The cochrane library an introduction for rheumatologists - 17 feb 2014

www.thecochranelibrary.com
Archie Cochrane
The Cochrane Collaboration is named in honour of Archie
Cochrane, a British medical researcher who contributed greatly to
the development of epidemiology as a science.
He is best known for his influential book, Effectiveness and
Efficiency: Random Reflections on Health Services, published in
1972.
The Gold Standard
The Cochrane Library contains high-quality, independent evidence
to inform healthcare decision-making from Cochrane and other
systematic reviews, clinical trials, and more. Cochrane reviews
bring together the combined results of the world’s best medical
research studies, which are recognised as the gold standard in
evidence-based health care.
The Library consists of a collection of healthcare
databases, providing access to articles reviewing the effects of
healthcare interventions.

What is a Systematic review?
A systematic review identifies an
intervention for a specific disease or other
problem in health care, and determines
whether or not this intervention works
More than 5,000 now online

The output of the Cochrane
Collaboration are systematic reviews.
These are published in the Cochrane
Library

The Databases
1. Cochrane Database of Systematic Reviews (Cochrane Reviews)
2. Central Register of Controlled Trials (Clinical trials)
3. Database of Reviews of Effects (Other reviews)
4. Health Technology Assessment Database (Technology Assessments)
5. Methodology Register (Methods Studies)
6. NHS Economic Evaluation Database (Economic Evaluations)
+ About The Cochrane Collaboration and the Cochrane Collaborative Review Groups

• Cochrane Reviews
• Other Systematic Reviews
• Trials – Cochrane Central
• Methods Studies
• Technology Assessments
• Economic Evaluations
6 databases in 1

9
The Cochrane Database of Systematic Reviews (CDSR)
• The database that contains all the Cochrane Reviews
• Issue 12, 2013 of CDSR (December):
8,190 TOTAL RECORDS:
• Comprises 5804 full reviews and 2386 protocols.
– in html & PDF format
• Updated daily – (new publish-when-ready
model launched in 2013)

• DARE
• Called ‘Other Reviews’ in the search results
• Sometimes accompanied by assessment or
commentary
Database of Abstracts of Reviews of Effects

Cochrane Central Register of Controlled Trials
• Called CENTRAL or (Trials in your search results)
• RCTs and quasi-RCTs
• includes MEDLINE and Embase
records
• records from other
databases,
hand-searching journals,
and conference proceedings.
CENTRAL
650,000
records
MEDLINE
375,000
Embase
55,000
Other
220,000

• Also called (Technology Assessments)
• Example: Pressure ulcer prevention: pressure ulcer
risk assessment and prevention, including the use of
pressure-relieving devices (beds, mattresses and
overlays) for the prevention of pressure ulcers in
primary and secondary care (Structured abstract)
• National Institute for Clinical Excellence. 2003
Health Technology Assessment Database

• (Methods Studies)
• Reviews of research methods or ‘what works
in research’.
• Example: How effects on health equity are
assessed in systematic reviews of
interventions Vivian Welch , Peter Tugwell ,
Mark Petticrew et al.
Cochrane Methodology Register

• Cost and Cost benefit analysis are part of these
reports
• Example: Cost-effectiveness of total knee
arthroplasty in the United States: parient risk
and hospital volume
• Losina E , Walensky RP , Kessler CL , Emrani PS ,
Reichmann WM , Wright EA , Holt HL , Solomon DH ,
Yelin E , Paltiel AD and Katz JN Archives of Internal
Medicine, 2009, 169(12), 1113-1121
NHS Economic Evaluation Database
(Economic Evaluations)

Why systematic reviews?
• efficient way to access the body of research
– saves time required for searching
– critical appraisal
– interpretation of results
• explore differences between studies
• reliable basis for decision making
– unbiased selection of relevant information
– useful for health care, policy, future research

• SRs are important to:
– Practitioners – to determine if an intervention is
effective in a given situation
– Consumers – to weigh potential benefits and
harms of alternative courses of care
– Policy makers – to help make choices intended to
maximize health for society
How can reviews inform practice?

17
When would you search the Cochrane
Library?
• What is the effective treatment of y?
• What is the effective treatment of y in
condition x?
• Is treatment y better than treatment z?
• What is the accuracy of a diagnostic text ‘x’?
Boagey, Paul. Using the Cochrane Library. University of Southampton Library, November 2007.
http://www.soton.ac.uk/library/subjects/sonm/pptcochranenov2007.ppt

18
When NOT to use the Cochrane Library
• General health care information:
prognosis, etiology, epidemiology...
• Incidence and prevalence of a condition
• Mechanism of action of a drug or technology
• Needs assessment studies
Boagey, Paul. Using the Cochrane Library. University of Southampton Library, November 2007.
http://www.soton.ac.uk/library/subjects/sonm/pptcochranenov2007.ppt

• Clinical Problem
• Question formulation
• Searching the Cochrane Library
Using the Cochrane Library

• From clinical problem to answerable question
Question formulation (PICO):

A searchable question
• Break your question down into concepts:
P I C O
• Population
• Intervention
• Comparison
• Outcome

Your query…
You notice at a rheumatology meeting that
views are polarised about whether low-dose
prednisolone has a place in early rheumatoid
arthritis.
You wonder what is the evidence that
prednisolone reduces joint damage?

PICO
Population = early RA
Intervention = low dose glucocorticoids
Comparison = placebo or active controls
Outcome = radiological progression

• What are the PICO elements in the following
case?
• 5 min
Case #1 Paul

Case study: Paul, age 55, has OA of
the knees.
Paul, 55 years old, came to his doctor seeking advice for a 3-year
history of progressively worsening pain in both knees. His knees
were stiff for about 20 minutes when he woke up in the morning.
He could not walk > 30 minutes because of pain, and his
symptoms were worsened by kneeling, squatting, or descending
stairs. Although sitting and resting relieved the pain, he became
stiff if he stayed in one position for too long. His brother thought
he should try acupuncture because of a positive report in a
newspaper article.

• www.cochranelibrary.com
• 15 min
• What review did you find?
• Did you find any other results?
Finding your answer in the
Cochrane Library

• What are the PICO elements in the following
case?
• 5 min
Case #2 Barbara

Case Study: Barbara, age 59, faces a decision of whether to
take Alendronate to prevent a future bone fracture.
While on holiday Barbara fell and broke her arm and left shoulder. Her
arm was put in a sling and she was given painkillers. When she came
back home, her doctor referred her for an X-ray which showed she had
multiple fractures in her arm and shoulder. Since the fractures
seemed excessively severe for the type of fall she had, her doctor
arranged a bone density test and examination by a specialist. She was
told she was at high risk of having another fracture and should take
Alendronate to prevent this.

What to consider when reading a review…
Do the studies address a sensible clinical question?
Do the studies possess high quality designs and methods?
Are the results from the studies similar or widely different?
Are the conclusions drawn consistent with the method employed?
Are all relevant and important outcomes considered?
How do the results apply to the care of my patients?

Three broad issues to consider…
• Is the review valid?
• What are the results?
• Will the results help my patients?

Is the review valid?
• systematic review methods vary
• quality of reporting may vary
• caveat emptor: up to you to decide

Is the review valid?
• clearly focused question (PICO)
• inclusion of relevant, high quality studies
• comprehensive and reproducible search strategy
• ‘a priori’ method for assessing quality of included
studies

• Some people find systematic reviews
unwieldy, too technical, and inaccessible.
• New features aim to make the messages in
Cochrane reviews clear and easier to use in
decision-making.
New formats to disseminate
review results

Podcasts from The Cochrane Library
Essential audio summaries of key reviews
More than 250 Podcasts
available for download
Podcasts include key new
reviews, most accessed
reviews and key topics
Download or listen to the
latest podcasts online at
www.cochrane.org/podcasts

■ Read the original review article for FREE
■ Podcasts: download or listen online
■ PowerPoint Slides: download or view online
■ Interactive: ask the authors a question and
receive a reply
■ Discussion Points: what are the questions
you should be asking as you read this paper?
Cochrane Journal Club
“If you are running a journal club, or interested in doing so, we provide the materials to
help you plan a session concentrating on an important, practice changing, Cochrane
Review.” -Dr David Tovey, Editor-in-Chief

Cochrane Clinical Answers
http://cochraneclinicalanswers.com/
■ A point-of-care clinical support tool for
busy health professionals
■ Distills high-quality evidence from
Cochrane systematic reviews into practical
answers to common clinical questions
■ Designed to mimic the way health
professionals gather information
■ New questions continually added to
ensure broad coverage across a range of
medical topics
■ Available now for purchase by Cochrane
Library subscribers

■ A suite of online learning activities designed for
health care professionals
■ Learning activities are based upon high-quality
evidence from Cochrane systematic reviews
■ Reflective evaluation encourages practice change
■ Meets the rigorous accreditation standard of the
ACCME*
■ Launching in 2013
*Accreditation Council for Continuing Medical Education
Cochrane Learning

■ Access a monthly selection of specially
curated Cochrane Reviews via The
Cochrane Library iPad Edition
■ Each issue includes a selection of new
and recently updated reviews specially
abridged for iPad users
■ Includes podcasts, Slide decks and
Cochrane Editorials
■ Monthly issues automatically download
to your Newsstand
■ FREE app available in iTunes
Cochrane iPad Edition

New Search Tools
The Cochrane Library’s new search interface launched September 15.
Highlights of the new search features include:
■ Auto-suggest features within both basic and MeSH search functions
■ Updated display of search results
and filtering options
■ Ability to view search terms
and results on the same page
■ Ability to insert lines and add
one search to another
■ Improved MeSH look-up feature
■ Hover-over Tool Tips

Online Training
Monthly instructor-led training
sessions with a focus on how to search
The Cochrane Library
Navigate your browser to
https://wiley-onlinelibrary.webex.com/
to register and attend a session
Or contact Gavin Stewart at Wiley
(gstewart@wiley.com) if you require a
bespoke session for your team

Cochrane Canada
Live Webinar
series
http://ccnc.cochrane.org/training-and-events

• Cochrane Musculoskeletal Group:
musculoskeletal.cochrane.org
• Cochrane Back Group: back.cochrane.org
• Cochrane Child Health Field:
childhealth.cochrane.org
Ways to get involved:

44
The Cochrane Library Users’ Group
Offers:
Answers from the experts
A forum for information-sharing
An opportunity for feedback
To get involved:
www.CLUG.iwh.on.ca
Or contact Emma Irvin eirvin@iwh.on.ca

What to do when there is no
Cochrane review

PubMed Clinical Queries

Turning Research into Practice
(TRIP) Database

Thank you for joining
us today!
ccc.cochrane.org/training-and-events
trader@uottawa.ca

Acknowledgements
• Based on materials by the Australasian
Cochrane Centre and Canadian Cochrane
Centre, also with thanks to Wiley.
• Thank you to Eileen Vilis, Miranda Cumpston,
and Gavin Stewart for help with the slides.

The cochrane library an introduction for rheumatologists - 17 feb 2014

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