more
  43. 43. The "Human Evidence Project" + + Methods Data Metadata + Most sound individual and population-level summary evidence for continuous learning
  44. 44. Conclusion • How to get from Cochrane Present to Cochrane Future? – new methods built on open data and ontologies – design hybrid human-computer systems • In new Big Data world, methodologically sound but pragmatic, sustainable evidence synthesis will be critical • Need Cochrane now more than ever

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