Abstracts of the 21st Cochrane Colloquium

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21st Cochrane Colloquium
Better Knowledge for Better Health
Un meilleur savoir pour une meilleure santé
19–23 September 2013
Abstract and Workshop Committees
Thank you to those who contributed to the committees and to those who were willing
to contribute, but were not called on. We appreciate your time and effort!
Abstract Committee:
Marialena Trivella (co-chair)
Erin Ueffing (co-chair)
Nadera Ahmadzai
Regis Bruni Andriolo
Mohammed Ansari
Amir Azarpazhooh
Lynda Bélanger
Elaine Beller
Joseph Beyene
Mary Brachaniec
Jennifer Cartwright
Esther Coren
Luis Gabriel Cuervo
Pierre Dagenais
Karin Dearness
Robert Dellavalle
Carolyn Doree
Pierre Durieux
Zbys Fedorowicz
Ricardo Fernandes
Michelle Fiander
Damian Francis
Joel Gagnier
Chantelle Garritty
Francois-Pierre Gauvin
Stephen Gichuhi
Claire Glenton
Janet Gunderson
Gill Gyte
Lisa Hartling
Jill Hayden
Eftyhia Helis
Sally Hopewell
Evan Kontopantelis
Carol Lefebvre
Simon Lewin
Tianjing Li
John MacDonald
Mala Mann
Teresa Marin
Alain Mayhew
Steve McDonald
Sreekumaran Nair
Mona Nasser
Mandi Newton
Denise O’Connor
Ajima Olaghere
Nikolaos Pandis
Elena Parmelli
Rafael Perera
Tracey Perez Koehlmoos
Elizabeth Pienaar
Livia Puljak
Kusala Pussegoda
Gabriel Rada
Georgia Salanti
Nancy Santesso
Holger Schunemann
Guido Schwarzer
Ian Shemilt
Ian Shrier
Harry Siristatidis
Becky Skidmore
Andrew Smith
Rene Spijker
Adrienne Stevens
Caroline Struthers
Katrina Sullivan
Yemisi Takwoingi
Elizabeth Tanjong Ghogomu
Lori Tarbett
Britta Tendal
Prathap Tharyan
Karine Toupin April
Lucy Turner
Luke Vale
Eileen Vilis
Janet Wale
Marilyn Walsh
Vivian Welch
Phil Wiffen
Robert Wolff
Julia Worswick
Workshop Committee:
Marialena Trivella (co-chair)
Erin Ueffing (co-chair)
Jennifer Cartwright
Christopher Cates
Jackie Chandler (co-chair)
Esther Coren
Luis Gabriel Cuervo
Pierre Dagenais
Karin Dearness
Zbys Fedorowicz
Joel Gagnier
Francois-Pierre Gauvin
Claire Glenton
Lisa Hartling
Jill Hayden
Eftyhia Helis
Julian Higgins
Sally Hopewell
Karsten Juhl Jørgensen
Toby Lasserson
Carol Lefebvre
Alain Mayhew
Sreekumaran Nair
Denise O’Connor
Nathan Pace
Matthew Page
Elena Parmelli
Nancy Santesso
Holger Schunemann
Katrina Sullivan
Elizabeth Tanjong Ghogomu
Lucy Turner
Luke Vale
Julia Worswick
Abstracts of the 21st Cochrane Colloquium
Supplement 2013
Poster Abstracts
Poster Abstracts
Special Sessions
Special Sessions Abstracts
Oral sessions
Session O1.01: Online Tools for Dissemination and Communication
Session O1.02: Publication/Reporting Bias
Session O1.03: Statistical Methods –Intention-to-treat
Session O1.04: Conflicts of Interest
Session O1.05: Searching and Information Retrieval –Session 1
Session O1.06: Investigating Bias –Session 1
Session O1.07: Accessing and Disseminating Cochrane Evidence
Session O1.08: International Approaches
Session O1.09: Knowledge Translation and Communicating the
Evidence –Session 1
Session O1.10: Outcomes
Session O1.11: Qualitative Evidence
Session O1.12: Diagnostic Test Accuracy Review Methods
Session O1.13: Evidence Packaging
Session O1.14: Cochrane Structure and Processes
Session O1.15: Tools for Review Authors
Session O1.16: New Tools of Dissemination
Session O1.17: Methods for Improving Review Efficiency
Session O1.18: Complexity
Session O1.19: Investigating Bias –Session 2
Session O1.20: Using Cochrane Systematic Reviews
Session O2.01: Review Methods
Session O2.02: Skill Development
Session O2.03: Individual Participant Data
Session O2.04: New Developments in Training
Session O2.05: Conducting Risk of Bias Assessments
Session O3.01: Advanced Review Methods
Session O3.02: Partner/Knowledge User Engagement
Session O3.03: Statistical Methods –Advanced, Session 1
Session O3.04: Rapid Response
Session O3.05: Heterogeneity
Session O3.06: Shared Decision-making
Session O3.07: Challenges in Review Methods
Session O3.08: Review Impact
Session O3.09: Future Tech
Session O3.10: Statistical Methods –Advanced, Session 2
Session O3.11: Global Health and Equity –Session 1
Session O3.12: Reporting Evidence
Session O3.13: Knowledge Translation and Communicating the
Evidence –Session 2
Session O4.01: Quality of Guidelines
Session O4.02: Statistical Methods –Network Meta-analysis
Session O4.03: GRADE and Summary of Findings Tables
Session O4.04: Mixed Methods and Realist Reviews
Session O4.05: Global Health and Equity –Session 2
Session O4.06: Editorial Processes and Supporting Review Authors
Author Index
Author Index
Abstracts available online at www.cochrane.org
Abstracts of the 21st Cochrane Colloquium
New marketing and communication strategies
of the Brazilian Cochrane Centre
Posters sessions
Evidence meets the media: working with science
journalists in South Africa
Fioretti BTDS, Carvalho MR, Riera R, Torloni MR, Martimbianco ALC,
Grande AJ, Porfı́rio GJM, Costa MB, Torres MFS, Silva V, Costa CS, Macedo
CR, Silva EMK, Puga MES, Melnik T, Atallah Á
Brazilian Cochrane Centre, Brazil
Schoonees A1 , Naude CE1 , Lombard MJ2 , Young T1
1 Centre for Evidence-Based Health Care, Faculty of Medicine and Health
Sciences, Stellenbosch University, South Africa; 2 Division of Human
Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University,
South Africa
Background: In 2012, Brazilian Cochrane Centre (BCC) decided to
increase dissemination of its activities to professionals and consumers,
emphasizing the importance of looking for systematic reviews (SR)
when facing health related decisions. Objectives: To report new
communication and marketing strategies implemented by the BCC.
Methods: Over the last 6 months, volunteer collaborators of the BCC
have held monthly meetings to plan integrated communication and
marketing strategies. Results: The following strategies have been
implemented: • Improved visual identity: The BCC logo has been
modified improving its quality and the metanalysis diamond is now
represented by the Brazilian flag. • Standardization of the logo in all
the material used in virtual and paper communication. • Improvement
of the language used in the BCC webpage and continuous updating
of events, workshops and activities promoted, including links to new
translations and online courses. • Relationship strategies: creation of
material (postcards, e-mails) for special dates. • Social media: creation
and updating of a BCC Facebook account, using informal language to
inform users about EBH, the Cochrane Collaboration and the BCC. In
its first month, the page had 130 followers. The Basic Workshop post
had 2333 accesses. • Journalism: Creation of an electronic quarterly
online Newsletter with information about the BCC, the Cochrane
Collaboration and EBH, distributed to the press, health institutions,
research agencies, universities and policy makers. The first edition will
be available on the BCC webpage in May 2013. Conclusions: The
aforementioned activities, all developed by volunteer collaborators of
the BCC, are promoting (a) increased visibility and interaction of the
BCC with different publics, (b) increased recognition of the BCC as a
pioneer research center in Brazil and (c) large scale dissemination of
the concepts of EBH in our country and the importance of role of SR
when taking health related decisions.
Background: Consumers are important stakeholders within
evidence-based health care (EBHC). Journalists are gatekeepers to
consumers’ understanding of healthcare, thus influencing consumer
decision-making. Consequently it is important to build capacity of and
engage journalists in knowledge translation activities and the use of
best evidence to inform healthcare decisions. Objectives: To enhance
the capacity of South African science journalists to better understand,
find and apply EBHC principles when reporting on health research.
Methods: As part of an initiative to facilitate engagement between
researchers and science journalists, we are facilitating a workshop on
the use of best evidence and the role of EBHC in October 2013. Content
development: the workshop will focus on the first three steps of EBHC
and is divided into the following subsessions: EBHC: the why, the
what and the how; Ask and you shall retrieve; and Critical appraisal:
not all evidence is equal. We will end off with structured discussions
centred on enablers and constraints of applying EBHC principles during
reporting. There will be ample interaction, using local scenarios
for formulating questions, and referring to The Cochrane Library
for retrieving research. Basic principles of critical appraisal will be
covered and demonstrated. Measuring potential impact and feedback
Potential impacts will be measured by pre- and post-assessments,
consisting of five Likert-scale questions testing confidence in EBHC
knowledge and skills and three multiple-choice questions assessing
application. An evaluation form will be used to obtain constructive
feedback from journalists for improving the workshop. Results: We
will share details regarding the content of the workshop, including the
approach, content and measuring impact. Conclusions: Engaging
with journalists is key to enhance use of best evidence in media articles.
It is of equal importance to familiarise ourselves with journalism
etiquette, and learn about the context and challenges which journalists
operate in.
Consumer involvement in the Cochrane
Musculoskeletal Group
Gunderson J, Fyfe C, Lyddiatt A, Walsh M, Rader T, Ghogomu E,
Maxwell L, Pardo J
Cochrane Musculoskeletal Group
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Background: There is a world-wide trend toward patient involvement
in their health care and in all levels of health research. The Canadian
Institutes of Health Research as well as the Cochrane Musculoskeletal
group has adopted this approach, in the hopes that it will produce
research findings that have greater relevance and usefulness to
consumers are more relevant to consumers and more likely to be used
by them when making health care decisions. Objectives: To showcase
the many different ways consumers are involved with the Cochrane
Musculoskeletal Group. Methods: The Cochrane Collaboration is
an international, independent, not-for-profit organization dedicated to
making up to date, accurate health information available worldwide.
The Cochrane Musculoskeletal group is one of many groups within
the Cochrane Collaboration. Consumers within the Musculoskeletal
group have many different roles including: • Providing comments
on systematic reviews and protocols • Helping to guide research
priorities • Evaluating decision aids and plain language summaries
• Oral and poster presentations at national and international
conferences • Promotion of the Cochrane Library • Knowledge
translation • Recruitment and training of new consumers • Mentoring
new consumers • Joining author teams in writing a systematic
review • Consumer representation on the Cochrane Musculoskeletal
editorial board. Results: The role of consumers within the Cochrane
Musculoskeletal Group continues to expand due to the support and
encouragement of the Group’s staff. There are many ways that
consumers can become involved at a meaningful level. Conclusion:
Within the Cochrane Musculoskeletal Group there are many roles that
consumers can assume including promoting widespread use of The
Cochrane Library Consumers support and work with Collaboration
staff to have full access to The Cochrane Library available for all
Canadians. A challenge faced by the consumer group is recruiting
more members from countries where English is not the first
Critical outcomes in a Cochrane Systematic
Review: patients’ perspective
Omar MI, Lam T, MacLennan S
University of Aberdeen, UK
Background: GRADE methodology requires that up to seven critical
outcomes are selected to highlight the most relevant findings of the
systematic review (1). However, the selection of these outcomes has so
far been left to the review authors. As far as we are aware, no Cochrane
systematic reviews have explored the views of patients while selecting
outcomes for summary of findings tables. Objective: To identify
which outcomes are important to patients undergoing short-term
urinary catheterisation. Methods: We contacted content experts to
identify outcomes of importance to patients undergoing short-term
urinary catheterisation that could be included in a Cochrane systematic
review. The content experts included clinicians, nurses, and a health
economist. Subsequently, through a local charity (UCAN), we identified
five individuals who had undergone urinary catheterisation and invited
them to take part in a group discussion to identify important outcomes
from their perspective. The participants were not aware of the views
of the content experts. Results: The content experts identified the
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
following critical outcomes: symptomatic catheter-associated urinary
tract infection (CAUTI) with microbiological evidence; symptomatic
CAUTI without microbiological evidence; patient discomfort whilst
catheter is in situ; bacterial resistance to the antimicrobial agent; and
urinary sepsis. Participants suggested that infections and discomfort
were certainly important from their point of view. However, they also
highlighted length of hospital stay and the duration of catheterisation
as important. Interestingly, participants also raised issues around
being catheterised and the impact on self-esteem and ability to wear
clothes comfortably. Conclusions: There was some overlap between
the views of the participants and the content experts on important
outcomes, but patients reported that broader quality of life issues
were also of importance. It is paramount that patient’s perspective
is at the heart of Cochrane Reviews in order to maximise their
1. Guyatt GH, et al. GRADE guidelines:12. Preparing summary of
findings tables-binary outcomes. JCE 2013; 66(2):158–172.
The Cochrane Library publicity programme—
promoting Cochrane evidence worldwide
Urquhart B, Beal J
Wiley, Chichester, UK
Background: Press releases highlighting selected new and updated
Reviews are an important part of the monthly marketing strategy for
The Cochrane Library. Reviews published in the Cochrane Database
of Systematic Reviews are often reported by journalists and bloggers,
and coverage is increasingly international. Objectives: The objective
of Wiley’s publicity strategy is to raise the international profile of The
Cochrane Library through professional and consumer media, and to
increase usage. Methods: A number of new and updated reviews
are selected for publicity from each monthly issue of The Cochrane
Database of Systematic Reviews. The resulting coverage is analysed
by region, and we also look for a corresponding increase in usage
for the articles that are most widely reported. Results: In 2012
Wiley issued press releases on 33 Cochrane Reviews, generating 4268
stories in the media. Cochrane stories were covered in over 2400
media outlets in over 80 countries. Of the media outlets which covered
Cochrane stories, 18 ran 10 or more pieces (0.73%), 89 ran 5 or
more pieces (3.6%), and 390 ran 3 or more stories (15.7%). 9.7%
of stories were in a language other than English, from 15 different
languages in total. The US was the country with the most coverage,
reporting 2176 stories. Increasingly our press releases are highlighted
and reported via social media in addition to traditional and broadcast
media, especially on blogs and Twitter. Conclusions: Media coverage
of new and updated Cochrane Reviews raises the international profile
of The Cochrane Library in both professional and consumer media, and
increases the usage of Cochrane Reviews. With the move to ‘when
ready’ publication of CDSR in 2013 it will be important to ensure that
relevant Reviews continue to be highlighted in traditional and social
Cochrane Database Syst Rev Suppl 1–212 (2013)
The ‘Implications for Practice’ of empty reviews:
an analysis of Cochrane Systematic Reviews with
no included studies
Yaffe J1 , Shepard L1 , Hopewell S2 , Montgomery P2
University of Utah, USA; 2 University of Oxford, UK
Background: Systematic reviews that find no studies eligible for
inclusion, commonly known as ‘empty reviews’, may be especially
problematic for clinicians and other decision-makers. The reporting of
implications for practice in particular has been suggested as potentially
sustaining a risk for bias. Objectives: This research examines
the reporting of ‘Implications for Practice’ of empty reviews in The
Cochrane Database of Systematic Reviews (The CDSR). Methods: All
empty reviews within the CDSR as of August 15, 2010 were identified,
extracted, and coded for analysis. Descriptive characteristics and the
complete ‘Implications for Practice’ section were extracted from each
empty review. Thematic content analysis was performed by two authors
(JY & LS) and refereed by the third author (PM). Results: 376 (8.7%)
active reviews in the CDSR report no studies eligible for inclusion.
Of these, 117 (31.1%) contained a one sentence ‘Implications for
Practice’ section, generally concluding that no studies were identified
for inclusion. 59 (15.7%) appeared to contain recommendations to use
the reviewed intervention (39.0%), restrict the use of the intervention
(22.0%), not use the intervention (25.4%), or use something else
(13.6%). 26 (6.9%) were written in such tentative language, that
it was not possible to come to an agreement as to whether or not
the section made recommendations. Around half of ‘Implications for
Practice’ sections made reference to evidence, but only 16% of these
cited its source. At least one Cochrane Review Group (Schizophrenia
Group) provided implications for multiple audiences, though resulting
in rather lengthy discussions given the absence of eligible studies.
Conclusions: The reporting of ‘Implications for Practice’ sections
appears to differ widely across empty reviews. A considerable number
of these reviews were shown to simply conclude no studies were
included or to issue recommendations, discuss excluded studies, use
vague language, and/or fail to cite referenced studies.
A crib sheet for Cochrane Review authors’ use
of trial registries
Abrams A, Pienaar E, Kredo T
South African Cochrane Centre, MRC, South Africa
Background: Clinical trial registries offer free, useful tools for
identifying ongoing trials to be included in updates of reviews, assessing
topics where reviews should be undertaken, and as a networking
tool for review authors seeking further information or unpublished
research. Prospective trial registration is an important means of
ensuring transparency and completeness in trial reporting. Cochrane
authors face challenges assessing selective outcome reporting when
adjudicating bias in trials they include in reviews. A trial registry is
a useful cross-referent for judging bias. Increasingly, trial registries
allow retrospective registration of trials to ensure that databases
make accessible as much information as possible. This shift in practice
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
means reporting identification numbers provided by registries no longer
provides authors with proof that a trial’s outcomes have not changed
or can be tracked from the trials inception. Objectives: To describe
and demonstrate the important differences across trial registries that
relate specifically to Cochrane Review authors ability to judge bias.
Methods: First we describe the utility of a registry in adjudicating bias.
We then describe each of the member registries in the WHO Network
of Primary Registers, their timing policies for the trials they accept,
and the related impact this may have on Cochrane authors. Of the
14 registries, the majority are now accepting retrospectively registered
trials. Such a change could affect the utility of the registry as a tool,
and we provide warnings to ensure that review authors are aware of
the implications. Conclusions: A trial registry is a free, valuable tool if
used correctly. In order to do so, users must be kept abreast of changes
made to the registration processes of such registries. This research will
provide a clear outline of those changes and the potential ramifications
that such changes have for adjudicating bias and inclusion of trials for
systematic reviews.
Illuminating review results using systematic
evidence mapping
Coren E1 , Hossain R1 , Pardo J2 , Kavanagh J3
Cochrane Public Health Group, UK; 2 Cochrane Equity Methods Group,
Canada; 3 Eppi Centre, UK
Background: Of 29 151 citations retrieved for a review about street
children, the majority were excluded as not topic relevant, and 2085
potentially relevant studies were excluded on study design. Given that
street children are a ‘hard to reach’ research group further analysis
of these studies was undertaken, using systematic mapping methods.
A further 1087 citations were included following an updated search.
Objectives: 1. To systematically and transparently describe this
additional research literature 2. To identify a subset of studies for
inclusion in thematic synthesis. Methods: 294 research studies
from low and middle income countries (LMICs) only were included
in the map. They were screened and coded according to a range
of predetermined categories (e.g country, study design, population,
study purpose) using Eppi Reviewer 4 software. A thematic synthesis
was performed on selected studies focusing primarily on intervention
processes. Results: 294 publications were included and descriptively
coded (NB. approximately 7% are awaiting coding). There was a
wide range of study designs: cross-sectional surveys (n = 125%,
43%); 95 (33%) qualitative/ethnographic studies; 27 (9%) each
were reviews, case-control, or case-studies, 10 (3%) used other
designs. Research purpose varied, 102 (36%) studies gathered
young people’s views about their lifestyles, 90 (n = 31%) reported
epidemiological/medical data about street children, 51 (n = 19%)
evaluated contextual/predictive factors, and 9% reported young
people/provider views about services. Mapping identified an important
gap between the wealth of descriptive research and the relative absence
of intervention evaluations in LMICs in this area Further descriptive
characteristics and the findings of the thematic synthesis will be
presented. Conclusions: This project illuminated a body of literature
providing insights into the mechanisms and processes of effectiveness,
enabling the research team to access the views and experiences of
Cochrane Database Syst Rev Suppl 1–212 (2013)
street children. Systematic mapping provides a broader overview of a
topic, and useful information for practitioners and policy makers.
Attachments: Map abstract Table 1.pdf
Registered paediatric trials worldwide:
frequency, location and focus
Joseph D, Caldwell P, Craig J
University of Sydney and The Children’s Hospital at Westmead, Australia
Background: The need for more, better, and relevant paediatric
clinical trials have been recognised internationally with several
initiatives underway to fix these gaps, but the current status of trials
involving children is unclear. Objective: To describe and evaluate
the spectrum of registered paediatric clinical trials on the World Health
Organisation International Clinical Trials Registry Platform (ICTRP).
Methods: All clinical trials on ICTRP from 2000 to 2012 were reviewed.
Data extracted included the number of paediatric (0–18 years) and adult
trials, medical conditions treated, intervention type, funding sources,
and location (classified by country). Results: Overall 16.7% (31
587/189 592) of registered trials are paediatric trials. The proportion
of paediatric trials have decreased from 22.9% in 2000 to 15.4% in
2012. However, the total number of trials overall have increased from
484 in 2000 to 4514 in 2012. There are significantly fewer paediatric
trials conducted in low to middle income countries compared to high
income countries (21.8% of trials), considering that 89.3% of children
live in those countries. Paediatric trials in low to middle income
countries focussed on respiratory problems (630, 9.2%), malaria (422,
6.1%), HIV (386, 5.6%), perinatal health (360, 5.2%) and cancer (321,
4.7%) and trials in high income countries focussed on cancers (2447,
9.9%), respiratory health (2360, 9.5%), musculoskeletal diseases
(1645, 6.6%), infections (1203, 4.9%) and metabolic/endocrine
diseases (1074, 4.3%). The majority of registered paediatric trials
were pharmaceuticals trials (10 509, 33.3% of trials). Slightly
more paediatric trials were sponsored by the pharmaceutical industry
compared with adults (4116, 13.0% vs. 19 623, 12.4%, p = 0.002).
Conclusion: Although the total number of trials have increased,
there remains disproportionately fewer paediatric trials compared with
adult trials, particularly in low to middle income countries, with
many pharmaceutical sponsored trials. The focus of the trials seems
appropriate to the disease burden faced by children in those countries.
The therapeutic drug management program:
a collaborative initiative of teaching hospitals
Dupont C1 , Michel M2 , Pelletier É3 , Turgeon M4 , Varin F5 , Deschênes L2 ,
Farand P4 , Froment D5 , Gaudreault P3 , Rajan R1
1 McGill University Health Centre (MUHC), Canada; 2 CHU de Québec,
Canada; 3 Centre Hospitalier Universitaire Sainte-Justine (CHU SainteJustine), Canada; 4 Centre Hospitalier Universitaire de Sherbrooke (CHUS),
Canada; 5 Centre hospitalier de l’Université de Montréal (CHUM), Canada
Background: The Therapeutic Drug Management Program (TDMP)
is an innovative joint venture of university teaching hospitals (UTH)
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
to share expertise, clinical practice experiences and evidence-based
information. The TDMP represents a unique collaborative evidencebased practice initiative between pharmacists and physicians from
different UTHs. Objectives: With limited qualified resources in each
center, the TDMP enables sharing of high quality information to
better address the challenges surrounding the introduction of new
drugs on hospital forms, and to perform drug utilization reviews
(DUR). Methods: An executive committee sets priorities while the
scientific committee develops the methodology for drug evaluations
and DUR. The process integrates systematic reviews of literature,
revision by peers, evaluative and outcome research and assessment
of economic impact. Models for dissemination and integration of the
recommendations are currently under study by the TDMP. Results:
Since its creation in January 2004, the TDMP has published many drug
evaluations, descriptive analyses, and has realized a number of DUR.
Experts from different fields have teamed up with the TDMP, resulting
in publications and talks at different meetings. The main beneficiaries
of the TDMP’s work are the Pharmacy and Therapeutic committees
through facilitation and harmonization of the decision making process.
Since 2004, documents produced by the TDMP are integrated to the
UTH executives’ decision-making process. Conclusions: The TDMP
allows clinicians to access quality and evidence-based information to
optimize drug utilization in their centers. The TDMP converts research
into innovative tools for clinicians and in doing so, facilitates the transfer
of theory into every day practice and therapeutic decision-making.
Attachments: Cochrane Abstract TDMP.20130326.pdf
Shaping HTA to meet new regulatory and pricing
evidence requirements in the UK
Sutton AJ, Abrams KR
University of Leicester, Leicester, UK
Background: As regulators are turning to early and conditional
licensing of new pharmaceuticals to mitigate market access delays;
payers such as the Department of Health in the UK are simultaneously
considering value-based pricing (VBP) as a new scheme to efficiently
allocate scare funds to promising medicines. These on-going regulatory
and pricing changes will have significant implications for the conduct
of health technology assessment (HTA) in coming years. Objectives:
First, to identify key evidential and methodological issues associated
with early drug evaluations, conditional licensing and VBP; second, to
identify potential analytical and statistical solutions to address these.
Methods: A systematic literature review in Medline, EMBASE, and
the Cochrane Library; as well as a comprehensive search of relevant
institutional and government websites was conducted. In addition,
a horizon scan across different research areas was performed to
identify methodological developments not currently used in the health
sciences that could be applicable to the issues raised. Relevant
documentation was reviewed and expert opinion considered for
discussion. Results: Earlier assessment of relative effectiveness
necessitates the consideration of wider sources of evidence than
purely RCTs, in addition to issues surrounding the analysis of small
numbers/subgroups, heterogeneity, immature/incomplete datasets,
and issues of bias. Additional limitations were considered for
VBP, particularly in combination with the above, such as data
Cochrane Database Syst Rev Suppl 1–212 (2013)
constraints for (network) meta-analysis and uncertainty. A number
of statistical approaches are currently used to address these issues
such as stratified analysis according to study ‘quality’, bias modelling,
model averaging, etc. Conclusions: HTA practice needs to evolve
to embrace the regulatory and pricing changes in the UK. Tools are
available to tackle the evidential and methodological issues arising from
new clinical data requirements; however, these have not necessarily
been used jointly nor been evaluated in the context of HTA.
The potential of text mining to reduce screening
workload in systematic reviews: a retrospective
Thomas J1 , O’Mara-Eves A1 , McNaught J2 , Ananiadou S2
EPPI-Centre, Social Science Research Unit, Institute of Education, London,
UK; 2 National Centre for Text Mining, University of Manchester
Background: The task of identifying relevant studies for systematic
reviews in an unbiased way is increasingly time consuming. Text mining
may be able to assist in the screening process in two ways: (1) by
prioritising the list of items for manual screening so that the studies at
the top of the list are those that are most likely to be relevant (‘screening
prioritisation’; Fig. 1); (2) by using manually-assigned include/exclude
decisions in order to ‘learn’ to apply such categorisations automatically
(‘semi-automatic classification’; Fig. 2). Objectives: To evaluate the
performance of two text mining methods to reduce screening workload
by assessing their performance in completed reviews. Methods:
Data from ten previous reviews covering health care and public health
were entered into the system. Data included the record’s title and
abstract text plus reviewer decisions on whether to exclude the study
or not. We ran simulations of the screening process (ten times for
each condition) testing how the following affected the performance of
the two text mining processes: the size of the initial training sample
(5, 10, 20 or 40 studies); the method and frequency of re-running the
search/training the classifier (after 5 or 20 includes were identified,
or after 25, 250 or 500 records were screened). Performance was
assessed using accuracy, precision, recall/sensitivity, F-measures, and
Area Under a (ROC) Curve and burden. Results: There was some
variability between the performance of the tools between reviews, but
consistency within reviews. Screening workload can be reduced, but
at the risk of missing potentially relevant studies. Conclusions: A
balance needs to be drawn between the number of studies it is feasible
to screen manually and the gain that accrues from screening thousands
of ultimately irrelevant studies. Text mining is likely to have a role to
play, though further evaluation is required.
Attachments: TMFigures.png
Turning a scientific procedure into an online
participative tool
Chalon PX, Vlayen J, Mertens R
Belgium Health Care Knowledge Centre (KCE), Belgium
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: Since 2003, creation of the Belgian Health Care
Knowledge Centre (KCE), our researcher benefit from an explicit
scientific procedure describing how to produce a scientific report. This
procedure is based on international standards and was first updated
in 2007 (3 PDF documents). Objectives: In 2011, the management
asked for an on-line publication that would facilitate the access to
and updates of the procedure. Methods: A panel of researchers
was invited to agree on a new table of content and define functional
requirements for the on-line tool. A demonstrator was build based on
an existing and already known technical option in order to evaluate its
feasibility. A survey was conducted using a web form on the Intranet
in order to evaluate satisfaction about the on-line tool and receive
suggestions. Results: Drupal Open Source Content Management
System (CMS) was used to build the website. A table of content and
navigation facilities are provided, as well as printer friendly version,
internal links, import/export of references and link to the full-text. The
layout mimics the layout of PDF documents. Each author is responsible
of a set of pages, all researchers may provide comments directly on
the pages; the page owner is responsible for managing the comments:
suggestion can be directly included, or will result in the organisation
of a workshop in order to reach consensus among the researchers.
The survey showed a general satisfaction about the new system and
allowed to identify points to ameliorate. It also helped to recall the
possibility to provide comments on the site. Conclusions: The Process
Book on-line has been provided for a limited cost thanks to the use of
an Open Source CMS, and mainly internal development. This successful
approach could inspire a change in the publication of reports that
would benefit to Semantic Web.
Attachments: chalon vlayen mertens.png
The evolution of technology for Cochrane
Thomas J1 , Mavergames C2 , Dooley G3 , Elliott J4
Cochrane IMS Team, Copenhagen, Denmark; 2 Cochrane Web Team,
Freiburg, Germany; 3 CRS, Oxford, UK; 4 Infectious Diseases Unit,
Melbourne, Australia
Background: In celebrating twenty years of The Cochrane
Collaboration, we can also celebrate 20 years of advancing technologies
in evidence-based health care. Cochrane Reviews have always been
electronic and have thus benefited from advances in technology to
aid in their creation and dissemination. Since its inception, Cochrane
has been at the forefront of online provision of high quality data and
has contributed to and inspired the development of both technological
and methodological advances in the field. In doing this we have
supported increased access to more people worldwide. Objectives:
At this juncture, we have a prime opportunity to consider our place in
the healthcare knowledge economy vis-a-vis technology. This poster
documents the technological advances that Cochrane has pioneered
over the last 20 years and looks forward to future developments that
will keep Cochrane Reviews as up-to-date and accessible as possible
and confirm Cochrane’s place as champions of technology in the
creation and dissemination of Cochrane Reviews. Results: The results
will highlight Cochrane’s direction of travel, including considering the
role of linked data and how technology can support the next evolution
in evidence-based health care. Conclusions: Through this poster
and its associated editorial, we will show how far The Cochrane
Cochrane Database Syst Rev Suppl 1–212 (2013)
Collaboration has come and what we have achieved in support of
health care by the use of technology. We will also discuss how future
advances in technology can contribute to Cochrane’s mission and to
the broader field of evidence-based health care.
An innovative tool for incorporating risk of bias
ratings into the GRADE assessment
Marin T1 , Furlan A2
Institute for Work and Health, Canada; 2 Institute for Work and Health,
Department of Medicine, University of Toronto, Canada
Background: Assessing the risk of bias (RoB) of included studies and
then incorporating this information into the GRADE assessment is one of
the most complicated aspects of conducting a review. This is especially
true for reviews of non-randomized studies (NRS). Objectives: To
develop a useful tool for rating RoB in included studies that (1) clarifies
which RoB items to use for both RCTs and NRS with a control group
and (2) organizes the ratings by bias category to help reviewers make
a decision about downgrading the evidence due to study limitations.
Methods: We used Excel to create a spreadsheet for conducting RoB
for both RCTs and NRS with a control group. We took RoB items from the
Back Group’s RoB tool and the Downs & Black checklist and organized
them by bias category (i.e., performance, attrition, measurement, and
selective outcome reporting). Users are instructed to make a rating of
‘Bias’ or ‘No Bias’ within each category. These ratings are automatically
copied into outcome-specific tables for ease of making judgements
about downgrading the evidence. We sent a draft of the spreadsheet
to colleagues within the Collaboration for evaluation. Results: Six
authors and three editors provided feedback. Respondents agreed
that the tool is useful, especially the way it links RoB to GRADE.
Three respondents expressed concern about having to re-enter the
same information into our spreadsheet, RevMan, and GRADEpro.
There were suggestions for making it more user-friendly; including
the use of drop-down menus to minimize user errors. Conclusions:
A simplified version of our tool may be useful to new authors and
authors working with NRS, and it may be especially valuable for training
purposes. The next steps will be to communicate our findings to the
Informational Management System team, conduct further validation
work, and consider adapting the tool for use on smartphones.
Implementing the extended risk of bias tool
for non-randomised studies: feedback from the
Cochrane Epilepsy Group
Pulman J, Marson T
University of Liverpool
Background: Over the past couple of years the Cochrane NonRandomised Studies Methods Group have been developing the
Cochrane risk of bias tool to be used with non-randomised studies. This
has included the addition of a seventh domain examining the aspect
of confounding variables and the implementation of a scale ranging
from 1 (low risk of bias) to 5 (high risk of bias). The Cochrane Epilepsy
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Group (CEG) tested the extended tool in two systematic reviews that
included non-randomised studies, further results to follow from a third
review. Methods: A reference table of 1–5 scale parameters was
developed by the CEG to aid decision making on each domain of bias.
46 non-randomised studies were assessed using the extended risk of
bias tool from two systematic reviews. For allocation concealment and
sequence generation each study was rated either low/high or unclear.
For blinding, confounding variables, incomplete outcomes data,
selective reporting and other bias each study was rated 1–5 according
to pre-specified criteria. Results: For allocation concealment and
sequence generation all 46 studies were rated as high risk of bias and
agreement was 100%. For blinding, agreement was reached +/− 1 in
45 studies. For confounding variables agreement was reached ± 1 in
43 studies. For incomplete outcome data, agreement was reached ± 1
in 38 studies. For selective reporting agreement was reached ± 1 in 44
studies, and for other bias agreement was reached ± 1 in 36 studies.
Using the tool was time-consuming with regards to developing the 1–5
scale, training other authors and first usage however became more
feasible with time. Conclusion: Agreement on bias judgements was
more prevalent in the domains of allocation concealment, sequence
gerneration, blinding and confounding variables. Challenges with using
the extended risk of bias tool and recommendations will be presented.
The effectiveness of interventions for reducing
publication bias
van Noord M, Thaler K, Nussbaumer B, Kien C, Gartlehner G
Austrian Cochrane Branch, Austria
Background: Publication bias occurs when the publication of research
depends on the nature and direction of the results–a study’s positive,
negative, or null result can influence its chances of publication. The
non-publication of clinical trial results might mean that the findings
are entirely unavailable or inaccessible, which decisively reduces the
benefit of systematic reviews of drugs, medical devices, or procedures
as the results from the research that is available differs from the results
of all the research that has been completed in an area. This makes
it difficult for clinicians, decision-makers, and patients to rely on the
available evidence when making informed decisions about health care.
Objectives: To evaluate the effectiveness of interventions designed
and implemented to prevent and reduce publication bias related to the
publishing of study results from clinical trials. Methods: A systematic
literature search, completed in May 2012, was conducted in MEDLINE
(via PubMed), the Cochrane Library, EMBASE, Web of Science, CINAHL,
PsycINFO, and AMED databases. We manually searched reference lists
of pertinent reviews, included studies, and background articles. Two
independent reviewers identified studies on interventions to reduce
publication bias where an analysis was performed that sought to
quantify or determine the success of the intervention in reducing
publication bias overall. Results: We identified 2634 citations from
searches and reviews of reference lists (Fig. 1). We located 15
articles that analyzed the effectiveness of interventions to prevent
or reduce publication bias in the following categories: changes in
publication process (i.e., peer review process, disclosure of commercial
interest, electronic publication), prospective registration of trials, open
access policy, right to publication, research sponsors’ guidelines, and
confirmatory large-scale trials. Conclusions: Many interventions
Cochrane Database Syst Rev Suppl 1–212 (2013)
that should supposedly reduce publication bias and that have been
advocated by researchers and organizations over many years are not
supported by any study data.
Attachments: figure 1.png
Factors related to biases of randomized
controlled trials published from Japan
Yoneoka D, Ota E, Hisashige A, Nomura S, Miyamoto K, Segawa M,
Kanda M, Wariki W, Shibuya K
The university of Tokyo, Japan
Background: Randomized controlled trials (RCTs) are an important
foundation for evidence-based healthcare. Despite an increase in
the number of RCTs in Japan, existing international databases fail to
capture them, and factors related to biases of Japanese RCTs is lacking.
Objectives: This study assessed the number, characteristics, and
risk of bias, and analyzed factors related to biases of RCTs published
from Japan in 2010. Methods: One Japanese database and four
international databases were searched for all RCTs published from
Japan in 2010. Sixty percent of the included RCTs were randomly
sampled and the quality was assessed using the risk of bias tool.
Twelve domains of risk of bias was compared with a random sample of
534 trials from 50 Cochrane systematic reviews in the Cochrane Library
and the quality of Japanese RCTs classified by the type of journals
was compared. Finally, the factors affecting RCT quality were analyzed
using a logistic regression model. Results: Among 2957 studies, 1013
were identified as RCTs. Japanese RCTs had significantly higher odds
of risk of bias (p < 0.05) compared with relevant Cochrane systematic
reviews in the following domains: sequence generation, allocation
concealment, blinding of the outcome assessor, and selective outcome
reporting. Non-indexed RCTs in international databases were lower
in quality than indexed RCTs in some domains. From the result of
regression analysis, factors such as disease and conditions, type of
intervention, sample size, trial registration and number of arms were
shown to be positively associated with quality, but overall quality was
not significantly different. Conclusions: The CONSORT statement
should be endorsed by Japanese researchers, funding bodies and
organizations to promote and improve the quality of Japanese RCTs.
In addition, since the overall quality of indexed and non-indexed
Japanese RCTs was not significantly different, systematic reviewers
should consider including Japanese databases.
Assessment of risk of bias due to blinding
for objective and subjective outcomes:
an exploratory study of Cochrane Reviews
Okwundu C1 , Durão S2 , Motaze V3
Centre for Evidence-Based Health Care, Faculty of Medicine and Health
Sciences, Stellenbosch University, South Africa; 2 South African Cochrane
Centre, MRC, Cape Town, South Africa; 3 Community Health Division,
Faculty of Medicine and Health Sciences, Stellenbosch University, South
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: In Cochrane Reviews, the risk of bias (RoB) in included
studies is assessed to determine the likelihood that the intervention
effects have been affected by bias. The Collaboration’s tool for
assessing RoB has different domains related to particular types of
bias - sequence generation, allocation concealment, blinding, selective
outcome reporting and incomplete outcome data. For blinding,
RoB assessment should be done separately per outcome reported,
especially for studies with a mix of subjective and objective outcomes.
Objectives: To evaluate whether Cochrane Review authors assess risk
bias due to blinding separately for subjective and objective outcomes.
Methods: We included all new or updated reviews published in
The Cochrane library in January and February 2013. Two assessors
independently classified the reported outcomes in each review as
objective or subjective, and whether authors of the reviews assessed
the risk of performance and detection bias separately per outcome.
Discrepancies were resolved by discussion and with input from a
third assessor. Results: We identified a total of 158 new and
updated reviews (66 new reviews and 92 updated reviews). Twenty
of the reviews (12.7%) did not have included studies, seven (4.4%)
included non-randomised controlled trials (RCTs), while 131 (82.9%)
included RCTs. Of these, 82 (63%) reported a mix of subjective
and objective outcomes. The risk of performance and detection bias
was assessed per outcome in seven (5.3%) and 14 (10.7%) of these
reviews respectively. Conclusions: Few Cochrane authors separate
risk of performance or detection bias for objective and subjective
outcomes. Objective outcomes are less likely to be influenced by lack
of blinding, compared to subjective outcomes. Authors should thus
be more careful in evaluating the risk of bias from lack of blinding
per outcome, especially in reviews reporting a mix of objective and
subjective outcomes.
Risk of bias in pediatric critical care randomized
controlled trials: a systematic review
Duffett MC1 , Choong K1 , Cupido C1 , Hartling L2 , Menon K3 , Thebane L1 ,
Cook DJ1
McMaster University, Canada; 2 University of Alberta, Canada; 3 University
of Ottawa, Canada
Background: Risk of bias is a critical consideration when interpreting
and applying the results of randomized controlled trials (RCTs).
Objective: To describe the risk of bias in RCTs in pediatric critical
care. Methods: As part of a scoping review we searched MEDLINE,
EMBASE, LILACS and CENTRAL (from inception to January 4, 2013).
We included RCTs and quasi-randomized trials published in English
that administered any intervention to children in a critical care unit. We
excluded trials enrolling exclusively newborns, cross-over trials, and
those only published as abstracts. Pairs of reviewers independently
screened studies for eligibility, abstracted data, and used the Cochrane
Risk of Bias Tool to describe the risk of bias for the included trials.
Results: We included 221 trials. Figure 1 shows the assessments for
the individual domains of the Cochrane Risk of Bias tool. 97 trials
(44%) were assessed as high risk of bias for at least one domain. 10
trials (5%) were assessed as low risk of bias for all domains. All trials
at low risk of bias were published since 2006 and the proportion at
low risk of bias increased over time (p for trend < 0.001). All trials
at low overall risk of bias were published since 2006. Trials at high
Cochrane Database Syst Rev Suppl 1–212 (2013)
risk of bias less frequently reported a commercial source of funding
(10% vs. 23%; p = 0.02) and less frequently studied medications
(52% vs. 70%; p = 0.01) than trials at low or unclear risk of bias.
The median (IQR) number of children randomized was not different
between trials at high 48 (28–97) and low or unclear risk of bias [46
(36–92); p = 0.89]. Conclusions: Many trials in pediatric critical care
are at high risk of bias, most commonly because of lack of blinding.
The proportion of trials at low risk of bias is increasing over time.
Attachments: rob.png
Outcome domains reported by Chinese
randomized controlled trials of postoperative
analgesia for children
Sun R1 , Zhang HJ2 , Zhao WY2 , Tian JH1 , Yang KH1
Evidence-Based Medicine Center, School of Basic Medical Sciences,
Lanzhou University, China; 2 The First Clinical Medical College, Lanzhou
University, China
Background: Standardization of outcome domains and measures in
pediatric pain randomized controlled trials (RCTs) would streamline
designing and reviewing research protocols and articles, simplify and
strengthen systematic reviews, and help clinicians make treatment
decisions. The Pediatric Initiative on Methods, Measurement, and Pain
Assessment in Clinical Trials (PedIMMPACT) has recommended six core
domains be considered in clinical trials of pediatric acute pain (Table 1)
(J Pain 2008;9(9):771–783). Objectives: To explore the distribution of
outcome domains reported by Chinese RCTs of postoperative analgesia
in the pediatric population, and determine whether they followed the
PedIMMPACT recommendation. Methods: Four Chinese medical
databases, including Chinese Biomedicine Literature Database (CBM)
were searched using the search terms ‘child’, ‘pediatrics’, ‘infant’,
‘postoperative pain’, ‘postoperative analgesia’ and ‘randomized’ in
July 2012 for RCTs of postoperative analgesia for children. Outcome
domains of included RCTs were recorded. MetaAnalyst 3.13 software
was used to analyze data. Results: Our study included 296 relevant
RCTs, with 10 outcome domains being reported (Table 1). Each
RCT reported a median of 3 (range: 1–7) outcome domains. Pain
intensity was reported by the most RCTs, and followed by symptoms
and adverse events, vital signs and effective analgesic time. For
the six outcome domains PedIMMPACT had recommended, none of
included RCTs reported all of them; most RCTs (266/296, 90%)
reported less than four domains; two RCTs (1%), however, even
reported none of them. Conclusions: Although most RCTs reported
pain intensity, an important outcome for acute pain trials, other
patient-important outcomes, such as patient satisfaction and physical
recovery were reported at a very low proportion. Researchers should
pay more attention on patient-important outcomes, and follow the
PedIMMPACT recommendation when designing and conducting RCTs
of postoperative analgesia in the pediatric population.
Attachments: Table 1. Outcome domains reported by Chinese RCTs
of postoperative analgesia in the pediatric population.pdf
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Suspected publication bias regarding efficacy
of psychoeducative interventions on burden
experienced by caregivers of people with
Ballesteros J1 , González-Fraile E2 , Santos B3 , Solá I4
1 University of the Basque Country UPV/EHU & CIBERSAM, Spain; 2 Instituto
de Investigaciones Psiquiátricas, Spain; 3 University of the Basque Country
UPV/EHU, Spain; 4 Iberoamerican Cochrane Centre, Spain
Background: The effect of publication bias on the efficacy of
pharmacological interventions has been extensively studied, but less is
known on its effect in systematic reviews about non-pharmacological
interventions. Objectives: To assess the possibility of publication
bias on a systematic review of the efficacy of psycho-educative
interventions on the burden experienced by informal caregivers
of people with dementia. Methods: We searched randomized
clinical trials in CENTRAL, PubMed, Embase, and PsycInfo reporting
the efficacy of psycho-educative interventions versus usual care on
dementia caregiver’s burden. We also searched lists of references of
relevant qualitative and quantitative reviews on caregiver’s burden. We
obtained pooled Hedges’ g effect sizes using a random effect model.
We assessed the possibility of publication bias by the asymmetry of
the funnel plot and quantified subsequently the likely of bias on the
observed effect size by means of the trim & fill method and the
Copas selection model. Results: We obtained data for effect sizes
of psycho-educative interventions from 11 trials. Although random
effect model estimates showed small to moderate effects favouring the
intervention (g = −0.25; 95% CI = −0.43 to −0.07), the funnel
plot (Fig. 1) was clearly asymmetric (rank correlation p = 0.004; linear
regression p = 0.0063). The trim and fill approach suggested 4
more trials and a smaller effect (g = −0.11; 95% CI = −0.30 to
0.08), whereas the Copas selection model suggested 11 trials might be
unpublished and decreased even further the effect size (g = −0.0015;
95% CI = −0.1889 to 0.1860). Conclusions: Our results show a
huge impact of publication bias in a systematic review on the efficacy
of non-pharmacological interventions, as others have suggested in
this field. Since the registry of such trials is not yet mandatory and
practically inexistent, the quantification of the problem is harder than
for pharmacological interventions.
Attachments: Figure 1.jpeg
Poor reliability between Cochrane Reviewers
and blinded external reviewers when applying
the Risk of Bias Tool in physical therapy trials
Armijo-Olivo S, Ospina M, Jorge F, Humam S, Annabritt C, Dion P, Greta C
University of Alberta, Canada
Background: The Risk of Bias (RoB) tool is an emerging method for
determining the risk of bias of health trials. Recent research have
recommended further testing of the psychometric properties of the RoB
domains, and validating the tool in a wider range of research fields.
Inter-rater reliability of the RoB tool has been evaluated for child trials,
Cochrane Database Syst Rev Suppl 1–212 (2013)
general medical and nursing trials. The inter-rater reliability of the RoB
has not been evaluated for physical therapy (PT) trials. Objectives:
To test the inter-rater reliability of the RoB tool applied to PT trials by
comparing ratings from Cochrane Review authors and blinded external
reviewers. Methods: Randomized controlled trials (RCTs) in PT were
identified by searching the Cochrane Database of Systematic Reviews
for meta-analysis of PT interventions. RoB assessments of PT trials
included in the meta-analyses were conducted independently by two
reviewers blinded to the RoB ratings reported in the Cochrane Reviews.
Consensus ratings between the two reviewers were compared with
the Cochrane RoB ratings. Agreement between Cochrane and blinded
external reviewers for individual domains and the final rating of the
RoB tool was assessed using weighted kappa (K) for categorical data
(K = 0.0–0.40 poor; K = 0.41–0.60 moderate; K = 0.61–0.80
substantial). Results: In total, 109 trials included in 17 Cochrane
Reviews were assessed. Interrater agreement on the overall RoB
rating was poor (K = 0.07). Agreement on individual domains of
the RoB tool was poor (median K = 0.20) ranging from K = 0.01
(‘Other bias’) to K = 0.63 (‘Sequence generation’). Conclusions:
Risk of bias assessments are not consistent across different research
groups. Results have implications for decision making since different
recommendations can be reached depending on the group analyzing
the evidence. Improved guidelines to apply the RoB tool and revisions
to the tool for different health areas are needed.
Selective reporting: a proxy or a more direct
indicator of our confidence in the summary
Rutjes AW
ISPM, University of Bern, Switzerland
Background: The Cochrane Handbook for Systematic Reviews of
Interventions advises to judge the risk of bias potentially introduced by
selective reporting of outcome data on the trial level. From a ‘Grading of
Recommendations Assessment, Development and Evaluation’ (GRADE)
perspective, a judgment on the outcome level would however more
directly inform the confidence we have in the summary estimate of
an outcome, together with the other (risk of bias) domains to be
considered. Objectives: To summarize and discuss applied methods
to judge and handle risk of bias (RoB) due to selective reporting in
Cochrane Reviews. To generate an informed discussion how future
Cochrane Reviews should handle this RoB item, inviting stake-holders to
express their preferences. Methods: Reviewing the reviews published
in the past 5 years by authors from the Cochrane Musculoskeletal
Group and Cochrane Peripheral Vascular Diseases Group. Extraction
items include definitions used to judge the RoB by selective reporting,
the frequency of scoring low, high or unclear RoB due to selective
reporting, and the handling of this item in the Summary of Finding
Tables (SoF). The different definitions and approaches will be tabulated
and discussed. Informed by the results, templates will be constructed
from different perspectives of assessing RoB for selective reporting
at the trial versus the outcome level, while demonstrating how this
item could be considered in future systematic reviews. The summary
of our review and the constructed templates, including SoF tables,
will then be circulated to consumers, Cochrane Reviewers, experts
from the bias methods group and the GRADE working group asking
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
them for feedback and asking them to indicate which would be the
preferred method. Results and Conclusions: Will be presented at
the colloquium.
Systematic review of the empirical evidence
of the selective reporting of analyses
Dwan K1 , Williamson PR1 , Gamble C1 , Higgins J2 , Sterne J2 , Altman DG3 ,
Clarke M4 , Kirkham JJ1
1 The University of Liverpool, UK; 2 The University of Bristol, UK; 3 The
University of Oxford, UK; 4 Queen’s University, Belfast
Background: Selective reporting of information in trials may occur
for many aspects of a trial. Examples include the selective reporting of
outcomes, the selective reporting of analyses: e.g. subgroup analyses or
per protocol rather than intention to treat analyses. Selective reporting
bias occurs when the inclusion of analyses in the report is based on
the results of those analyses. Objectives: We review and summarise
the evidence from studies that have assessed the selective reporting of
analyses in randomised controlled trials. Methods: Systematic Review
of studies that have assessed the selective reporting of analyses in
randomised controlled trials. Along with the collaboration with experts
in this area, the review will feed into the development of guidelines
to support the appropriate reporting of a clinical trial with respect
to outcomes, outcome measures, subgroups and analyses. Results:
Fifteen studies have been included in this review and consider aspects
of selective reporting such as statistical analyses (7); subgroup analyses
(4); the use of different scales (1); composite outcomes (2) and
quality of life measures (1). Guidelines will be discussed at a face
to face meeting scheduled for July 2013 and the output presented at
The Cochrane Colloquium. Conclusions: This work highlights the
evidence of selective reporting and demonstrates the importance of
pre-specifying analysis and reporting strategies during the planning
and design of a clinical trial, for the purposes of minimizing bias when
the findings are reported.
Comparing apples and oranges? A Bayesian
meta-regression of effect estimates from
non-randomized studies and randomized
controlled trials
Sandhu L, Tomlinson G, Kennedy ED, Wei AC, Baxter NN, Urbach DR
University of Toronto, Canada
Background: Multiple studies suggest that effect estimates from
non-randomized studies (NRS) are comparable to those from
randomized controlled trials (RCTs). There is also evidence of bias
associated with specific design characteristics of RCTs. Accordingly,
comparisons of NRS and RCTs to date have often compared NRS
with a heterogeneous group of RCTs. Objectives: To compare
the results of NRS with those of RCTs at low risk of bias. Studies
evaluating the surgical treatment of colon cancer were used for
this case study. Methods: All studies comparing laparoscopy
with conventional surgery for the management of colon cancer were
Cochrane Database Syst Rev Suppl 1–212 (2013)
identified. Bayesian meta-analysis was separately performed for two
subjective outcomes, post-operative complications (binary) and length
of stay (LOS, continuous) and two objective outcomes, mortality (binary)
and number of lymph nodes harvested (continuous). Meta-analysis was
performed for (i) All Studies, (ii) NRS, (iii) RCTs, (iv) Typical RCTs and
(v) Strong RCTs. The Cochrane Risk of Bias Tool was used to classify
studies as ‘Strong’ (low risk of bias) or ‘Typical’ (unclear and high risk
of bias). A Bayesian meta-regression was conducted with study design
(NRS, Typical RCT, Strong RCT) as a predictor variable. Sensitivity
analyses assessed the impact of period effects and between-study
case-mix. Results: 145 studies reported the outcomes of interest
(Table 1). For post-operative complications, the odds ratios from
NRS were 36% smaller (i.e. demonstrating more benefit) than those
from Strong RCTs [ROR 0.64, (0.42-0.97), p = 0.04] (Fig. 1). The
same exaggerated benefit among NRS was seen when assessing LOS,
[Difference in Mean Difference, −2.15, (−4.08, −0.21), p = 0.03].
This pattern was not observed for the objective outcomes (mortality,
p = 0.38, and number of LN harvested, p = 0.62). Meta-regression
results, adjusted for period effects and case-mix between studies,
showed persistent bias among NRS. Conclusions: When evaluating
subjective outcomes, effect estimates from NRS may be associated with
significant bias.
Table 1 – Lakhbir Sandhu.png, Figure 1 –Lakhbir
Glaucoma drug trials: Why 349 trials and 130
unique interventions?
Li T1 , Wormald R2 , Dickersin K1
Cochrane Eyes and Vision Group US Project & US Cochrane Center, USA;
2 Cochrane Eyes and Vision Group, UK
Background: Theoretically, unlimited variations of interventions or
combination of interventions can be evaluated in randomized controlled
trials (RCTs) for a given condition, for example, by varying dose and
usage, and by combining one drug with another. However, not all
interventions may pan out as worthy and ethical pursuits. Objectives:
To examine the history of glaucoma drug trials and to explore factors
contributing to ‘isolated’ trials, defined as single trials evaluating
interventions not evaluated in any subsequent trial for the condition.
Methods: As part of a network meta-analysis, we examined the
number of times an intervention was evaluated in RCTs of medical
treatment for glaucoma. We are in the process of comparing the
characteristics of ‘isolated’ trials with other trials, and examining factors
(e.g., sponsorship, statistical significance and direction of results)
associated with the frequency that an intervention was evaluated in
RCTs. Results: We included 349 trials on glaucoma medication
published between 1966 and 2009 (median 2001). These 349 trials
examined 130 unique interventions; 62/130 (48%) interventions were
examined in only one RCT. These isolated interventions were largely
drugs not typically used for glaucoma (e.g., celiprolol), non-standard
dosages (e.g., timolol 1%), or two drugs used as a combination
therapy (e.g., dipivefrin 0.1% and levobunolol 1% used together).
The combination therapies constituted more than half of all isolated
interventions. Conclusions: Examining any trial in the context of the
entire evidence base provides an opportunity to investigate factors that
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
may contribute to selecting interventions in RCTs. Curious investigators
may test drugs off-label, at a different dose, or in combination with
other drugs to explore potential benefits to patients. Alternatively,
if trials are initiated for marketing purposes or a way to obtain a
publication, which are of little relevance or value to patient care, recent
claims of avoidable waste in clinical research ring true.
Are all Cochrane Reviews born equal? Statistical
methods in Cochrane Reviews (could be
Pantoja T1 , Claro JC2 , Moreno G3
Department of Family Medicine, Pontificia Universidad Catolica de
Chile/Cochrane EPOC Group; 2 Department of Internal Medicine, Pontificia
Universidad Catolica de Chile; 3 Department of Family Medicine, Pontificia
Universidad Catolica de Chile
Background: Systematic reviews combine the quantitative evidence
from primary studies using statistical methods. The correct choice,
implementation and interpretation of these methods are key to obtain
reliable estimates of effect sizes. Although the Cochrane Handbook
offers advice about these methods, their implementation is not easy and
in many cases requires statistical support. Objective: To assess the use
of statistical methods in systematic reviews published in the Cochrane
Library. Methods: All the new reviews published in the Cochrane
Library issue 2, 2013—with at least one meta-analysis—were selected
for appraisal. Two evaluators assessed independently each selected
review using items 9 and 10 of the AMSTAR tool. Results: Fourteen
of the 35 new systematic reviews retrieved were selected for appraisal.
They included a median of 5 studies (2–39) and presented a median
of 9.5 forest plots (1–82). All of them stated in the Methods section
how they would assess heterogeneity. The most commonly planned
methods were the I2 statistic and the chi-squared test. Eleven of the
14 reviews stated in the Methods section how they would examine the
causes of heterogeneity. All of them planned to use either subgroup or
sensitivity analyses. In the Results section, potentially moderate/large
heterogeneity was identified in 9 of the 14 reviews. Five of these nine
reviews did not explore potential causes of heterogeneity. Nine of the
14 reviews stated in their Methods section how they would assess
publication bias, but only four described an assessment in their Results
or Discussion section. Conclusions: There are deficiencies in the use of
statistical methods for measuring and investigating heterogeneity and
publication bias in Cochrane Reviews. Because of the limited number
of reviews assessed, our findings should be considered as preliminary,
and further work is needed for identifying factors associated with the
deficiencies identified.
Using QUADAS-2 in systematic reviews
of diagnostic test accuracy studies: survey
of users’ experience
Zhelev Z1 , Hunt H1 , Hyde C1 , Davenport C2 , Leeflang MM3
1 University of Exeter, UK; 2 University of Birmingham, UK; 3 University of
Amsterdam, Netherlands
Cochrane Database Syst Rev Suppl 1–212 (2013)
Background: Quality of Diagnostic Accuracy Studies (QUADAS) was
first developed in 2003 as an assessment tool to be used in the
context of systematic reviews of diagnostic test accuracy (DTA) studies.
Following a number of evaluations and feedback from users, the
tool was further updated and a new version, known as QUADAS-2,
published in 2011. QUADAS-2 differs from the original tool on
a number of points, among them the strong emphasis that the
tool is more like a guideline and should be customised for each
review, as detailed in the background document. At present, no
formal evaluation of the tool has been conducted and only isolated
comments suggest potential difficulties and confusions. Objectives:
To investigate common problems encountered by users of QUADAS-2
when customising and applying the tool in the context of DTA reviews
and to elicit hypotheses about the sources of these problems and
possible solutions. Methods: A brief on-line questionnaire has been
devised to elicit the experience of systematic reviewers with QUADAS-2.
Authors of Cochrane and non-Cochrane DTA reviews will be identified
through electronic searches and invited to take part in the survey.
Thematic analysis supported by descriptive statistics will be used to
analyse the data and, whenever possible, the results will be compared
with those from QUADAS-1 evaluations. Results: The main result will
be a narrative description of the common difficulties encountered by
review authors in the process of customising and applying QUADAS-2
in DTA reviews; the sources of these difficulties; and suggestions how
to overcome them. Current stage of the study: An on-line questionnaire
has been devised and sent to experts in the field for feedback. We expect
the final results from the survey to be available by the end of July 2013.
Challenges in conducting a systematic review
of diagnostic test accuracy of genetic test: an
example of the genetic diagnosis of familial
Sharma P, Mowatt G, Boachie C, Stewart F, Miedzybrodzka Z, Simpson W,
Boyers D, Kilonzo M, McNamee P
University of Aberdeen, UK
Background: The availability and uptake of genetic tests is increasing.
The UK National Institute for Health and Care Excellence commissioned
a review on rapid genetic tests for the diagnosis of familial hypercholesterolaemia (FH). Objectives: To explore methodological
challenges of undertaking a review of diagnostic accuracy of genetic
tests and to give recommendations for future reviews. Methods:
A systematic review of diagnostic accuracy of Elucigene FH20 and
LIPOchip (rapid genetic tests) for the diagnosis of FH was performed.
The problems encountered, decisions made and the recommendations
suggested were tabulated and summarised descriptively. A review
of systematic reviews on the diagnostic accuracy of genetic disorders
was conducted to corroborate our issues. A comparative analysis
of the methodological aspects, including reporting of sensitivity
and specificity, a meta-analysis, susceptibility to bias and quality
of reporting, was performed. Results: Lack of valid data on diagnostic
indices, heterogeneity across studies, the use of incomplete reference
standards and poor quality of reporting imposed problems during the
evaluation process. For example, due to the nature of genetic tests given
in practice, no studies reported false positive data. An assumption of no
false-positives, and therefore 100% specificity was made. Studies were
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
also susceptible to differential and partial verification bias. Decisions
to deal with these problems were made with the help of clinicians
and the statistician involved in the process. Two systematic reviews
were included from the review of systematic reviews. Data comparing
methodological aspects of these reviews with our review will be
reported. Both reviews stated the lack of carefully designed studies to
make valid evaluation similar to our findings. Conclusions: Reviewers
should implement strategies (intensive scoping, clinician advice etc)
early in the process to deal with the complexity of genetic tests. There
is a need of specific guidelines for the reporting of diagnostic accuracy
studies of genetic tests.
Inter-rater reliability of the QUADAS-2 for
assessing screening accuracy studies
Guo B
Institute of Health Economics, Canada
Background: Published empirical evidence is scarce on the inter-rater
reliability of the latest version of the Quality Assessment of Diagnostic
Accuracy Studies the QUADAS-2. Objectives: To evaluate the
inter-rater reliability of the QUADAS-2 used in a systematic review to
assess the methodological quality of 34 screening accuracy studies
of transcutaneous bilirubin meters used to test neonatal hyperbilirubinemia. Methods: A review-specific guidance was developed for
the 11 signaling questions; possible answers include ‘yes’, ‘unclear’
or ‘no’. Two reviewers independently piloted the QUADAS-2 tool in
four studies. One question in the domain of reference standard was
removed from the tool, resulting in 10 questions. Two independent
reviewers assessed 34 studies using the modified QUADAS-2 tool along
with the refined guidance. Agreement between the two reviewers for
each of the 10 questions was measured by proportion of agreement
(po), Kappa coefficients (κ), and prevalence adjusted bias adjusted
kappa (PABAK) which takes into account the effects of prevalence and
bias the two paradoxes associated with the Kappa statistic. Results:
For the 10 questions, po ranged from 41 to 97%; κ ranged from
−0.03 to 0.57, indicating poor agreement for 2 questions, slight to
fair for 3 questions, and moderate for 5 questions. PABAK ranged
from −0.18 to 0.94, indicating poor agreement for two questions, fair
for one question, and moderate to almost perfect for seven questions.
After adjusting for bias and prevalence, κ values increased for six
questions. In one question, κ increased from 0 (poor agreement) to
0.94 (almost perfect agreement), mainly due to a large prevalence
effect (prevalence index of 0.97). Conclusions: The low prevalence of
certain items may result in a substantial reduction in κ values, which
can be misleading. When measuring inter-rater reliability for accuracy
studies using the QUADAS-2, PABAK should be measured when a
significant discrepancy exists between po and κ.
Direct versus indirect comparisons in systematic
reviews of test accuracy studies: an IPD case
study in ovarian reserve testing
Wang J, Bossuyt PM, Geskus R, Leeflang MM
Academic Medical Center, University of Amsterdam, The Netherlands
Cochrane Database Syst Rev Suppl 1–212 (2013)
Background: Comparative systematic reviews of diagnostic test
accuracy compare relative accuracy of two or more tests. Direct
comparisons evaluate all tests in the same study, even in the same
patients, are most valid and regarded as the reference approach.
Indirect comparisons are more prone to bias than direct comparisons,
but excluding them may lead to a loss in precision in the summary
estimates. Objectives: To investigate the difference of indirect
comparisons compared with the results of direct comparisons in
meta-analysis; to develop appropriate methods of adjusting indirect
comparisons to improve their comparability. Methods: A dataset from
Individual Patient Data (IPD) meta-analysis on the test accuracies of
Anti-Müllerian Hormone (AMH), Antral Follicle Count (AFC) and Follicle
Stimulation Hormone (FSH) in relation to ovarian response was used in
this case study. Test accuracies were measured by the area under the
ROC curves (AUCs) and compared in each pair of tests under direct and
indirect comparisons. Inconsistency was defined as statistical significant
difference in comparative results between the direct and indirect
evidence. Results: 32 studies were included with IPD from 4762
women undergoing IVF. By comparing AUCs, the difference between
AFC and FSH (0.0948, p < 0.001) is significant in direct comparison
but not significant (0.0678, p = 0.09) in indirect comparison; while the
difference between AFC and AMH is significant (−0.0830, p < 0.001)
in indirect comparison but not significant (−0.0176, p = 0.29) in direct
comparison. Adjusting for indirectness by considering covariate effect
could improve the comparability but these differences still existed
after covariate-adjustment. Conclusions: Comparative results of
test accuracy obtained through indirect comparisons are not always
consistent with those obtained through direct comparisons. There is no
straight forward way to make indirect comparisons more comparable.
Evidence from indirect comparisons should be assessed carefully and
combined with direct comparisons after adequate assessment of the
consistency and with adjustment.
How do authors investigate selective publication
in diagnostic test accuracy reviews?
van Enst WA1 , Ochodo EA2 , Leeflang MM2 , Scholten RJPM1 , Hooft L1
Dutch Cochrane Centre, Academic Medical Center, Amsterdam, The
Netherlands; 2 Department of Clinical Epidemiology, Biostatistics and
Bioinformatics, Academic Medical Center, The Netherlands
Background: Systematic reviews can be misleading when the results
are affected by selective publication. For intervention reviews it is
advocated to investigate the presence of publication bias graphically by
funnel plots or by the use of statistical tests. These methods, however,
appear to be less useful for investigating publication bias in diagnostic
test accuracy (DTA) reviews and to date it’s not clear how these methods
could be applied or interpreted in the DTA setting. Objective: To
explore what methods authors use to investigate publication bias in
DTA reviews and how they interpret the results. Methods: We have
searched MEDLINE for DTA reviews published between September
2011 and January 2012. We have extracted methods that were
applied to investigate publication bias (graphically or statistically), the
results thereof and the author’s conclusion. Results: We included
113 reviews whereof 44 investigated publication bias: seven explored
publication bias graphically, 11 performed a statistical test and 26 did
both. Funnel plots addressed the diagnostic odds ratio in 22 cases,
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
sensitivity/specificity in 3 cases, and 8 addressed other parameters.
The statistical methods to investigate publication bias were Egger’s
test (n = 17), Deeks’ test (n = 10) and Begg’s test (n = 4), while
multiple or other methods were used in six reviews. High risk of
publication bias was identified by graph and test in four cases, only
by graph in one case, only by test in seven cases and in three cases
graphs and tests gave conflicting results. Conclusions: Little is known
about the actual presence and the potential impact of publication
bias in DTA reviews. Statistical methods to test for publication bias
in diagnostic meta-analyses have their limitations, though they are
frequently applied (39%). More guidance and empirical studies on the
use and interpretation of these tests are needed.
Search methods for diagnostic test accuracy
reviews in dementia: an overview
of a programme grant
Noel-Storr A
Cochrane Dementia and Cognitive Improvement Group, University of
Oxford, Oxford, UK
Background: In 2010 the Cochrane dementia and cognitive
improvement group began work on a series of diagnostic test accuracy
systematic reviews as part of a programme grant. Objectives: Three
years on, and 200 000 citations screened later, this poster aims
to consider the effectiveness of the search activities performed for
this is body of work. Methods: This will include evaluation of
the range of sources searched, the effectiveness of peer review, the
sensitivity, specified, precision and accuracy of the search strategies
and consideration of whether we are any closer to a topic-specific
methodological search filter. An evaluation of the reporting standards
in the abstracts of included studies will also be shown with specific
attention paid to study population and setting. Conclusions: Looking
back, what could we have done better? This evaluation will identify
what the main challenges were and offer recommendations to those
about to or in the process of undertaking extensive search activities for
a portfolio of diagnostic test accuracy reviews.
The quality survey of campbell systematic
reviews using AMSTAR
Bai Z, Chang J, Feng Y
Evidence-Based Medicine Center, School of Basic Medical Sciences,
Lanzhou University, Lanzhou, China
Background: Campbell Systematic Review (C2 review) was
acknowledged to be a high quality evidence, especially in fields
of social work, education and so on. However no study was found to
evaluate the quality of them. Objectives: To evaluate the quality of C2
review associated with international development, education, social
welfare, crime and justice. Methods: We downloaded all studies
about the following four fields: international development, education,
social welfare, crime and justice in Campbell Library. Two researchers
evaluated the quality of these C2 review independently using AMSTAR
Cochrane Database Syst Rev Suppl 1–212 (2013)
tool, which includes 11 items and each item measured by Y,N, Can’t
answer and Not applicable. Results: From 2003 to 2012, 90 studies
met the inclusion criteria and all of them were downloaded: 1 article
(1.11%) is about international development, 13 articles (14.44%) are
about education, 35 articles (38.89%) are about crime and justice and
41 articles (45.56%) are about social welfare. General speaking, the
quality of C2 review was pretty good, over 80% of studies reported Y
in five items (include item 1, 3, 4, 6 and 7) and over 60% of studies
reported Y in five items (include item 2, 5, 8 and 9). On the other
hand, only 55.56% of studies reported Y in item ‘Was the likelihood
of publication bias’ assessed. And another quality index ‘Was the
conflict of interest stated’? were done only by 48.89% of studies.
Conclusions: The quality of Campbell Systematic Reviews was high
based on assessment results, however, some details could be improved
like publication bias and interest stated.
of test accuracy studies evaluate the quality of eligible studies, but
only 3 out of 10 reviews consider quality assessment when drawing
conclusions or making recommendations. We recommend the results of
quality assessment be always factored into the conclusions of reviews,
to limit misleading presentation of the performance of the diagnostic
tests under review.
Attachments: Cochrane2013-Table-QualityInterpretationDTAs.doc.
Using AMSTAR to assess methodological quality
of systematic reviews/meta-analysis of animal
studies in China
Attachments: Attachment.pdf
Poor interpretation of quality assessment results
in diagnostic accuracy reviews
Ochodo EA1 , van Enst WA2 , Naaktgeboren C3 , Leeflang MM1 , Hooft L2 ,
de Groot JA3 , Reitsma JB3 , Moons KGM3 , Bossuyt PM1
1 Academic Medical Center-University of Amsterdam; 2 Dutch Cochrane
Center-University of Amsterdam; 3 Julius Center, Utrecht University
Background: Interpreting and presenting results in systematic reviews
without taking into account the outcome of quality assessment has been
shown to be common in systematic reviews of interventions, but may
also play a role in reviews of test accuracy studies. Drawing conclusions
or making recommendations without considering the risk of bias and
limited applicability of included studies may lead to unwarranted
optimism about the value of the corresponding test. Objectives: To
identify and compare approaches used to make conclusions out of the
results of quality assessment in diagnostic accuracy reviews, and to
provide guidance on recommended methods. Methods: We searched
MEDLINE and EMBASE for test accuracy reviews published between
May 2012 and September 2012. We examined the abstracts and main
texts of these reviews to check whether and how the results of quality
assessment were taken into account when drawing conclusions. Data
was extracted by one author; a sample was checked by a second
author. Results: Our search identified 53 eligible reviews. Of these,
49 (92%) had formally assessed the methodological quality of included
studies; Twenty-two (45%) distinguished high quality from low quality
studies using summary scores (n = 13), summary graphs (n = 5)
and other methods. Overall, only 5 articles (9%) incorporated quality
assessment results in the conclusions of the abstracts; in the main
texts, only 14 (26%) reviews considered results of quality assessment
in the recommendations or conclusions. Examples of approaches used
to mention and interpret quality assessment in the sample of reviews
can be found in the Table. Conclusions: Almost all recent reviews
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Gou Y1 , Shi L1 , Jin A2 , Xiong H1 , Huang X3
1 The Second Clinical College of Lanzhou University; 2 The First Clinical
College of Lanzhou University; 3 The Second Hospital of Lanzhou University
Background: Systematic reviews (SRs) of animal studies in the world
have become increasingly popular in recent years. This review try to
provide the first examination of methodological quality of these SRs
in China use the AMSTAR guidelines. Objectives: To examine the
methodological quality of SRs of animal studies in China. Methods:
Four Chinese databases were searched (CBM, CSJD, CJFD and Wanfang
Database) for SRs of animal studies, from January 1978 through to
December 2012. Data were extracted into Excel spreadsheets. The
AMSTAR checklists was used to assess the methodological quality.
Results: A total of seven SRs were identified. Compliance with
AMSTAR checklist items ranged from 0 to 100% (Table 1). Most
reviews were compliant with the following checklist items: used
appropriate methods to combine the findings of studies (100.0%),
reported the status of publication (i.e.grey literature) used as an
inclusion criterion (85.7%), provided a list of studies (included and
excluded) (85.7%); More than half of the reviews assessed and
documented the scientific quality of the included studies (71.4%),
appropriately addressed the quality of included studies in formulating
conclusions (71.4%), reported that a comprehensive literature search
was performed (57.1%), assessed the likelihood of publication bias
(57.1%), provided the characteristics of included studies (57.1%); Few
studies reported duplicate study selection and data extraction (42.9%).
No studies provided an ‘a priori’ design, or stated whether there
was a conflict of interest. Though all of the reviews used the term
‘systematic review’ or ‘meta-analysis’ in the title, no reviews reported
a protocol and none were updated even after they had been published
after two or more years. Conclusions: Although some SRs of animal
studies have been published in Chinese journals recently, the reporting
quality is troubling. So, on one hand, animal research publication
checklist should be abide by in order to improve the quality of animal
research; On the other hand, reporting items for systematic reviews
and meta-analyses of animal studies should be discussed.
Attachments: Table 1. AMSTAR Checklist Assessment.png
Cochrane Database Syst Rev Suppl 1–212 (2013)
Quality of systematic reviews of diagnostic test
accuracy on Alzheimer’s disease dementia and
other dementias
Arevalo-Rodriguez I1 , Segura O1 , Solà I2 , Sánchez E1 , Bonfill X2 ,
Alonso-Coello P3
1 Fundación Universitaria de Ciencias de la Salud, Hospital de San
José/Hospital Infantil de San José, Bogotá D.C., Colombia; 2 Iberoamerican
Cochrane Centre - Institute of Biomedical Research (IIB Sant Pau), CIBER
Epidemiologı́a y Salud Pública (CIBERESP), Spain - Universitat Autònoma
de Barcelona, Barcelona, Spain; 3 Iberomerican Cochrane Centre, Clinical
Epidemiology and Public Health Department, Institute of Biomedical
Research (IIB Sant Pau), Spain. CIBER de Epidemiologı́a y Salud Pública
Background: The Cochrane Handbook of Diagnostic Test Accuracy
(DTA) has introduced important guidelines in order to develop
high-quality DTA reviews. In dementia, clinical diagnosis has become
a paramount issue related to early and adequate management.
Systematic reviews (SRs) of accuracy of dementia tests can establish
which diagnostic tools should be used in daily-practice. It is important
to know the rigor of these reviews in order to know their role to guide
decision-making process. Objectives: To describe the characteristics
and quality of DTA SRs in the field of Alzheimer disease (AD) and other
dementias. Methods: We searched MEDLINE, EMBASE, The Cochrane
Library and DARE (from their inception to March 2013), as well as
list of references of included studies. Two researchers independently
assessed eligibility, extracted data and assessed risk of bias (RoB) using
the AMSTAR-II tool, according to the Cochrane methodology for DTA
reviews. Results: We included 23 SRs with sample sizes ranging
from 160 to 26 019 participants. Only ten reviews (43%) assessed
RoB of included studies, being patient’s spectrum and incorporation
bias the most frequent biases. One review (4.3%) reported to have a
protocol, 20 (86.9%) not provided a list of included/excluded studies
and 15 (65.2%) did not reported a duplicate study selection/data
extraction. Eight reviews pooled data with methods addressed to SRs
of interventions (34.7%). Five reviews (21.7%) analyzed publication
bias by means of funnel plots and/or Egger’s Test. All SRs did not
report consequences of inconclusive results, adverse events or use of
resources. Conclusions: The set of assessed SRs shows important
flaws with an impact in the confidence of their results. In order
to improve the quality of DTA SRs is necessary to value the nature
of the diagnostic evidence, apply appropriate statistical methods for
summarize the evidence and provide an assessment of quality of
included studies.
Reporting and methodological quality
of systematic reviews of interventions published
in Chinese surgical journals
Ge L1 , Zeng QL2 , Liang L1 , Li YR2 , Ma JC1 , Liu YC1 , Tian JH3
The First Clinical College of Lanzhou University, China; 2 The Second
Clinical College of Lanzhou University, China; 3 Evidence-Based Medicine
Center, School of Basic Medical Sciences, Lanzhou University, China
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: Systematic reviews (SRs) or Meta analyses (MAs) of
randomized controlled trials (RCTs) are considered to provide the
highest level of evidence for surgeons to access the sources of
information. However, not all published SR or MA are rigorously
performed. Objectives: To assess the reporting and methodological
quality of SRs or MAs of intervention published in Chinese surgical
journals. Methods: 3 Chinese databases were used to search 20
Chinese surgical journal for SRs or MAs on interventions of RCTs, from
inception through October 2012. Data were extracted into Excel soft.
The PRISMA and AMSTAR checklists were used to assess reporting
characteristics and methodological quality, respectively. Results: 262
records were searched, 79 SRs or MAs on interventions of RCTs were
identified, most (69/79, 87.34%) of which used the terms SR or MA
in the title. 84.81% (67/79) studies were written by hospital and
only 12.66% (10/79) by hospital and university. The most commonly
treated conditions were diseases of the musculoskeletal system and
connective tissue (24/79, 30.38%), diseases of the digestive system
(22/79, 27.85%). And surgical intervention (53/79, 67.09%) was most
commonly. Funding sources were reported for 7 reviews (8.86%), 57
reviews (72.15%) reported the tool of quality assessment, the most
commonly is Cochrane Handbook (28/79, 49.12%). According to the
AMSTAR checklist (Table 1), the score range of the methodological
quality was 2.0 to 10.0, the average score was 6.49 ± 1.50. The
results of PRISMA checklist shows that the score range of the reporting
quality was 8.0–23.0, the average score was 17.76 ± 3.27 (Table 2).
Conclusions: The reporting and methodological quality of SRs or MAs
published in Chinese surgical journal is poor, we recommend AMSTAR
and PRISMA statement for the optimal conduct and reporting of SRs
or MAs in surgery.
Attachments: Table 1 The results of methodological quality assessment (n = 79).pdf, Table 2 The results of reporting quality assessment
(n = 79).pdf
The quality of economic studies in respiratory
diseases in China by QHES tool
Zhuo M1 , Zhao L1 , He Y1 , Zhang X1 , Liu F1 , Jiang H1 , Tian JH2
Evidence-Based Medicine Center, School of Basic Medical Sciences
of Lanzhou University, China; 2 School of Public Health of Lanzhou
University, China
Background: Economic studies(ESs) are increasingly common in the
respiratory diseases. Although clinical trials are subjected routinely
to critical appraisal, there has been no attempt to appraise the
quality of ECs in this field. Objective: To assess the quality of ESs
in respiratory diseases, and to identify predictors of study quality.
Methods: An electronic literature search of all ESs of respiratory
diseases from inception to December 2012 was conducted using the
following text and keywords in combination both MeSH terms and text
words, the search strategy was (cost OR cost effective OR cost benefit
OR cost utility) AND (respiratory diseases) in four databases. The
methodological quality was assessed independently by two reviewers
using the the Quality of Health Economic Studies (QHES). Results:
Of 77 ESs were included and analyzed, there were not high quality,
96.10% were fair, and 3.90% were poor. Compared with before 2003,
the number of articles is significantly increasing, but the quality was
Cochrane Database Syst Rev Suppl 1–212 (2013)
not improved. Compared with the foreign ECs, the score of Chinese
ESs (Mean ± SD:62.51 ± 5.96) was lower (Table 1, 2). Conclusions:
There is not ESs in respiratory diseases meet criteria for high quality.
QHES is a validated instrument to appraise the quality of health
economic analyses. In the future, the journal editors and peer reviewers
should pay more attention to the quality of ESs in reparatory diseases.
Attachments: Table1 the quality of Published Economic Studies in
Respiratory Diseases in China.pdf,
Table2 the difference between
Chinese studies and foreign studies.pdf
Navigating the rough waters of knowledge
translation (KT) research: effective search
strategies for systematic reviews with a KT focus
Chojecki D1 , Boruff J2
Institute of Health Economics/University of Alberta, Canada; 2 McGill
University, Canada
Objectives: To discuss the role that literature searching/information
specialists can play in the knowledge to action cycle and the
challenges of searching within the research field of knowledge
translation (KT); to present practical and effective literature searching
techniques and methods used for reviews of KT studies. Methods:
Knowledge translation (KT) is a growing area of research in the health
sciences. The problem of inconsistent language and indexing has been
well-documented in the literature, but few practical strategies exist to
assist those who must create comprehensive searches for systematic
and scoping reviews in this field of study. Through the experience
of creating KT searches for researchers in medicine, nursing, and
rehabilitation, the presenters have developed suggested best practices
for approaching KT questions. Results: Examples of successful search
strategies and the rationale behind the creation of these strategies
will be presented. Concrete methods for approaching the development
of KT searches will also be presented with an emphasis on the
following key areas: KT theory versus KT interventions and tools,
suggestions on resources to search, and guidelines for selecting MeSH
terms and keywords. Discussion: The challenges and opportunities for
information specialist involvement with knowledge translation research
will also be discussed.
Where to look for studies to include in EPOC
Johansen M1 , Paulsen E1 , Mathisen M2 , Odgaard-Jensen J1
1 Cochrane Effective Practice and Organisation of Care Group, Norway;
Vestfold Hospital Trust, Norway
Background: The Cochrane Effective Practice and Organisation of
Care Group (EPOC), prepares systematic reviews about non-clinical
interventions targeting health personnel, health services and health
systems. EPOC reviews may include study designs other than RCTs,
and these studies are often considered hard to find due to where and
how they are indexed. Rada et al. (2009) found that systematic reviews
in Health Policy and Systems Research had searched an average of
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
7.7 resources. MEDLINE and Embase were among the resources most
frequently searched, but their contribution is unknown. Objectives:
To find how many studies included in EPOC reviews are indexed in
MEDLINE, Embase, or elsewhere. Methods: We looked at all EPOC
reviews published in Issue 1 2013 of The Cochrane Library. We used
OvidSP to find whether included studies were indexed in MEDLINE,
Embase, or in neither of the two databases. Results: 84 reviews
included a total of 1462 studies. 1348 studies were indexed in both
MEDLINE and Embase. 9 were indexed in MEDLINE only, 23 in Embase
only, and 82 elsewhere. Discussion: Although we know where most
‘EPOC studies’ are indexed, they may still be hard to identify when
conducting a systematic search. We have yet to investigate how hard
they are to find, and the number of records needed to screen in order
to find them. Conclusions: Even though MEDLINE and Embase are
known as clinical databases, they both include studies relevant to
non-clinical reviews. There is also a large overlap between MEDLINE
and Embase which could lead one to question whether it is necessary
for EPOC reviews to search both databases.
Rada G, Neumann I, Herrera C, Manrı́quez JJ, Pantoja T. Where do
systematic reviews in Health Policy and Systems Research search
for studies? 17th Cochrane Colloquium, 2009.
Finding evidence from developing countries:
the use of regional databases and other search
Bangpan M, Dickson K, Stansfield C, Tripney J, Vigurs C, Stewart R,
Oliver S
EPPI-Centre, Institute of Education, UK
Background: The past few years has seen the number of systematic
reviews relevant to developing countries increase substantially. It is
essential that systematic reviews include all available, relevant evidence
to minimize bias and maximize the generalisability of their findings
across settings. Recently, The Norwegian satellite of the Cochrane
Effective Practice and Organisation of Care (EPOC) group and its
partners produced a collection of search sources relevant to developing
countries. Objective: To explore the usage of regional databases
and other search sources used in systematic reviews relevant to
developing countries focusing on healthcare. Methods: We identified
Cochrane Systematic Reviews using ‘developing countries’ terms in
both free text and MeSH term searches. The retrieved citations were
imported into EPPI-Reviewer software. Data on databases and search
sources were coded and analysed. Results: We identified 34 relevant
systematic reviews; 32 were published in the past 5 years. Nearly
two-thirds (n = 23) carried out searches in regional databases. The
most commonly searched regional database was LILACS (n = 20),
followed by MEDCARIB (n = 3) and African Index Medicus (n = 3).
Nearly half also searched topic-specific databases (e.g. ERIC, POPLINE,
AGRIS). Searches in grey literature (e.g. dissertations, conference
proceeding databases), international development specialists (e.g.
ELDIS, BLDS) and non-English databases (e.g. Banque de Données
Santé Publique database) were less common. Further sourcing methods
included references checking, website searching and personal contact
Cochrane Database Syst Rev Suppl 1–212 (2013)
with experts, authors, and/or relevant organisations. Conclusions:
Identifying relevant research evidence in developing countries is
challenging. Most systematic reviews identified searched only one
regional database, namely LILACS. There is potential to improve search
strategies by including other regional databases and other search
sources to identify relevant research evidence in health in developing
Investigating the use of the McMaster Premium
Literat Ure Service (PLUS) as a method to
efficiently update systematic reviews
Athale A, Iorio A
Department of Clinical Epidemiology and Biostatistics, McMaster University,
Hamilton, Canada
Background: Systematic reviews (SRs) of treatment effects are
evidence syntheses that inform clinical practice decisions and healthcare
policy by providing the best answer to a clinical question. To maintain
validity, SRs should be regularly updated to include novel research,
which is why timely updating of SRs is a primary goal of the Cochrane
Collaboration. In reality, updating practices are irregular, with resource
and time constraints cited as major barriers. The McMaster Premium
LiteratUre Service (PLUS) is a database of high quality, pre-appraised
evidence, which has been shown to be of potential help in efficient
updating of SRs. Objective: To determine the performance of PLUS
to locate studies that drove a change in the conclusions of updated
Cochrane SRs. Methods: All updated Cochrane SRs, published from
January 2012 to January 2013, with conclusions changed from prior
versions will be included in this study. We will identify the new
references in the updated version. We will classify SRs based on the
type of conclusion change (i.e. change in magnitude or direction of
treatment effect), and identify mean number of new trials and new
patients added (both expressed as absolute number and proportion of
total trials). We will determine which new references are captured by
PLUS, and how excluding references, not captured by PLUS, impacts
the conclusions for each review. Results: From January 2012 to
January 2013, 31 Review Groups published 96 SRs with changed
conclusions. Overall approximately 900 new studies were added.
Detailed study results will be available by mid-2013. Results will
include characteristics of SRs with changed conclusions, proportion of
new studies captured by PLUS, and impact on conclusions of excluding
studies not included in PLUS. Significance: The results of this study
will provide empirical knowledge about characteristics of updated
Cochrane SRs and a method to improve efficiency of updating SRs.
MAPA: a live meta-analysis with customized
tables in a live map
Ciapponi A, Glujovsky D, Garcı́a Martı́ S, Bardach A
Institute for Clinical Effectiveness and Health Policy (IECS)
Background: Latin America and Caribbean (LAC) remains the most
unequal region in the world. Besides, LAC has experienced rapid
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
and complex epidemiological changes in recent decades. Despite the
need of having available updated data, most countries in the region
rely mostly on external financing to sustain long-term research and,
therefore, it is not easy to be achieved. The production of documents
with systematic reviews and economic evaluations are useful but not
enough to provide the whole produced information in the research
.A live epidemiological map with customized tables could provide
a valuable contribution to the health part of the population in the
region. Objectives: To show an online interface that allows to
retrieve interactive quantitative data with a graphic support, based
on meta-analysis about some specific diseases in LAC population.
Methods: We performed systematic reviews with meta-analysis about
certain diseases in LAC countries. That information has been uploaded
to a database. Firstly, an online interface has been developed in order
to show interactive tables where rows, columns, filters and outcomes
can be customized. Besides, the information that feeds each of those
cells can be easily retrieved by the users. Secondly, a customized forest
plot can be shown. Thirdly, a list of other systematic reviews and
economical evaluations that were found in the performed systematic
review can be seen. Finally, an interactive map with several graphics
will help users to see distributions along the region. Results: An online
interface with the previously mentioned information. Conclusions:
The living tables, meta-analyses and maps allow researchers, decision
makers and health providers to acquire some specific and detailed
customized information, which fits their needs and convenience.
Filtering for findability in systematic review
search strategies
Hagstrom C, Cunningham H
Gerstein Science Information Centre, University of Toronto, Canada
Background: Researchers constructing a search strategy require
results that meet sensitivity and specificity needs. Search filters are
collections of search terms designed to retrieve articles of a specific
study design, such as randomized control trials or observational studies,
or by some other aspect of the research question, such as economic s
or patient issues. Filters are a sophisticated combination of controlled
vocabulary, keywords and methods that take advantage of the unique
tools and indexing of particular databases. Search filters can run from a
few search lines to over one hundred lines in length. Since researchers
need to search several databases in order to be comprehensive and
reduce bias of results, filters are also specific to the database and
platform such as Ovid for MEDLINE or EBSCO for CINAHL. They are
created by research teams and are pre-tested and evaluated to ensure
the quality of retrieved results. Objectives: This poster will illustrate
the importance as well as the limitations of search filters in the
overall searching and information retrieval process. Methods: We will
illustrate various sources of search filters in accordance with relevant
study types and database interfaces. We will include links and QR codes
to the websites of the filters, the organizations that created them, as
well as supporting evidence. Results: Knowledge of where to find an
appropriate search filter and how to incorporate into the search strategy
can lead to efficiencies, as the search results will be more relevant.
Conclusions: Search filters can aid in retrieving relevant citations and
weeding out unwanted results, thus saving valuable time for analysis.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Comprehensive overview of conduct
and reporting of cross-sectional studies
on STROBE statement in public health field
of China
Ding G1 , Li H2 , Yao Q1 , Li XL2 , Bai Z3 , Yang KH3
1 School of Public Health, Lanzhou University, Lanzhou, China; 2 School
of Public Health, Evidence-Based Medicine Center, Lanzhou University
Lanzhou, China; 3 Evidence-Based Medicine Center, School of Basic Medical
Sciences, Lanzhou University, China
Background: Cross-sectional Studies are widespread in public health,
however, the studies’ quality are unclear in China. STROBE statement,
with the common aim of STrengthening the Reporting of OBservational
studies in Epidemiology, provides recommendations in the conduct
and dissemination of observational studies. Objectives: To assess
the conduct and reporting of cross-sectional studies in public health
in China based on STROBE. Methods: An electronic literature search
of cross-sectional studies was conducted using the China Disease
Knowledge Total Database (CDD), which has one part on cross-sectional
studies classified by journals. We selected cross-sectional studies from
CDD’s journals in public health randomly by computer and analysed
completely on STROBE statement. Two researchers independently
screened and extracted the related data, disagreements were resolved
by the third one. Results: 199 cross-sectional studies from 13 journals
in public health were included. We checked all the 22 Checklist of
items of STROBE for cross-sectional studies, 12.6 items were reported
on average across included studies. More than half of included studies
didnot report or report uncompletely in nine items (4 in Methods, 3 in
Results, 1 in Conclusion and 1 in Other Information part). In Methods
part, 196 (98.49%) papers didnot report Bias, 186 (93.47%) didnot
explain the studies size, 142 (71.36%) didnot explain how quantitative
variables were handled and 104 (52.26%) didnot describe all statistical
methods. In Results part, 179 (89.95%) didnot reporte main results
completely, 168 (84.42%) didnot reporte other analyses done and
135 (67.84%) didnot give descriptive data of participants. 133
(66.83%) papers didnot give the funding information. Conclusions:
Most cross-sectional studies in public health of China are not up to
standard of STROBE statement. For the purpose of improve reliability
and standardization of public health research, there is a need to
disseminate the STROBE statement on the reporting requirement in
public health in China.
Search filter accuracy to LILACS (via iAHx 2.6-5
interface) for retrieving Randomized Controlled
Trials by Brazilian Cochrane Centre
Puga MES, Silva V, Soares BGDO, Atallah Á
Brazilian Cochrane Centre - Discipline of Emergency Medicine and
Evidence-Based Medicine, Federal University of Sao Paulo (UNIFESP),
São Paulo, Brazil
Background: The translation and validation of a clinical trial filter
for identifying studies scientifically correct and clinically relevant in the
bibliographic index LILACS is critical to use in the systematic reviews.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Objective: To assess the accuracy of the new translation of the search
filter for retrieving clinical trials in the LILACS in the new interface
iAHx 2.6–5. Methods: Stages were completed to translate and
identificate the new terms found in other works by the gold standard
handsearch and therefore incorporated into this new version. The
chosen methodology as an alternative to handsearch was the Relative
Recall. Analysis was done in the references of Cochrane Systematic
Reviews that used the LILACS bibliographic index. The search using
the words ‘LILACS and Cochrane’ was performed in PubMed and the
full text of Systematic Reviews was retrieved in the Cochrane Library
through the free version for Brazilians at http://cochrane.bireme.br/.
Results: After searching the literature, we found that none of the
versions available are translated to the new interface and also are
not validated. The stages of identifying terminology which formed
a set ‘gold standard’ for the new filter were performed considering
the development and assessment based in performance (sensitivity),
specificity, and accuracy. Conclusions: We established a new
accurate search filter for retrieving clinical trials in the LILACS (via iAHx
2.6–5 interface).
Electronic culling of the clinical research
literature: filters to reduce the burden of hand
Wilczynski N, McKibbon A, Haynes B
McMaster University, Canada
Background: To facilitate the transfer of new, valid, relevant
knowledge into clinical practice, research staff in the Health Information
Research Unit at McMaster University have created a health knowledge
refinery (HKR). The HKR begins with critical appraisal of original and
review studies in 122 top clinical journals and leads to the creation
of the McMaster PLUS (MacPLUS) database. The time and resources
to critically appraise the literature are substantial. Objectives: To
determine if Clinical Queries search filters (available for use in PubMed)
for large bibliographic databases could be modified to electronically cull
the clinical research literature to reduce the burden of hand searching.
Methods: The Clinical Queries were modified to include only text
words and a NOT string to exclude irrelevant content. A retrospective
database of all content indexed in the 122 journals was created by
searching Medline via PubMed for a 17 month period. We tested the
modified Clinical Queries in this retrospective database to determine
if articles contained in the MacPLUS database were retrieved by the
modified Clinical Queries. Results: 66 939 articles were downloaded
from PubMed for the 122 journals over 17 months of publishing, May
1, 2010 to September 30, 2011. This is the number of articles that
HiRU staff would need to review over 17 months (average of 3938
articles per month—at a time estimate of 92 hours per month). Of
these 66 939 articles 3701 (5.5%) met our criteria for the MacPLUS
database. Given prior validation of the search filters, results are shown
in the Table using all articles rather than showing the results for the
development and validation data sets. Use of the new filters reduced
manual processing time by 55%. Conclusions: Search filters can be
used to electronically cull the clinical research literature to reduce the
burden of hand searching.
Attachments: Wilczynski Table Cochrane-2013.png
Cochrane Database Syst Rev Suppl 1–212 (2013)
To improve the efficiency of database searches
for the identification of reports of RCTs used in
NICE guidelines
Alderson P1 , Ashe J2 , Beckles Z3 , Boynton J1 , Glover S1 , Hasler E4 , Lai R3 ,
Stockton S5
1 NICE, UK; 2 National Clinical Guideline Centre, UK; 3 National Collaborating
Centre for Women’s and Children’s Health, UK; 4 National Collaborating
Centre for Cancer, UK; 5 National Collaborating Centre for Mental
Health, UK
Background: The National Institute for Health and Care Excellence
(NICE) ‘Guidelines manual’ outlines a core number of databases that
should be routinely searched for identifying reports of randomised
controlled trials (RCTs), including MEDLINE, Embase and CENTRAL.
Current practice is to search each bibliographic database from its
inception. However, the Cochrane Handbook recommends that
searches of MEDLINE and Embase for trials should be undertaken
in knowledge of the fact that both MEDLINE and EMBASE have been
searched systematically for reports of trials and that these reports of
trials have been included in CENTRAL (section Objectives:
To estimate the accuracy and reliability of the processes used by the
Cochrane Collaboration to identify reports of RCTs from MEDLINE and
Embase, for CENTRAL. To validate the Cochrane Handbook approach
of searching CENTRAL supplemented by searches of MEDLINE and
Embase for the more recent years. A further objective is to develop
a common filter(s) for identifying reports of RCTs from MEDLINE and
Embase for the more recent years that optimises the balance between
sensitivity and precision. Methods: A sample of ‘included’ RCTs
from NICE guidelines from each of the four National Collaborating
Centres (NCCs) and Internal Clinical Guideline (ICG) team will be used
to validate the Cochrane Handbook approach for identifying reports
of RCTs. The sample will also be used to objectively develop RCTs
filters for searching MEDLINE and Embase for the more recent years.
Results: This is an ongoing project, interim data will be presented on
the number and proportion of RCTs indexed in MEDLINE and Embase
which are also indexed in CENTRAL. Conclusions: We plan to draw
conclusions about the validity of the Cochrane Handbook searching
approach compared to the current ‘all years’ searching approach which
will inform the methods for searching for RCTs for NICE guidelines.
On beyond endnote: doing more with search
Witteman W
Centre Hospitalier Universitaire du Québec, Canada
Background: Your search results represent more than just days or
weeks of hard work - they are also data, locked in a range of formats
and difficult to analyze, re-purpose or transform. Objectives: This
presentation demonstrates a collection of software tools that allow
access to this data, as well as couple of example applications. Results:
The first sample application is a tool for comparing the keywords
in a set of references, generating Venn diagrams of the keywords
in common to the citations. When developing search strategies for
systematic review we often begin with two or more references that
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
exemplify what we hope to include in our review. This software allows
the systematic examination of the keywords used in a set of references.
This process will hopefully make the decisions of which keywords to use
in a search strategy more transparent. Also, if the development of the
search strategy does not have the benefit of subject matter expertise, a
data-driven approach can aid the search strategy developer to produce
a result that is improved by the examination of latent data in a corpus
of references. The second sample application is a tool for exporting a
set of references to a spreadsheet. More than once I wished for a way
to send references to colleagues without bibliography-management
software - but they did have access to a spreadsheet program and
furthermore they knew how to use it. Also, by transforming search
results into a spreadsheet format they are vastly easier to import into
statistical software for analysis. Conclusions: This presentation will
discuss these and other potential applications, the tools needed to
build them, and the source code of all the tools discussed.
The development of highly sensitive retrieval
strategy for cluster randomized controlled trial
Chen YL1 , Yao L1 , Wang M2 , Wei D1 , Wang Q1 , Yang KH1
Evidence-Based Medicine Center of Lanzhou University; 2 The First Hospital
of Lanzhou University
Background: There has been an increasing interest in cluster
randomized controlled trial (CRT) over the past 20 years. If several
cluster randomization trials are performed to investigate similar
interventions for the same outcome then it may be of interest to
combine the results using the techniques of meta-analysis. Objectives:
To develop, through revision of the Cochrane Collaboration search
strategy, a highly sensitive search strategy to retrieve reports of CRT
in PubMed. Methods: We identified all CRTs published in the
BMJ, Lancet, JAMA, and New England Journal of Medicine from
2003 to 2012 by searching their own official websites as golden
standard records. Then we searched CRTs in PUBMED with revised
highly sensitive Cochrane strategy in the four journals from 2003 to
2012. Sensitivity was defined as the number of gold standard records
retrieved/the number of gold standard records × 100, Precision was
defined as the number of gold standard records retrieved/the number
of records retrieved × 100. Results: We identified 175 CRTs as
golden standard records. We searched PUBMED and used the different
combination strategy, the results showed in the Table. No. strategy
References CRTs Sensitivity Precision 1 the highly sensitive Cochrane
strategy(HSC) for RCT 5254 174 99.4% 3.3% 2 HSC AND cluster[ti]
152 129 73.7 84.9 3 HSC AND cluster[ti/ab] 226 165 94.3% 73% 4
HSC AND (group*[Title] OR cluster* [Title/Abstract]) 264 166 94.8 62.9
5 HSC AND (communit*[Title] OR cluster* [Title/Abstract]) 271 172
98.3 63.5 6 HSC AND (group*[Title] OR communit*[Title] OR cluster*
[Title/Abstract]) 308 173 98.9% 56% 7 HSC AND (group*[Title] OR
field*[Title] OR communit*[Title] OR cluster* [Title/Abstract]) 315 173
98.9% 55%. Conclusions: Combining the highly sensitive Cochrane
strategy AND (communit*[Title] OR cluster* [Title/Abstract]) could be
the highly sensitive strategy for searching CRTs.
Attachments: table-cluster.jpg
Cochrane Database Syst Rev Suppl 1–212 (2013)
Is there a potential of umbrella reviews to inform
guideline development?
Bekkering GE1 , Emmers E2 , Hannes K2
KU Leuven - Methodology of Educational Sciences Research Group,
Belgium; Belgian Branch of the Dutch Cochrane Centre, Belgium; 2 KU
Leuven - Methodology of Educational Sciences Research Group, Belgium
Background: A best practice guideline on the prevention of
substance misuse in adolescents was developed in Belgium, using
the ADAPTE methodology. A comprehensive search revealed three
high-quality relevant guidelines. However, several clinical questions
formulated by the stakeholders involved could not be answered by
these guidelines. As multiple systematic reviews were available, we
conducted an umbrella review in an attempt to fill in the gaps.
Objectives: To summarize the evidence on programs to prevent
adolescent substance misuse in order to inform the guideline adaptation
process. Methods: We searched seven electronic databases, websites
and checked reference lists of relevant articles for reviews on the
effectiveness of school-based, family-based, community-based or
multicomponent prevention. We also assessed who should deliver
the program, what content and delivery method would be best and
which groups should be targeted. Systematic reviews that met our
predefined inclusion criteria were critically appraised using the AMSTAR
instrument. Due to the heterogeneity of outcome measures and the
way these were reported, the findings were synthesized using a
vote-counting approach. Results: We found 22 reviews reporting on
several populations and a wide range of interventions and outcomes.
Many reviews also lacked detail in the reporting of process and
implementation related aspects of the prevention programs which
hampered overall conclusions of which programs are effective, who
should deliver the programs, what content and delivery method is best
and which subgroups should be targeted. Conclusions: None of
the outstanding clinical questions could be answered by the results
of the umbrella review. This may be due to the heterogeneity in
population, interventions and outcomes and the low level of detail of
reporting. The potential of umbrella reviews to adapt guidelines need
to be investigated for topics with a higher level of standardization in
interventions and outcome measures.
Analysis of clinical guidelines developed based
on evidence in China
Liu M
The Chinese Cochrane Center, West China Hospital, Sichuan University,
Background: The clinical guideline is the bridge from the research
evidence to practice and evidence based guideline is thought as current
better guideline which developed by scientific methods. Chinese
medical association is the major academic organization to develop
national practice guidelines in China. Objective: To analyze the
quality of clinical practice guideline mentioned evidence based in
China. Methods: We selected clinical guidelines developed based
evidence issued by the Chinese medical association in 2010–2012
and with additional search for guidelines on clinical major diseases.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Excluded those published common sense, translation, abstract and
discussion, etc. Guidelines quality evaluated by 8 items selected
from the assessment of the methodological rigour which reference to
the Appraisal of Guidelines for Research and Evaluation (AGREE II).
Results: (a) Twenty-two guidelines included, 13 were originated and
9 were updated at 3–5 years, diseases covered on stroke, diabetes,
hypertension and chronic hepatitis, etc. (b) The number of guideline
references cited were 10–218, seven cited 24 Cochrane systematic
review (CDSR), which occupied reference 2.62% (24/916) and the top
was the acute ischemic stroke guideline (cited 7 CDSR). (c) The number
of experts involved in guidelines development was 2–95, guidelines
page was 4–150. (d) The guidelines quality were generally scores 4–7,
most of them described the process of guidelines developed, mentioned
grades of recommendation consistent with the levels of evidence. Few
guidelines provided the systematic methods used to search to evidence,
have been externally reviewed by experts prior to its publication and
procedure for updating the guideline, etc. Conclusions: There is
growing trend that clinical guidelines developed based evidence in
China. However, the quality of report and methodological rigour
of included guidelines need further improvement. The number of
Cochrane systematic review cited in these guidelines is limited. We
suggest guidelines recommendations should be consistent with the
levels of evidence and adapt to the local conditions, and relevant
support policies for guideline implementation in practice. Key words
Evidence-based medicine Cochrane systematic review Clinical guideline
Evidence-based guideline development Evaluation.
Use and quality of Cochrane Reviews used
in knee and hip osteoarthritis clinical practice
Paterson G1 , Toupin April K2 , Ueffing E3 , Benkhalti Jandu M4 , McGowan
J4 , Welch V4 , Wells G4 , Towheed T5 , Altman R6 , Tugwell P4 , Hochberg M7
1 The Arthritis Society Canada; 2 Childrens Hospital of Eastern Ontario,
Canada; 3 Canadian Cochrane Centre; 4 University of Ottawa, Canada;
Queen’s University, Canada; 6 University of California, USA; 7 University of
Maryland, USA
Background: In the last 10 years, various clinical practice guidelines
(CPGs) have been developed to guide the pharmacologic and
non-pharmacologic management of knee and hip osteoarthritis (OA).
Evidence-based recommendations rely on a wide range of evidence,
including Cochrane systematic reviews (SRs). Objectives: To
determine the extent of use and quality of evidence provided by
Cochrane Reviews in the development of CPGs for OA. Methods:
All CPGs addressing both OA pharmacologic and non-pharmacologic
interventions from the last 10 years were reviewed. We selected the
2012 American College of Rheumatology (ACR) CPGs for OA because
they used the most recent evidence. The best available evidence
in the ACR CPGs was identified by searching for the most recent
SR for each treatment comparison and patient important outcome
(i.e. pain, function, adverse effects, adherence, withdrawals). If
no SR was identified, the most recent randomized controlled trial of
sufficient quality was chosen. Evidence quality for each outcome was
appraised using the GRADE (Grading of Recommendations Assessment,
Development and Evaluation) method. Results: Cochrane evidence
was chosen as the best available, most recent evidence for 5 of
Cochrane Database Syst Rev Suppl 1–212 (2013)
10 pharmacologic interventions and 4 of 14 non-pharmacologic
interventions. Cochrane Review GRADE scores for pharmacologic
interventions were moderate for 32% of reviews and high for 65%,
while scores for non-pharmacologic interventions were moderate for
37% of reviews and high for 29%. Non-Cochrane SR evidence was
generally rated lower, with some of the outcomes of interest not
reported. Evidence was high for 53% of pharmacologic treatments
and high for 14% of non-pharmacologic (61% low). Conclusions:
Cochrane Reviews were used extensively as evidence for the most recent
OA CPG, especially the pharmacological interventions. Cochrane
evidence quality was generally high for pharmacologic treatments
and moderate or high for non-pharmacologic treatments. Cochrane
evidence was of higher quality than other SRs.
Changing physician practice patterns: methods
for implementing clinical research and guidelines
Mostofian F, Ruban C, Simunovic N, Bhandari M
McMaster University, Canada
Background: There are various interventions for guideline implementation in clinical practice, but the effects of these interventions are
generally unclear. There is a plethora of primary research evidence
about the effectiveness of these interventions however it is dispersed
amongst medical literature. Objectives: We conducted a systematic
review to identify the most effective methods of implementing clinical
research findings and clinical guidelines to change physician practice
patterns, in surgical and general practice. Additional focus was
placed on presenting research findings on long-term effects and cost
effectiveness of the implementation methods. Methods: We searched
electronic databases (including MEDLINE, EMBASE, and PubMed)
for systematic reviews published in English, which evaluated the
effectiveness of different implementation methods. Two reviewers
independently assessed methodological quality and extracted relevant
data from the reviews. Results: Eighteen reviews were identified
covering a wide range of interventions. In general, passive approaches
are ineffective and unlikely to create physician behaviour change.
Most other interventions were relatively more effective when used as
multifaceted interventions, compared to single interventions. Overall,
continuing medical education was most effective in changing physician
practice pattern. Conclusions: Continuing medical education and
multifaceted interventions are the most effective implementation
methods. Additionally active approaches to changing physician
performance are shown to improve practice to a greater extent than
traditional passive methods. Further primary research is necessary to
inform the effectiveness of these methods specific to surgical settings,
their cost-effectiveness and long-term effects.
Attachments: Intervention Method Summary Figure.JPG
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Optimal use of GRADE in Cochrane Reviews
to inform clinical practice guidelines
Neumann I1 , Santesso N2 , Akl EA3 , Vandvik PO4 , Alonso-Coello P5 ,
Agoritsas T2 , Elias P2 , Mustafa RA6 , Schünemann HJ7 , Guyatt GH2
Department of Clinical Epidemiology and Biostatistics, McMaster
University, Hamilton, Canada. Department of Internal Medicine, School
of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile;
Department of Clinical Epidemiology and Biostatistics, McMaster
University, Hamilton, Canada; 3 Department of Internal Medicine, American
University of Beirut, Beirut, Lebanon. Department of Clinical Epidemiology
and Biostatistics, McMaster University, Hamilton, Canada. Department
of Medicine, State University of New York at Buffalo, Buffalo, NY, USA;
Norwegian Knowledge Centre for the Health Services, Oslo, Norway;
Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau
(IIB-Sant Pau), Barcelona, Spain; 6 Department of Clinical Epidemiology
and Biostatistics, McMaster University, Hamilton, Canada. Department
of Medicine, University of Missouri-Kansas City, Kansas City, Missouri,
USA; 7 Department of Clinical Epidemiology and Biostatistics, McMaster
University, Hamilton, Canada. Department of Clinical Epidemiology and
Biostatistics, McMaster University, Hamilton, Canada
Background: The GRADE approach (short for Grading of
Recommendations Assessment, Development and Evaluation) offers
a transparent, explicit and systematic way to summarize evidence, rate
its quality, and move from evidence to recommendations. Cochrane
Reviews are a valuable resource to inform trustworthy clinical practice
guidelines. However, systematic reviews are not always conducted or
reported in a way that facilitates their use for guideline development. An
optimal use of GRADE in Cochrane Reviews could help to enhance their
usefulness. Methods: Through an iterative process, we developed a
set of criteria to evaluate the optimal use of GRADE. In this report,
we focus on the criteria concerning the synthesis and evaluation of the
evidence, which are relevant for systematic reviewers. Results: We
developed six criteria for the optimal use of GRADE. Three are relevant
for Cochrane Reviewers (Table 1): 1. The outcomes selection should
be driven by what it is important to patients instead of what it is
reported in primary trials. 2. Reviewers should provide effect-estimates
for all the patient important outcomes relevant for decision making,
including relative and absolute measures. 3. Finally, the reasons
to rate down and up the confidence in effect-estimates should be
explicit and described in detail, ideally providing an Evidence Profile
in addition to the Summary of Finding table. Conclusions: The
adherence to a simple set of criteria could enhance the usefulness of
Cochrane Reviews for the development of clinical practice guidelines.
Table 1—Optimal use of GRADE in systematic reviews 1. Were all the
patient important outcomes relevant for decision making considered?
2. Did the systematic review provide explicit relative and absolute
effect estimates for all the relevant outcomes? 3. Were the judgements
about the confidence in the effect-estimates explicit?
Cochrane Database Syst Rev Suppl 1–212 (2013)
The use of GRADE methods in World Health
Organization (WHO) public health guidelines:
distributions of strength of recommendations
and confidence in estimates of effect
Alexander PE1 , Norris S2 , Brito JP3 , Stoltzfus RJ4 , Bero L5 , Djulbegovic B6 ,
Neumann I1,7 , Montori VM3 , Guyatt GH1
Department of Clinical Epidemiology and Biostatistics, McMaster
University, Hamilton, Canada; 2 World Health Association, Geneva,
Switzerland; 3 Mayo Clinic, Rochester, Minnesota, USA; 4 Division of
Nutritional Sciences, Cornell University, USA; 5 University of California,
San Francisco, USA; 6 University of South Florida & H Lee Moffitt Cancer
Center; 7 Department of Internal Medicine, School of Medicine, Pontificia
Universidad Catolica de Chile
Background: A perception exists that expert guideline panelists
are sometimes reluctant to offer weak/conditional/contingent recommendations. GRADE guidance warns against strong recommendations
when confidence in estimates of effect (quality of evidence) is low
or very low, suggesting that such recommendations may seldom be
justified. Objectives: To characterize the distribution of strength
of recommendations and confidence in estimates of effect in WHO
guidelines that have used the GRADE approach and graded strength of
recommendations and confidence in effect estimates. Methods:
436 WHO documents were initially reviewed (October/November
2012). We identified 116 (26.0%) guidelines of which 48 (41.3%)
referred to GRADE methods, and 43 (37%) utilized GRADE and
provided both a strength of recommendation and confidence in
estimates grading. We describe the distributions of strong and weak
recommendations and associated rating of confidence in estimates of
effect. Results: The 43 guidelines offered 456 recommendations:
290 were strong (63.6%) and 166 (36.4%) were weak. Of the 290
strong recommendations 50 (17.2%) were based on high confidence
in estimates, 80 (27.6%) were based on moderate confidence, 97
(33.4%) were based on low confidence, and 63 (21.7%) on very low
confidence (a total 55.2% on low or very low confidence estimates).
Of the 166 weak recommendations, 4 (2.4%) were based on high
confidence in estimates, 24 (14.5%) based on moderate confidence,
59 (35.5%) on low confidence, and 79 (47.6%) based on very
low confidence. Discussion: Strong recommendations based on
low or very low confidence in effect estimates are very frequently
made in WHO guidelines. Further study to determine the reasons
for such recommendations is warranted. Implications: Guideline
developers/authors should provide a clear, compelling rationale for
strong recommendations based on low confidence estimates.
Does journal endorsement of reporting
guidelines impact the completeness of reporting
of health research? A systematic review
Stevens A1 , Shamseer L2 , Weinstein E3 , Yazdi F1 , Turner L1 , Thielman J2 ,
Altman DG4 , HIrst A4 , Hoey J5 , Palepu A6 , Simera I4 , Schulz K7 , Moher D2
1 Ottawa Hospital Research Institute, Canada; 2 Ottawa Hospital Research
Institute and University of Ottawa, Canada; 3 Albert Einstein College
of Medicine, USA; 4 University of Oxford, United Kingdom; 5 Queen’s
University, Canada; 6 St. Paul’s Hospital, Canada; 7 FHI 360, USA
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: Reporting guidelines (RGs) have been developed to
overcome inadequate and incomplete reporting of health research.
Aside from CONSORT, which was assessed in a recently published
systematic review, the effectiveness of RGs for improving the
completeness of reporting is unknown. Objectives: To evaluate
the impact of journal endorsement of RGs (excluding CONSORT) on the
completeness of reporting of health research studies. Methods: We
conducted a systematic review assessing RG impact on completeness
of reporting by comparing studies published (1) before and after journal
endorsement and (2) in endorsing and non-endorsing journals for a
given RG. RGs providing a minimum set of items for reporting a specific
type of research, developed with explicit methodology, and using a
consensus process were identified from another systematic review and
the EQUATOR Network’s reporting guidelines library (to June 2011).
MEDLINE, EMBASE, the Cochrane Methodology Register, and Scopus
were searched (October 2011) for evaluations of RGs. Fulltext articles
were screened independently by two reviewers. One person extracted
data, and a second person verified 10% of study characteristics and
100% of validity and outcomes data. RGs were analyzed according
to individual checklist items and their total sum, where applicable.
RR, MD, or SMD with 99% confidence intervals using random effects
models were used. Results: 101 relevant RGs were identified. Of
15 240 records retrieved from the literature search for evaluations, 20
evaluations assessing 7 RGs were included. Of those, 10 evaluations
addressing 6 RGs (BMJ economic checklist, CONSORT for harms,
QUOROM, STARD, STRICTA, STROBE) could be analyzed. Most RG
checklist items were assessed by one evaluation; evaluations included
relatively few studies. Conclusions: Only 7 of 101 RGs have been
evaluated by a small number of evaluations assessing relatively few
publications. Insufficient evidence exists to determine the impact of
journal endorsement on completeness of reporting.
PEN - the global resource for nutrition
knowledge translation
Armour B1 , Byron A2 , Kellie S3 , Murray B2 , Thirsk J1
Dietitians of Canada, Canada; 2 Dietitians Association of Australia,
Australia; 3 British Dietetic Association, UK
Background: Dietitians translate research into practice when applying
the science of nutrition to the feeding and education of individuals
or groups in health and disease. Maintaining currency is challenging
when knowledge is constantly expanding. In 2005 Dietitians of Canada
launched a dynamic knowledge translation subscription service called
Practice-based Evidence in Nutrition (PEN) for dietitians, including
those working in two Canadian provincial government call centres.
Establishing international partnerships required modifying PEN
processes of knowledge translation. Methods: Collaborating authors
from each global partner use protocols to identify, analyse and
synthesise the evidence to create new or update existing practice
questions, practice-based evidence toolkits/guidance summaries and
client resources, the key components of PEN. While the evidence
to develop these components comes from the international literature,
including Cochrane Systematic Reviews, global partners have
customised PEN to take into account national reference documents e.g.
nutrient reference values and dietary guidelines. Additional partners
have meant enrichment in knowledge pathway content and usage data
is helping to prioritise pathways for revision or development. Partners
Cochrane Database Syst Rev Suppl 1–212 (2013)
have used online tutorials, webinars and conference workshops to
build capacity and maximise use by practitioners, and to encourage
contribution to the PEN knowledge pool. Results: As of February
2013 there were 169 knowledge pathways, 1044 practice questions
and 3341 resources. Usage data indicates that client handouts are
often accessed more than practice questions. Social media confirms
the popularity of PEN with distribution to 12 000 first year PEN eNews
subscribers and greater than 1500 followers on each of Facebook and
Twitter. Universities report PEN as a tool to support student studies
and for students to gain recognition by refining their critical appraisal
skills and contributing to the global knowledge pool. Conclusions:
Problem solving and cooperation within the global partnership has
enabled the development of PEN as a valuable international resource
for practitioners.
The challenges of moving evidence to practice
Holly C, Salmond S
Background: Despite overwhelming clinical trial evidence, increasing
publication of systematic reviews, expert opinion, national guidelines,
and a vast array of educational conferences, evidence-based therapies
continue to be underutilized. Such underutilization leads to a gap in
care, such that reports indicate: 55% of patients get less than adequate
care; 30–40% do not get what they should get; 20–25% get what they
should not have or they do not need. Purpose: To begin to address this
issue, a project was undertaken to translate evidence to practice using
methods of action research and quality improvement. Conclusions:
This poster will detail the challenges encountered in moving evidence to
practice: The Challenge of Commitment, The Challenge of Democracy,
The Challenge of a Slow and Messy Process, The Challenge of Obtaining
Baseline Data, The Challenge of Context and Real World Complexities,
and The Challenge of Competing Priorities.
The growing role and impact of Evidence Aid: its
10-year vision
Kayabu B1 , Clarke M2
Evidence Aid/Centre for Global Health, Trinity College, Dublin, Ireland;
Evidence Aid/All Ireland Methodology Hub, Queens University, Northern
Ireland, UK
Background: Evidence Aid, an independent international organisation, promotes the use of systematic reviews in disasters, humanitarian crises and other health care emergencies. Since its creation
by The Cochrane Collaboration after the Indian Ocean Tsunami of
December 2004, it has as grown and has provided summaries of
reviews to humanitarian aid workers during disasters such as the
earthquake in Japan and Haiti and during floods in Pakistan, Thailand
etc. Objectives: To share the recent developments of Evidence Aid
and its 10-year vision. Methods: Through the needs assessment,
organisation of two international conferences on evidence in disasters,
and increasing collaboration with aid agencies, systematic reviews
are increasingly being discussed in the humanitarian aid community.
Additionally, a priority setting meeting in June 2013 will lead to ten
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
priority themes, and from those themes the selection of 30 intervention
questions for systematic reviews in disaster management. These
new reviews will be added to the Special Collections which already
contain more than 100 reviews. Results: Evidence Aid Special
Collections (earthquakes, flooding and poor water sanitation, Post
Traumatic Stress Disorders (PTSD) and burns) containing more than
100 Cochrane Reviews are freely available. Thirty other reviews from
the priority setting meeting will be added to the resources, alongside
other identified reviews, and will allow Evidence Aid to build a system
to deliver relevant information which is seamlessly integrated into
other information systems in the field. Conclusions: Evidence Aid will
become a one-stop shop to search for evidence on the effectiveness
of interventions in disasters, humanitarian crises and major healthcare
emergencies. Evidence Aid’s impact is growing and it has been able
to build strong partnerships with aid agencies, research centres and
donors. Further steps will focus on increasing collaboration with
users of systematic reviews in order to adapt them to the appropriate
circumstances in which those users work.
Exercise for lower limb osteoarthritis: systematic
review incorporating trial sequential analysis
and network meta-analysis
Uthman O1 , van der Windt D2 , Jordan J2 , Dziedzic K2 , Healey E2 , Peat G2 ,
Foster N2
1 University of Warwick, UK; 2 Keele University, UK
Background: International guidelines recommend exercise to be
part of ‘core’ management of osteoarthritis, given existing evidence
regarding the beneficial effects of exercise, ease of application, few
adverse effects and low costs. Objectives: To determine whether there
is sufficient evidence that exercise interventions are more effective than
no exercise control and compare the effectiveness of different exercise
interventions in relieving pain and improving function in patients with
lower limb osteoarthritis. Methods: Nine electronic databases were
searched from inception to March 2012 for RCTs comparing exercise
interventions either with each other, or no exercise control for adults
with knee or hip osteoarthritis. Two reviewers evaluated eligibility
and methodological quality. Main outcomes extracted were pain
intensity and function limitation. Trial sequential analysis was used
to investigate reliability and conclusiveness of available evidence for
exercise interventions. Bayesian network meta-analysis was used to
combine both direct (within-trial) and indirect (between-trial) evidence
on treatment effectiveness. Results: A total of 51 trials covering
13 exercise interventions and 5116 patients met inclusion criteria.
Sequential analysis revealed that as of 2005 sufficient evidence had
been accrued to show significant benefit of exercise interventions
over no exercise control. For pain relief, aquatic strengthening
plus aerobic exercise (78%) was ranked as most effective followed
closely by land-based flexibility plus strengthening and aerobic exercise
(72%), land-based flexibility plus strengthening (70%) and land-based
strengthening (69%). Flexibility plus strengthening (95%) followed by
strengthening (67%) had the highest probabilities of being the overall
best exercise interventions for improving function. Conclusions: As of
2005 sufficient evidence had accumulated to demonstrate significant
benefit of exercise. Further trials of exercise versus no exercise are
unlikely to overturn this pooled result. This network meta-analysis
shows that the most effective exercise approaches are strengthening
Cochrane Database Syst Rev Suppl 1–212 (2013)
exercise alone or in combination with flexibility exercise. These results
inform optimal care for lower limb osteoarthritis.
Network meta-analysis of multiple outcome
measures with extrapolation of effects across
Achana F1 , Cooper N1 , Bujkiewicz S1 , Kendrick D2 , Sutton AJ1
University of Leicester, UK; 2 University of Nottingham, UK
Background: Recent advances in meta-analysis have seen increased
application of multivariate methods to evidence synthesis involving
multiple outcome measures or multiple treatment effects. These
methods are particularly appealing in evaluating the effectiveness of
healthcare interventions because many studies and systematic reviews
of individual studies typically focus on broader health effects and
therefore usually report on multiple treatment and outcome measures.
Analyses of such data should take into account the correlation structure
between effect estimates from the different outcomes. Objective:
To (i) extend the standard network meta-analysis (NMA) model for
simultaneous comparison of multiple intervention effects from the
univariate to a multivariate outcome setting and in so doing (ii) enable
intervention effects to be extrapolated across outcomes. Methods:
The standard NMA model is first described and then extended to
multivariate outcome settings. These random effects multiple outcome
NMA models allow appropriate modelling of the correlation structure
between outcomes through inclusion of the within and between-study
correlations. Then using a strategy first proposed by DuMouchel
and Harris for combining evidence from human and animal studies,
the multiple outcome models are adapted to enable extrapolation of
intervention effects across the related outcome measures. Analyses
are conducted using Markov Chain Monte Carlo (MCMC) techniques
implemented within the WinBUGS software. Results: The models
are applied to binary outcome data investigating the effectiveness of
seven home safety education interventions on four fire injury prevention
measures in households with children. Conclusion: In the absence
of individual trial evidence on all outcomes, extrapolation of evidence
across related outcomes can enable estimates of intervention effects
for all outcome measures to be obtained, including intervention effects
on outcomes where no trial evidence is available.
Closing the research-practice gap using
integrated knowledge translation: a practical
webinar series
Vilis E1 , Bradley C2
1 Canadian Cochrane Centre, Canada; 2 Canadian Physiotherapy Association, Canada
Background:The Canadian Cochrane Centre (CCC) and the Canadian
Physiotherapy Association (CPA) collaborated to develop a two-part
webinar program for clinical physiotherapists to apply evidence-based
healthcare information to practice. Objectives: There is continued
concern from knowledge producers and users how to effectively connect
research to clinical practice. Using an integrated knowledge translation
(IKT) model with active collaboration, a tailored online educational
program pairing researchers and clinicians was developed and delivered
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
to help bridge the gap. Methods:The program was divided into two
independent but related series. Each series included three 90-minute
webinars exploring the steps for finding, understanding and making
informed, effective use of the best evidence for clinical physiotherapy
decisions. The first series covered how to frame a clinical question
for researching, where to look for quality evidence, and practice
implications. The second series introduced statistics used in systematic
reviews, presented challenges and opportunities in understanding
research evidence, and illustrated how to put research into practice.
The CCC knowledge broker and the CPA education programs manager
recruited and coordinated both Cochrane and physiotherapy presenters,
delivered the webinars, and evaluated the webinars series. Results:
The sessions provided the basic foundation for interpreting research and
evaluating the evidence as it applies to clinical physiotherapy. Clinical
case examples illustrated how the concepts could be applied to a variety
of practice areas and patient populations. Feedback from participants
indicated that the webinars have improved their confidence and skill
level. They are able to better recognize and appraise relevant evidence
to answer clinical questions. Conclusions: It is anticipated that
physiotherapists with improved critical appraisal skills will understand
and use Cochrane Reviews in their clinical practice. Although presenter
timing and recruitment were challenging, this ‘pairing research/clinical
presenters’ model can be used to aid other health care professionals in
disseminating, interpreting, and applying Cochrane Review findings.
A case study on the reporting of effect size
estimates in breast cancer trials
Willson M1 , Ghersi D2 , Askie L3
Cochrane Breast Cancer Group, NHMRC Clinical Trials Centre, University
of Sydney, Australia; 2 Research Translation Group, National Health and
Medical Research Council, Canberra, Australia; 3 Systematic Reviews Health
Technology Assessment, NHMRC Clinical Trials Centre, University of
Sydney, Australia
Background: Guidance on trial reporting from the CONSORT
statement outlines that primary and secondary outcomes should be
presented with estimated effect sizes and range (item 17; [1]). In
oncology trial reports, time-to-event outcomes are commonly reported
in the form of survival curves. When pooling time-to-event data for
systematic reviews, the Hazard Ratio (HR) from survival curves is the
most appropriate way to express the results [2]. Objectives: To
conduct a preliminary assessment on whether trial reports comply with
CONSORT by providing the appropriate effect estimate and range for
each time-to-event outcome. Methods: A Cochrane Review update
on Taxane-containing regimens for metastatic breast cancer was used
as a test case. For each included study that had a full-text publication,
details on the time-to-event outcome reported and the presence or
absence of (i) a survival curve (ii) a P-value and (iii) HR, median survival
time or risk ratio and associated Confidence Interval (CI) were extracted.
Results: Twenty-four trial publications were included and publication
dates ranged from 1995 to 2011. Nearly all trial reports (23 out of 24)
provided survival curves for overall survival and time-to-progression
or time-to-failure and P-values, and reported one effect estimate (i.e.
either median survival times, risk ratios or HRs). The ranges for median
survival times or risk ratios were absent in 6 out of 24 trial reports.
Also, 6 out of 24 trials reported HRs and CIs, and this was observed in
trials published in the early 2000s and 2011. Conclusions: This case
Cochrane Database Syst Rev Suppl 1–212 (2013)
study showed that effect size estimates for time-to-event outcomes
were consistently reported, suggesting compliance with CONSORT.
However, only a small number of trials (6/24) reported the HRs and
CIs from the survival curves. The lack of reporting relevant effect sizes,
such as HRs, for time-to-event outcomes may have implications when
undertaking meta-analyses.
Attachments: References.pdf
Legal issues in health technology assessment:
a case study
Blouin M, Coulombe M, Rhainds M
UETMIS, CHU de Québec, Canada
Background: Health Technology Assessment (HTA) is a synthesis of
the evidence concerning mainly the effectiveness, safety, risks and costs
of different healthcare interventions. A review of ethical and legal issues
is also occasionally required in HTA. Question was raised in a neonatal
care unit at the CHU de Québec regarding the safety of specimen
container use to store expressed breastmilk (EBM). Objectives: To
assess the acceptability of specimen container use to store EBM.
Methods: A literature search was performed in PubMed, Embase, the
Cochrane Library and the grey literature between January 2002 and
March 2013. Recommendations and characteristics about containers
used to store EBM were retrieved from evidence-based practice
guidelines. Information on legal considerations about food packaging
and consumer product safety was retrieved from governmental sites
(Health Canada, U.S. Food and Drug administration). Article selection
and quality assessment were performed by one reviewer and data
extraction by two independent reviewers. Synthesis review was shared
with an interdisciplinary group of experts. Results: Following an
evidence-based process, there was no definitive research results aimed
to clarify the most suitable containers to store EBM in a hospital
setting. Characteristics of specimen container used at the CHU de
Québec appear to be in accordance with the recommendations in the
major clinical guidelines. From a legally-based standpoint, the safety of
container used to store EBM was in a legal vacuum. Taking into account
the applicable laws and the literature results, it was not possible to
determine if its use may be safe to human health. Conclusions: Legal
issues are relevant aspects in HTA processes. In this case study, an
alternative procedure was proposed to store EBM in neonatal care unit.
This procedure is in accordance with the precautionary principle and
the weight of legal considerations over evidence-based data.
Trying to introduce systematic comparisons
between randomized and non-randomized
studies into the surgery field: a case report
Wang Q, Shi CH, Tian JH, Yang KH
Evidence Based Medicine Centre of Lanzhou University, School of Basic
Medical Sciences, Lanzhou University, China
Background: The comparison of evidence of treatment effects in
randomized and nonrandomized studies has showed that there existed
good correlation between them. Meanwhile, on account of the
inherent nature of the surgery trials, it was almost impossible to
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
perform blinding except blinding of the statisticians. And random
sequence generation or allocation concealment was often unclear
in the included studies. So, as the new approach, the systematic
comparisons between randomized and non-randomized studies are
needed to perform to add more reliable evidence. Objectives: The
aim is to introduce this systematic comparison using an example on
the stents for Pancreaticoduodenectomy (PD). Methods: A systematic
literatures searching were performed (PubMed, EMBASE, ISI web of
knowledge, the Cochrane library, and four Chinese databases), as well
as other additional resources, which were finished in November 2012.
The relevant clinical trials about pancreatic duct stents were included.
Data was reviewed and extracted by two reviewers independently
and was analyzed via RevMan 5 (version 5.2.0). The primary and
secondary outcomes were concerned. Results: Based on searches of
the literature published before November 2012, 5 randomized clinical
trials (RCTs) and 11 non-randomized clinical studies (nRCTs) were
included. The meta-analysis showed that compared with non-stent,
the pancreatic duct stent following PD was associated with a statistically
significant reduction on overall postoperative pancreatic fistula rate
(POPF), as well as the postoperative morbidity, overall mortality,
delayed gastric emptying and intra-abdominal collections (the results
were showed in Table 1). Conclusions: The systematic comparisons
between randomized and non-randomized studies could provide the
extra evidence from the present data and also make the evidence more
Attachments: Tab. 1 .pdf
Enabling engagement: the UK Cochrane Centre’s
experience of using social media for
communication about Cochrane Reviews
and more!
Chapman S, Millward H
UK Cochrane Centre, UK
Background: Effective use of social media is central to the UK
Cochrane Centre’s new focus on engagement. Social media platforms
offer ways to communicate with all our stakeholders, such as patients,
policymakers and health professionals, about evidence-based health
care and Cochrane Reviews in particular, and about our activities.
Objectives: To engage effectively with all our stakeholders and
with others outside the UK, through social media. Methods: Since
September 2012 we have become active on Twitter and Facebook and
have a new, regularly-updated website. We have a blog, Evidently
Cochrane, where we write lay-friendly summaries of reviews, setting
them in context and giving key results and a comment on the quality of
the evidence. We have established monthly meetings to review the next
issue of the Cochrane Library and discuss with a team of clinicians the
potential impact of the reviews and how we might best disseminate
them. We are now going out to our UK-based Cochrane Review
Groups to offer training and support in using social media to promote
their reviews and activities. Results: Twitter is our most active social
media channel; we are sending tweets about Cochrane Reviews daily,
both through planned tweets and responding to health topics under
discussion, which often results in conversation about reviews. We have
used Twitter and Storify to increase our participation in conferences
and capture these events. We are blogging at least weekly and these
Cochrane Database Syst Rev Suppl 1–212 (2013)
are generating comments and interest. We disseminate around forty
Cochrane Reviews each month across several social media platforms.
Conclusions: Since starting to use social media in these ways we
have seen a growing following across these platforms. We are now in
conversation with a vast network of people about Cochrane Reviews
and related topics and can direct people to evidence that is timely and
relevant. Engagement in action!
Cochrane eyes and vision group reviews
and co-publications
Wang X1 , Hawkins B2 , Dickersin K1
Johns Hopkins Bloomberg School of Public Health; 2 The Johns Hopkins
University School of Medicine
Background: To achieve wide dissemination of Cochrane Reviews and
maximize their impact, the Cochrane Collaboration allows
co-publication of Cochrane Reviews in other journals. Objectives:
To identify co-publications of systematic reviews published by the
Cochrane Eyes and Vision Group (CEVG), and compare characteristics
of CEVG reviews and corresponding co-publications. Methods: For
the 104 CEVG reviews in The Cochrane Library published by Issue
2, 2013, we identified potential co-publications by: (1) using the
keywords in the title and first author’s name to search the Web of
Science, Scopus, EMBASE and PubMed, (2) searching for ‘Cochrane
eyes and vision’ in Google Scholar, and (3) querying 88 contact authors
of the 104 reviews. For each co-publication and corresponding CEVG
review, we recorded titles, authors, publication dates, and citation
information. We classified each co-publication as ‘identical’, ‘similar
but not identical’, ‘abridged’, or ‘other’ compared to the CEVG review.
Results: We found 22 co-publications that corresponded to 19 CEVG
reviews: 1 co-publication from 2 CEVG reviews, and 2 co-publications
from each of 4 CEVG reviews. We classified 3 of the 22 co-publications
as ‘identical’ (14%), 14 as ‘similar’ (64%), 3 as ‘abridged’ (14%), and
2 as ‘other’ (9%). In half the co-publications, either the names or order
of the authors differed from the CEVG reviews. CEVG co-publications
were published in ophthalmology (55%) and general medical (45%)
journals; most (77%) were published within 2 years of the CEVG review.
Six co-publications (27%) did not cite the CEVG review in the text or
reference list (Table 1). On average, co-publications were cited more
often (mean = 28–29.9) than the CEVG reviews (mean = 9.7–13.1)
according to Web of Science and Scopus (Table 2). Conclusions: The
Cochrane Policy Manual established co-publication standards in 2011,
expecting citations of CEVG reviews and consistent authorship to be
improved thereafter. Providing information on increased frequency of
citation of co-publications to journal editors and review authors may
help encourage co-publication.
Attachments: Table 1.pdf, Table 2.pdf
Brazilian Cochrane Center strategies
for disseminating the Cochrane methodology
for systematic reviews
Martimbianco ALC, Costa MB, Porfı́rio GJM, Silva V, Grande AJ, Torres
MFS, Carvalho MR, Fioretti BTS, Torloni MR, Riera R, Atallah Á
Brazilian Cochrane Center, Brazil
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: The systematic review (SR) is an essential study for
taking clinical decision and has attracted a great deal of people
interested in having a better knowledge of it. Cochrane Collaboration
makes available extensive support material for conducting such study,
but in English only. In order to disseminate that material to other
countries it is fundamental to have it translated and didactically
presented. The Brazilian Cochrane Center (BCC) has been developing
tools to broadcast the material in Portuguese in order to motivate
researchers from Portuguese speaking countries and promote the
adequate training for performing the Cochrane SR. Objectives:
Verifying the strategies elaborated by BCC for the dissemination
and learning of the methodology proposed by Cochrane Collaboration.
Results: The BCC created the Online Course of Cochrane Systematic
Reviews based on the Handbook for Systematic Reviews of Interventions
(available at http://www.virtual.epm.br/cursos/metanalise/#). It is a
free of tax course with no pre-requirements that presents the basic
principles for the planning and conduction of a Cochrane Review
in an easy and didactic way. Until April 2013 the course had a
total of 105.741 accesses. The students interested in deepen their
knowledge on Cochrane SR are instructed to participate in workshops
offered by BCC, which take part every 2 months in average, and are
split in two levels: basic and advanced. Conclusions: Among the
strategies proposed by BCC for the dissemination and learning of the
Cochrane methodology, the Online Course of Cochrane Systematic
Reviews seems to be a viable, didactic and accessible strategy for any
Portuguese speaking individuals. The course was updated by the BCC
team in 2012, according to the last version published by Handbook,
and the version will be available online until June 2013.
Barriers to knowledge translation in Chinese
doctors: a cross-sectional survey
Huang Y, Li J, Chen J, Wang J
Chinese Cochrane Center, China
Background: Knowledge translation is very important for
evidence-based practice. Little is known about the factors influencing
knowledge translation in China. Objectives: To explore barriers that
influence knowledge translation in China. Methods: We conducted
a cross-sectional survey using a questionnaire adopted from relevant
studies abroad. The questionnaire included 7 domains and 42 items.
The survey was conducted between August 2012 and March 2013
involving 650 doctors attending workshops of evidence-based practice.
The doctors were required to fill the questionnaire anonymously
before the workshops. Three reviewers independently input the
data to Microsoft Excel 2003. Data analysis was performed using
SPSS 17.0 software. Results: The validity and reliability of the
questionnaire was tested with Cronbach’s α 0.731. We distributed
650 questionnaires and collected 578 (response rate: 88.9%). Among
the respondents, 43% think that current acquired knowledge cannot
meet the clinical needs, 44.8% think that learning sources provided
by their hospital are not sufficient. When they meet difficult clinical
problems, 45.9% doctors prefer foreign database other than Chinese
database to find information of interest. When they try to understand
the efficacy and safety of an intervention, the most common problem
is that 22.5% doctors cannot find relevant information after systematic
search of all known databases. When they read the research reports,
the most principal problem is that 48.3% doctors find it difficult
Cochrane Database Syst Rev Suppl 1–212 (2013)
to understand the results and conclusion. When they apply a new
intervention to patients, 23% doctors think whether the insurance
company can pay for the intervention or not is the biggest factor
influencing their choice. There are significant difference among doctors
with different age, education background, English level, title and level
of hospitals. Conclusions: Insufficient learning resources provided
by their hospitals and doctor’s capability in dealing with knowledge
hinder knowledge translation in clinical practice.
The utility of systematic reviews for informing
agri-food public health policy: a survey of
Canadian policy makers
Rajic A1 , Young I2 , Sargeant J2 , Papadopoulos A2 , McEwen SA2
Laboratory for Foodborne Zoonoses, Public Health Agency of Canada,
Canada; 2 Department of Population Medicine, University of Guelph,
Background: In recent years, several systematic reviewsmeta-analyses (SR-MAs) have been published addressing various
agri-food public health topics. It is not known to what extent
agri-food public health policy-makers are aware of SR-MAs and
how their evidence could be used to inform policy. Furthermore,
the traditional format in which SR-MAs are disseminated (i.e. journal
articles) may present a barrier towards their use among these end-users.
Objectives: The objectives are this study were to investigate the extent
to which policy makers in Canada are aware of and have used evidence
from SR-MAs to inform their work, and to gather their feedback on
the utility of SR-MAs and three corresponding summary formats to
inform policy. Methods: An online survey was conducted from July to
September, 2012 with policy makers, advisors, analysts and program
managers and directors in Canada—from all levels of government
and industry. Nine questions pertained to familiarity with and use
of SR-MAs and other knowledge syntheses. Participants were also
asked to provide feedback on a SR-MA article and three corresponding
summary formats: a summary-of-findings table, a one-page summary
and a three-page summary with supporting contextual information
(e.g. costs, practicality, public sensitivity). Semi-structured interviews
were held with six participants interested in discussing their survey
responses in more detail. Results: The survey was completed by 92
individuals, comprised mainly of policy analysts (32.6%), policy advisors
(32.6%), and program managers/directors (15.2%). Most participants
had previously read a systematic review (73.9%), and 37.8% had used
evidence from a SR-MA to inform a policy. Given a choice between the
four formats, the three-page summary with contextual information was
the preferred resource to inform policy (50.5%). Conclusions: We
found a high awareness about SR-MAs and other knowledge synthesis
methods among participants in this study. The results indicate that
disseminating evidence from SR-MAs in more user-friendly formats can
maximize its potential uptake by end-users.
Evidence-based approaches for evidence
dissemination in Cameroon
Mbuagbaw L, Ongolo-Zogo P
Centre for Development of Best Practices in Health
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: The Centre for Development of Best Practices in
Health (CDBPH) in Yaounde, Cameroon is a knowledge translation
unit that collects, synthesizes and communicates relevant evidence to
stakeholders in user-friendly formats. Objectives: In collaboration
with the Effective Health Care Research Consortium (EHCRC) we
sought to promote evidence-based decision making in the health
sector by improving the generation, use and uptake of high quality
health research evidence related to developing countries, over 5 years.
Methods: We used email and door-to-door priority setting with
Ministry of Health staff and other stakeholders; systematic review
workshops with researchers; supporting authors of Cochrane Reviews;
evidence-based-practice workshops with clinicians, journalists and
civil society organisations; translation and dissemination of Cochrane
Review summaries, evidence assessments and the creation of evidencebased-medicine (EBM) task forces within selected hospitals in
Cameroon. Results: The door-to door priority setting exercise
was the most fruitful, with a three-fold response rate compared to
email. After 2 years, three protocols and one review have been
completed. Thirty seven locally-relevant Cochrane Review summaries
have been translated into French in collaboration with the French
Cochrane Centre. Eight bilingual evidence summaries have been
produced and four functional EBM task forces have been created. Four
workshops targeting a variety of stakeholders (journalists, civil society
organisations, researchers, clinicians) have been held. Conclusions:
Setting priorities with stakeholders enhances end-user participation.
Door-to-door priority setting is very effective in our setting and should
be encouraged for activities with a potential for low response.
Collaborating with other centres is necessary to avoid duplication
of translation efforts. Engaging a wide variety of stakeholders in the
generation of evidence augments uptake and use.
Cochrane Public Health Group South Asian
satellite-Public Health Evidence South Asia
(PHESA): early experience
Nair S1 , Saith R2 , Waters E3 , UnniKrishnan B4 , Nair S4
1 Manipal University & PHESA; 2 Oxford policy management & PHESA;
Cochrane Public Health Group; 4 Manipal University
Background: Public Health Evidence South Asia (PHESA) is a new
initiative started in January 2013 aiming to meet the public health
evidence needs of the South Asia region. The initiative, which is
part of a satellite of the Cochrane Public Health Group, is based
within Manipal University and apporved by the Cochrane collaboration
registration and monitoring group. PHESA is the outcome of more a
years of deliberations, meeting, video conferences etc. It is centered in
Manipal led by Prof.Sreekumaran Nair (Dr. TMA Pai Endowment Chair
in Systematic Reviews and Evidence Based Public Health, & Statistical
Editor, CPHG) and Dr Ruhi Saith (Senior Consultant, Oxford Policy
Management & Developing Countries Editorial consultant, CPHG).
Objectives: The major task of PHESA is to build capacity to address
South Asia evidence priorities in the domain of public health. The
satellite plan includes mentoring reviewers for Public Health reviews,
production of review relevant to south Asian region, translation of
the knowledge into policy through network of govt. and local level
institutions.Primary research including methodological development is
also another objective. Methods: The whole initiative is based on
Cochrane Database Syst Rev Suppl 1–212 (2013)
mentoring approach. We identified different set of people for this
mentoring. A group of 15–20 young medical students have been
identified for the systematic review appreciation programme. Another
group of similar number of medical faculty have been identified for
evidence creation and translation. A group of experience systematic
reviewers have been identified for mentoring these new mentees. Now
we are contacting a group of senior public health policy makers to
get relevant questions into place. We connect these mentees and
mentors. We are in the process of exploring funding for the mentoring
programme. Results: Our early experience provide confidence that
the programme will work and PHESA will be a successful attempt.
Conclusions: Our initial work givel confidence of success.
Should the PRISMA statement be fully qualified
to report an updated meta-analysis? A case
He X1 , Wang Q2 , Li P1
The School of Clinical Oncology of Perking University, Perking University
Cancer Hospital & Institute, Perking University, Beijing 100142, China;
The First Clinical Medical College of Lanzhou University, Lanzhou
730000, China
Background: The PRISMA statement (preferred reporting items for
systematic reviews and meta-analyses) was developed to provide
the reporting guidelines for reviewers of systematic reviews (SR) or
meta-analyses (MA), to improve clarity and transparency of SRs. On
the other hand, Meta-analyses are commonly updated when new trials
appeared, or authors of Cochrane Reviews are suggested to update the
reviews every second year. However, it might be a question whether
it should be fully qualified to report an updated MA/SR. Objectives:
To evaluate a published updated MA using the PRISMA statement
and put forward the questions. Methods: An updated MA was
included (The Lancet Oncol 2011; 12: 681–692), 27 items of the
PRISMA statement were concerned by using ‘point-to-point’ method
to evaluate its clarity and transparency. A table, included the 27 items,
was showed to put forward the questions. Results: The evaluated
results and our concerns were showed in Table 1. Conclusions: The
PRISMA statement might be not fully qualified when it was used to
guide the reporting of an updated MA/SR.
Attachments: table 1.pdf
Logic model templates for systematic reviews
of complex health interventions
Rohwer A, Rehfuess EA
Institute for Medical Informatics, Biometry and Epidemiology, University of
Munich, Germany
Background: Complex interventions are commonly encountered
in health service, public health and social welfare and present
significant challenges when conducting systematic reviews. Logic
models, originally developed in the field of programme evaluation,
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
can be useful at every stage of the process of a systematic review,
from scoping to defining and conducting the review to communicating
the results. While various templates of logic models for programme
evaluations exist, no such templates have been developed for systematic
reviews. Objectives: To develop two different logic model templates
for systematic reviews of complex health interventions, focusing either
on the underlying systems (systems-based logic model) or the processes
involved (process-orientated logic model). Methods: We conducted
literature reviews on complex interventions, conceptual frameworks
and logic models and the use thereof in systematic reviews, and
contacted experts for additional information. We developed logic model
templates based on the traditional PICO framework; and informed by
various templates on logic models for programme evaluations as well
as the current use of logic models in systematic reviews. Results:
The systems-based logic model template allows authors to focus on
the system into which the intervention is introduced, by considering
underlying theories, assumptions and contextual factors that play a role
in the relationship between the intervention and the outcomes. The
process-orientated logic model template focuses on the components
and implementation of the intervention, the different levels of outcomes
and the multiple causal pathways and relationships that exist between
them. Conclusions: The two logic model templates are useful tools
for authors of systematic reviews, because they provide a structured
framework that considers critical factors and pathways influencing the
effectiveness of the intervention. This template will be tested across
multiple systematic reviews of complex interventions and revised as
Challenges of complex interventions: a worked
Horey D, Horvat L, Romios P
Cochrane Consumers & Communication Review Group, Australia
Background: Complex interventions pose significant challenges for
Cochrane Reviews, especially when there is lack of consensus in a
particular field with relatively little experience or commitment to RCTs.
In a review of a widely used complex intervention we found five RCTs
but little agreement on how the interventions were described or the
outcomes selected. Objectives: To demonstrate a systematic approach
to managing a complex intervention in a Cochrane Review. Methods:
We compared interventions and outcomes from five RCTs by mapping
components to a conceptual model (derived from theory) developed
for the protocol and by applying common Cochrane approaches to
minimise bias. Outcomes were grouped into categories to increase the
potential for meta-analyses. Results: The evidence generated by the
review was low to medium quality due to methodological weaknesses
in the included studies. However all components in the conceptual
framework were addressed and outcomes for all primary outcomes were
identified. The conceptual framework provides the basis for further work
to establish agreement on the core components of the intervention and
how the intervention can be evaluated in future trials. Conclusions:
The processes of the review provided the means to develop a robust
framework that will be used to develop consensus on how a complex
intervention will be described and evaluated in future studies.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Development of a quality appraisal tool for case
series studies
Moga C1 , Guo B2 , Schopflocher D3 , Harstall C1
1 Institute of Health Economics, Canada; 2 Institute of Health Economics,
Canada; 3 University of Alberta, Canada
Background: Health technology assessment (HTA) researchers are
often confronted with situations where only case series studies (CSs)
are available; however, no universally accepted validated tool exists for
assessing the methodological quality of these studies. Objectives: To
describe the processes of developing a quality appraisal checklist for
CSs. Methods: An initial broad list of 30 criteria was compiled through
a limited search of the literature. Six HTA researchers from Canada,
Australia and Spain participated in a modified Delphi study to develop
the checklist. The checklist culled to 18 criteria was updated through
an additional search of newly published checklists. An explanatory
dictionary was developed for each of the final 20 criteria and the
resultant tool was piloted in a number of HTA reviews. Results: A
four-stage e-mail-based process culled an initial list of 30-criteria to
a more ‘user friendly’ 18-criteria checklist. Two new criteria were
added later to the checklist (i.e. prospective study design and blind
assessment of outcomes) based on the literature review of other CSs
checklists. First-hand experience with the checklist and its dictionary
indicated a general level of satisfaction by the researchers. Suggestions
were made to improve the clarity and feasibility of the checklist and the
dictionary. Conclusions: This comprehensive checklist and dictionary
was considered a valuable tool by its initial users, although it may not
include all the criteria seen to be crucial for assessing methodological
quality of CSs by reviewers outside of the HTA field. Reviewers involved
in the appraisal process should determine which of the 20 criteria are
essential in accordance to the specific condition and technology under
review. The dictionary may also need to be customized for each review.
The process of validation of the tool is continuing.
Using a combined realist and socio-ecological
approach to integrating quantitative
and qualitative systematic review evidence
in a health technology assessment setting
Robertson C1 , Archibald D1 , Avenell A1 , Douglas F2 , Hoddinott P3 , van
Teijlingen E4 , Boyers D5 , Stewart F1 , Boachie C1 , Fioratou E6 , ROMEO
Project Group AT7
Health Services Research Unit, University of Aberdeen, UK; 2 Rowett
Institute of Nutrition and Health, University of Aberdeen, UK; 3 Health
Services Research Unit, University of Aberdeen, UK and School of Nursing,
Midwifery and Health, University of Stirling, UK; 4 Centre for Midwifery,
Maternal & Perinatal Health, Bournemouth University, UK; 5 Health Services
Research Unit, University of Aberdeen, UK and Health Economics Research
Unit, University of Aberdeen, UK; 6 Health Services Research Unit, University
of Aberdeen, UK and Multidisciplinary Assessment of Technology Centre
for Healthcare, University of Nottingham, UK; 7 Men’s Health Forum, UK
Background: Systematic reviews of the effectiveness of interventions
can be complemented by including qualitative evidence. While the
Cochrane handbook offers guidance, many methods for synthesising
and integrating qualitative evidence exist and integrated reviews remain
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
rare. Objectives: To describe the process used for conducting an
integrated systematic review of evidence-based management strategies
for treating obesity in men. Methods: Quantitative and qualitative
researchers met weekly, with regular feedback from a UK service
user group, to identify and link data. We used quantitative pooling
where possible and narrative synthesis of the clinical, process and
cost effectiveness data. Deductive and inductive approaches guided
qualitative data analysis, with coding of data in a thematic index
according to a priori or emergent themes. We compared and
contrasted qualitative and quantitative findings both within and
between studies, and within epistemological disciplines. Results:
We included 31 randomised controlled trials, 16 non-randomised
studies and five economic evaluation studies in our quantitative
reviews. We included 22 qualitative studies linked to interventions.
Few included quantitative studies reported qualitative data or were
linked to qualitative publications, even where it was clear qualitative
work had been conducted. We developed an emergent logic model (see
Fig. 1) for conducting the integrated synthesis. We identified key social
determinants for obesity along with important motivators, barriers and
facilitators for engagement with obesity interventions. Conclusions:
Integrated reviews offer invaluable contextual socio-economic and
cultural information for those designing public health interventions.
Including qualitative evidence in our review provided valuable insights
for identifying factors associated with the effectiveness of obesity
interventions. Conducting an integrated review proved time consuming
and the extent of our integration was limited due to paucity of linked
quantitative and qualitative evidence. Clearer guidance for conducting
integrated reviews according to different research questions could
be useful.
Attachments: Figure 1.JPG
What is the current situation of the published
N-of-1 trial?
Yang KH1 , Yao D2 , Zhang F3 , He Y3
1 Evidence Based Medicine Center, School of Basic Medical Sciences of
Lanzhou University, China; 2 The Second Clinical Medical College of Lanzhou
University, China; 3 School of Public Health of Lanzhou University, China
Background: An N-of-1 trial is a clinical trial in which a single patient is
the entire trial, a single case study. It can be very effective in confirming
causality. This can be achieved in many ways. However, there is
no clear the epidemic characteristics of N-of-1 trial. Objectives:
To survey the current situation of N-of-1 trial and provide related
information on published year, author, country, journal, annual citation
information, the type of literature of N-of-1 trial. Methods: An
electronic literature search of all N-of-1 trial from inception to February
2013 was conducted using Web of Science. Using the following
search terms ‘randomized controlled trial in individual patient, single
case experiment, N-of-1 trial, N-of-1 RCT, N-of-1 study’ in the title
or keyword. Two reviewers independently determined study eligibility
and extracted details on published year, author, country, journal,
annual citation information, the type of literature. Disagreements were
resolved by the third author. Results: 111 studies were included, table
showed that the frequency and of citations of N-of-1 trial in each year,
published studies in different country and type of literature; 1 journal
published 4 N-of-1 trials, 2 journals published three N-of-1 trials, nine
Cochrane Database Syst Rev Suppl 1–212 (2013)
journals published 2 N-of-1 trials, 83 journals only published 1 N-of-1
trial; top 6 research areas were as follows: 19.82% N-of-1 trials
focused on neurosciences neurology, 14.41% for psychology, 13.51%
for general internal medicine, 10.81% for pharmacology pharmacy,
9.01% for rehabilitation, 7.21% for health care sciences services; As
well as, 365 authors wrote 111 papers, the average citations per paper
was 11.25, average citations per year was 46.26, the h-index was 19.
Conclusions: More and more N-of-1 trials are published in different
journals and focus on different research areas, which methodology is
still in the development stages. Therefore, undertake further research
to increase methodological transparency, develop reporting standards,
and report the methodological limitations of N-of-1 trials.
Attachments: N-of-1 trial.PDF
IPD meta-analyses are important to improve
evidence-based decisions in the geriatric
van de Glind E1 , Rhodius-Meester H2 , Reitsma JB3 , Hooft L4 ,
van Munster B5
Department of Internal Medicine, Section of Geriatrics/Dutch Cochrane
Centre, Academic Medical Center, Amsterdam, The Netherlands;
Department of Geriatric Medicine, Slotervaart Hospital, Amsterdam,
The Netherlands.; 3 Julius Center for Health Sciences and Primary Care,
University Medical Center Utrecht, The Netherlands; 4 Dutch Cochrane
Centre, Academic Medical Center, Amsterdam, The Netherlands; 5 Gelre
Hospitals, Department of Geriatric Medicine, Apeldoorn, The Netherlands
Background: In a meta-analysis of individual patient data (IPD),
original trial data may be used to analyse the effects of an intervention
in a particular subgroup. IPD meta-analyses may, therefore, be a
helpful method to generate evidence that is more applicable to the
geriatric population, which may have treatment effects that differ
from a younger population. Objectives: To provide an overview of
treatment differences between the older and younger patients based
on meta-analyses on an IPD-level. Methods: A MEDLINE search was
conducted for IPD meta-analyses of randomized controlled trials (RCTs)
published before July 2012. IPD meta-analyses involving patients with a
mean age of ≥ 70 years or describing a subgroup in this age range were
included. We evaluated whether the IPD meta-analyses reported similar
conclusions for both the younger and older populations. Results:
Twenty-six IPD meta-analyses with a subgroup of older individuals
were included (median N = 3.581). The most important reason for
applying the IPD methodology was the ability to perform a subgroup
analysis in the older population, as well as multivariable analysis
with additional patient characteristics (e.g., different tumor parameters
or type of drug). Fourteen IPD meta-analyses suggested that older
people should receive distinct treatments compared to younger people
due to differences in effectiveness, whereof eight reviews indicated
that the investigated treatment(s) should be avoided or adjusted in
older patients. However, in six reviews the investigated treatment
was more effective in older than younger patients. Conclusions:
IPD meta-analysis is a valuable approach for generating evidence for
older patients. In 54% of the included IPD meta-analyses, treatment
effects differed between older and younger patients. The collaborative
sharing of raw data should be promoted and facilitated to improve
evidence-based decisions in the growing population of older and more
vulnerable patients in our society
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
A practical taxonomy proposal for systematic
reviews of therapeutic interventions
Bender R1 , Lerch C2
Institute for Quality and Efficiency in Health Care (IQWiG), Germany;
2 Hanover Medical School, Germany
Background: No consistently used terminology is currently available
to classify systematic reviews of therapeutic interventions according to
their aim, their methodological rigor and the conclusiveness of their
results. Some researchers consider systematic reviews to be merely
observational studies, as in contrast to confirmatory randomized
controlled trials (RCTs), all data used for the evidence synthesis are
already available. This assumption results in the paradox that a
high-quality RCT is qualified for drawing confirmatory conclusions, but
a high-quality systematic review containing the same RCT together with
other high-quality RCTs, is only qualified for generating hypotheses.
Objectives: To avoid the paradox described above, a new taxonomy
for systematic reviews of therapeutic interventions is proposed,
taking into account the research question as well as the impact
of methodological and outcome issues on the value of the systematic
reviews. Methods: Different uses of systematic reviews and common
sources of variability regarding the methodological rigor of systematic
reviews and the resulting implications are discussed. Criteria to
assess whether the results of systematic reviews allow firm conclusions
regarding the considered therapeutic intervention are summarized.
Results: In a first step the proposed taxonomy discriminates between
exploratory and analytic systematic reviews considering their aim and
their methodological rigor. For analytic systematic reviews, a further
discrimination between conclusive and inconclusive systematic reviews
follows. Criteria for the second step include the risk of bias within
and across the studies considered in the systematic review as well
as the precision of estimated treatment effects. Conclusions: The
proposed taxonomy provides a simple and practical way to identify the
value of systematic reviews for decision making. Furthermore, the new
taxonomy avoids the paradox that a systematic review is on the one
hand considered to be the highest evidence level, but on the other
hand regarded merely as an observational study.
Survey of the reporting characteristics
of systematic reviews in rehabilitation
Gianola S1 , Gasparini M2 , Agostini M3 , Castellini G4 , Corbetta D5 ,
Gozzer P6 , Li L7 , Sirtori V5 , Taricco M8 , Tetzlaff J9 , Turolla A3 , Moher D10 ,
Moja L11
Clinical Epidemiology Unit, I.R.C.C.S. Orthopedic Institute Galeazzi, Milan,
Italy; 2 Department of rehabilitation, Asl Biella, Italy; 3 Laboratory of
Kinematics and Robotics. I.R.C.C.S. Fondazione Ospedale San Camillo,
Venezia, Italy; 4 COF Lanzo Hospital, Lanzo d’Intelvi, Como, Italy; 5 Unit
of Functional Recovery, Fondazione Centro San Raffaele del Monte Tabor,
Milan, Italy; 6 APSS Tn, Villa Igea, Trento, Italy; 7 Department of Physical
Therapy, University of British Columbia, Vancouver, British Columbia,
Canada;Arthritis Research Centre of Canada, Vancouver, British Columbia,
Canada ; 8 Rehabilitation Unit, University Hospital St. Orsola-Malpighi
Polyclinic, Bologna, Italy; 9 Department of Epidemiology & Community
Cochrane Database Syst Rev Suppl 1–212 (2013)
Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario,
Canada; 10 Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, Canada; 11 Department of Biomedical Sciences for
Health, University of Milan, Italy; Clinical Epidemiology Unit, I.R.C.C.S.
Orthopedic Institute Galeazzi, Milan, Italy
Background: Systematic reviews (SRs) have become increasingly
important for informing clinical practice; however little is known
about the reporting characteristics and the quality of the SRs relevant
to practice of rehabilitation health professionals. Objectives: To
examine the reporting quality of a representative cross-sectional sample
of published SRs on rehabilitation. We specifically focused on the
descriptive, reporting and bias-related characteristics. Methods: We
searched Medline for aggregative and configurative SRs indexed in
2011 focused on rehabilitation as restoring of functional limitations,
written in English. Two reviewers independently screened and selected
the SRs and extracted data using a 38-item data collection form derived
from PRISMA. The data were analyzed descriptively. Results: We
sampled 88 SRs published in 59 journals, with most journals publishing
only one Sr. Eight were Cochrane Reviews (10%). Nearly half [41/88
(47%)] of SRs were focused on musculoskeletal and connective tissue
diseases followed from neurological diseases. Over two-thirds of SRs
assessed the quality of primary studies (74/88 [84%]). One-third of
the studies included a meta-analysis. All Cochrane Reviews included
only randomized controlled trials (RCT) whereas 45% of non-Cochrane
Reviews used also other designs. Half of the Cochrane Reviews reported
a statistically favorable result for the primary outcome, whereas only
11% of non-Cochrane Reviews did so. Both non-Cochrane (83%)
reviews and Cochrane Reviews (100%) assessed dimensions of risk
of bias (e.g. allocation concealment). Conclusions: Our sample of
SRs in the rehabilitation field shows heterogeneous characteristics and
a moderate quality of reporting. Poor control of potential source of
bias might be improved if more widely agreed upon evidence-based
reporting guidelines will be actively endorsed and adhered to by authors
and journals.
Implementing a HTA-unit in a university-affiliated
child welfare agency: the challenge of adapting
the medical model of HTA to the social services
Bussières E, Beaumier I, Perron C
Centre Jeunesse de Québec-Institut Universitaire, Canada
Background: Health technology assessment (HTA)-units has originally
emerged from the medical domain, were systematic reviews (SR) of
randomized-controlled trials (RCT’s) are commonly done. Recently,
HTA-units have started to be implemented in the social services
context; in the province of Quebec, Canada, it’s implementation
is mandatory for every university-affiliated agencies. This situation
appears quite unique and requires different adaptations of the medical
model of HTA, in order to meet the specific needs of the social services
context. For example, far less RCT’s are performed in the social
literature, mainly for ethical reasons, but also because RCT’s cannot
answer numerous questions emphasizing more the process than the
outcome, a major concern in social sciences. Consequently, SR of
observational studies are more common in the social context; but is it
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
possible to perform them using the typical methodology and the usual
quality assessment tools? Objective: This presentation addresses the
challenges of implementing a HTA-unit in a University-affiliated child
welfare agency, and the necessity to adapt the medical model of HTA
in at least two ways: (1) the structure of the unit; (2) the way SR are
carried out, including the pertinence of quality assessment tools. As an
example, we will present the process of doing a meta-analysis (MA)
of observational studies in our social HTA-unit, with a particular focus
on the available quality assessment tools. Results/Discussion: The
challenges of implementing a HTA-Unit in the social services context will
be discussed. We propose that the paucity of quality assessment tools
available and pertinent for observational studies raises the question of
its actual pertinence in this context. As MA allows to do moderator
analysis, including methodological variables, we suggest that it can
represent an interesting way of doing high quality systematic reviews
in social sciences.
Intervention Now To Eliminate Repeat
Unintended Pregnancy in Teenagers (INTERUPT):
multiple integrated review method exemplar
Hendry M1 , Whitaker R2 , Noyes J1 , Rycroft-Malone J2 , Booth A1 ,
Carter B3 , Edwards RT2 , Williams N2 , Craine N4 , Lyons M4
Cochrane Qualitative and Implementation Methods Group, UK; 2 Bangor
University, UK; 3 Cochrane Public Health Group, UK; 4 Public Health
Wales, UK
Background: The UK has the highest rate of teenage pregnancies
in Western Europe, resulting in significant emotional, psychological
and educational harm, often with enduring effects on life chances for
mothers and babies. In this review we use a structured, innovative
and iterative methodological approach to address a complex topic;
reducing unintended repeat pregnancies. Objectives: With the
aim of informing policy makers, objectives are: • To quantify the
evidence for interventions used and estimate which are effective, how
they work, in what setting, and for whom • To determine who is
at greater risk of repeat unintended pregnancies • To identify the
barriers and facilitators to intervention uptake • To estimate the
cost-effectiveness of interventions. A parallel aim is to further develop
mixed method review methodologies. Methods: We will conduct a
mixed-method systematic review to examine world-wide literature on
repeat teenage pregnancies (Fig. 1). Traditional database searches will
be augmented by targeted searches for evidence ‘clusters’ (qualitative
studies, programme evaluations, etc. associated with effectiveness
studies). A mapping exercise will be undertaken to describe the
literature, identify evidence gaps, and provide a context for interpreting
the results and a basis for refining the scope of the review. We
will be guided by experts and stakeholders including teenage parents.
Where clinical homogeneity and data exists quantitative methods will
be used to summarise the evidence. These will include meta-analyses
of incidence of pregnancy, and the effectiveness of interventions.
We will also carry out a meta-regression to explore possible effect
modifiers. The qualitative data addressing facilitators and barriers
to uptake (feasibility), experience (appropriateness), and acceptability
(meaningfulness) will synthesised thematically. We will apply the
principles of realist synthesis to evidence of theories and mechanisms
underpinning interventions (what works, for whom and in what
Cochrane Database Syst Rev Suppl 1–212 (2013)
context). Finally we will conduct an overarching narrative synthesis
and interpretation of findings.
Attachments: Figure 1.pdf
Treatment of quasi-randomised trials
in Cochrane Reviews
Herbison P
University of Otago, New Zealand
systematic review was independently identified and evaluated by two
reviewers, and discussed with the third member when disagreement
appeared. Results: 67 relevant articles including 295 outcomes were
included. 1 (0.3%) outcome was rated as high quality, 55 (19.6%)
as moderate, 157 (53.2%) as low, and 82 (27.8%) as very low
(Fig. 1). The quality was downgraded for study limitations (93.2%),
imprecision (22.7%), inconsistency (17.3%), publication bias (90.5%),
and indirectness (0.7%). Conclusions: Most evidences in systematic
reviews about Chinese traditional medicine to cancer were low or
very low. Study limitations were the major factors for downgrading
Attachments: fugure1.jpg
Background: In some Cochrane Reviews the authors claim to exclude
quasi-randomised trials (qRCTs). This is contrary to guidance in the
handbook and is futile as many reports of trials just state participants
were randomised without enough information about how this was
done. Objectives: To determine how many authors specify that they
exclude quasi-randomised trials from Cochrane Reviews, and what
review group instructions say. Methods: A random sample of 300
Cochrane Reviews was selected and the methods scrutinised to see
if qRCTs were excluded. Details of all review groups were read to
determine policies regarding qRCTs. Results: Forty-seven of the 300
stated that qRCTs were excluded (15.7%, 95% CI 11.7–20.3%). In
addition, of the remaining 253 trials, 138 simply stated that RCTs
were included (54.5%, 95% CI 48.2–60.8%). In these it was unclear
whether this referred to securely randomised trials only. One Cochrane
Review group states in their suggested methods that qRCTs should be
excluded, and six suggest that they should only be included if there are
only a few or no RCTs, or only for adverse effects. Seven review groups
say that RCTs should be included with no further elucidation so it is
unclear whether they would like qRCTs to be excluded. Conclusions:
Contrary to the advice in the handbook many Cochrane Reviews
attempt to exclude qRCTs and some review groups support this. Many
reviews and groups are unclear with respect to qRCTs. While it is a
good idea to use only trials at low risk of bias this is unlikely to be
achieved by excluding qRCTs that are the better reported ones.
Using GRADE to evaluate the quality of evidence
in systematic reviews about Chinese traditional
Yao L, Wei D, Wang Q, Wang XQ, Wu QF, Sun LN, Yang KH, Chen YL
Evidence-Based Medicine Center, School of Basic Medical Sciences,
Lanzhou University
Background:Some systematic reviews about Chinese traditional
medicine have been produced in China. However, little is known
about the quality of evidence they provided. Objectives: Using
GRADE to assess the quality of evidence in systematic reviews about
Chinese traditional medicine. Methods: We selected the systematic
reviews about Chinese traditional medicine to cancer as our sample.
The mesh terms ‘meta-analysis’ and ‘systematic review’ were used
to search the Chinese Biomedicine Literature Database (CBM) up to
September 2012. And the systematic reviews about Chinese traditional
medicine to cancer were screened and included to analyze. Each
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Evidence synthesis of implementation studies in
health research: a systematic scoping review of
methodological approaches
Thompson Coon J, Whear R, Abbott R, Rogers M, Bethel A, Stein K
PenCLAHRC, University of Exeter Medical School, University of Exeter, UK
Background: The synthesis of implementation studies in health
research to identify shared messages would be helpful in understanding
the issues that prevent or slow effective implementation of evidence
based health recommendations. There are no published methodological
guidelines for best practice for evidence synthesis in this area.
Objectives: To identify and explore methods used to synthesise
evidence from implementation studies in health research. Data
Sources: Medline, Embase, CINAHL, HMIC, The Cochrane Library,
relevant websites including KT+ and KT exchange, forward and
backward citation searches for all included papers. Methods: All
evidence syntheses of implementation studies in health research with
explicit, predefined and reproducible methods were included. Study
selection was performed by two reviewers independently; quality
appraisal (using AMSTAR or a bespoke instrument based on ENTREQ)
and data extraction were performed by one reviewer and checked
by a second. All disagreements were resolved by discussion with
arbitration where necessary. For each included review, details of
the methodological process were extracted and tabulated. Results:
Electronic searches identified 3106 unique references. Final study
selection processes are near to completion and we anticipate in
the region of 140 included papers; approximately two-thirds of
which were published in the last 5 years. There is a wealth
of published evidence syntheses of implementation studies from a
broad spectrum of health research; from regulation and policy to
clinical practice. Systematic review of quantitative data from studies
of the effectiveness of implementation, knowledge translation and
improvement strategies and process evaluations was the predominant
methodological approach. Other approaches included the qualitative
synthesis of barriers and facilitators to implementation, realist synthesis
and the consideration of the determinants of behaviour change.
Conclusions: The synthesis of implementation evidence is an area
of increasing focus. Establishing guidelines for methodological best
practice and reporting that encompass both quantitative and qualitative
approaches to synthesis is warranted.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Development of an innovative theory-based
instrument to assess the impact of continuing
professional development activities on clinical
Légaré F1 , Borduas F1 , Jacques A2 , Drolet R3 , Godin G4 , Luconi F5 ,
Rousseau M6 , Freitas A3
1 Université Laval, Canada; 2 Collège des médecins du Québec; 3 Centre
de recherche du CHU de Québec, Canada; 4 Université Laval; 5 McGill
University; 6 Université du Québec à Trois Rivières, Canada
Background: A group of continuing professional development (CPD)
decision-makers met with knowledge-translation (KT) researchers.
They identified needs for high-quality evaluation methods to assess the
impact of CPD activities. Objectives: To present the development of
a theory-based, reliable instrument to assess the impact of accredited
CPD activities on clinical practice. Methods: After a systematic review
and analysis of existing instruments assessing healthcare professionals’
intentions and behaviours, an inventory of instruments based on social
cognitive theories was created. Items most relevant to the constructs
of an integrated theoretical model were selected from this inventory
to devise a new tool. An e-Delphi study with experts from different
domains was conducted to check its face validity and likely acceptability
in CPD settings. A test-retest validation was done with end-users.
Results: We identified 47 eligible instruments with 1218 items. These
items were reclassified into the eight constructs of an integrated
theoretical model for the study of healthcare professionals’ intentions
and behaviours. Through an interactive process, 61 items were selected
to compose the preliminary tool. Following an e-Delphi process, a
generic questionnaire with 40 items was created. By completing
the 40-item questionnaire at the end of a CPD activity (test), 138
physicians indicated their agreement to participate in the validation
study. The same questionnaire was completed 2 weeks after by 121
participants (retest). Exploratory factorial analysis allowed an item
reduction process resulting in a 12-item questionnaire. The Cronbach
α coefficient of a global score was determined for each construct of the
integrated model. Values varied from 0.77 to 0.89. Conclusions: We
propose a new instrument for assessing the impact of CPD activities on
physicians’ clinical practice. Before its implementation on a large scale,
further studies are needed to validate its ability to predict intentions and
behaviour and its sensitivity to change in response to CPD activities.
Rapid evidence reviews: the CADTH experience
Mann J, Kamel C
Canadian Agency for Drugs and Technologies in Health (CADTH), Canada
Background: Constant, rapid, and often expensive advances in
medical technologies make evidence-based information essential in
healthcare decision-making. While comprehensive systematic reviews
are used to support many deliberations, the urgency of some decisions
requires a more immediate response. To support these decisions,
CADTH offers a range of products through its Rapid Response Service.
Objectives: The objective of CADTH’s Rapid Response Service is
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
to provide Canadian healthcare stakeholders with timely, relevant
evidence to support informed decision-making. Methods: Rapid
Response topics are requested by CADTH customers. Modified review
techniques accommodate accelerated evidence synthesis and can be
tailored to the decision-makers’ needs. Recently, for more in-depth
reviews, a one-page plain language Report-in-Brief is prepared in
English and French and posted with the full report on the CADTH
website. HTML coding and keywords are assigned to ensure
search engine optimization, and further dissemination efforts may
be undertaken depending on the topic. Results: The Rapid Response
service has continued to evolve. In 2012–2013, 233 reports were
produced with 65% addressing a question on non-drug health
technologies. A variety of report types are available—from reference
lists to summaries with critical appraisal—however in recent years more
requests for the latter may indicate that these reports represent the
ideal balance of rigour and timeliness for decision-makers. Customer
evaluations of the reports and the Reports-in-Brief have demonstrated
the success of the program. Conclusions: Using rapid review
techniques, CADTH ensures our customers have the evidence they
need in time to help with their decision-making processes about drugs
and health technologies. Through knowledge mobilization techniques
we assist our customers to effectively share information with their
teams while also broadening the reach of our reports. Improvements
to the rapid review methodologies and processes will continue to be
made based on our evaluations and advances in the field.
Improving practice: Rx for Change - an
intervention research database for healthcare
decision-makers and researchers
Grimshaw JM1 , Hill S2 , Worswick J3 , Mayhew A3 , Fiander M3 , Lowe D4 ,
Taylor M5 , Wu J3 , Belanger D6
1 Cochrane Canada, Ottawa Hospital Research Institute, University of
Ottawa, Canada; 2 Cochrane Consumers and Communication Review
Group, Centre for Health Communication and Participation, La Trobe
University, Australia; 3 Cochrane Effective Practice and Organisation of Care
Review Group, Ottawa Hospital Research Institute, Canada; 4 Centre for
Health Communication and Participation, La Trobe University, Australia;
5 Cochrane Consumers and Communication Review Group, Australian
Institute for Primary Care & Ageing, La Trobe University, Australia;
Canadian Agency for Drugs and Technologies in Health, Canada
Background: Improving health care often requires changing the
behaviour of healthcare professionals and consumers. While there
is abundant evidence available on the effects of behaviour change
strategies across diseases, populations and systems, it is difficult for
decision-makers and others to reliably access and assess. The Rx for
Change (www.rxforchange.ca) database attempts to close the gap
between research discovery and program implementation by gathering
and translating the evidence from systematic reviews into a single
accessible package to inform healthcare decision-makers. Objectives:
To describe the Rx for Change database and disseminate evidence
gathered on the effectiveness of interventions designed to change
professional practice and medicines use by consumers. Methods:
We identify, analyse, summarise and report our findings from included
systematic reviews using standardised methods. We organise and
present this data using a multi-layer format. Using intervention
Cochrane Database Syst Rev Suppl 1–212 (2013)
categories developed by two Cochrane Review groups, we provide
summaries of the evidence found for each intervention, list all systematic
reviews that address each intervention topic with corresponding quality
scores, describe and summarise results and conclusions from each
individual review, and provide links to the reviews and their trials.
Results: Updated eight times since 2007, the database contains
summaries of key findings for 310 systematic reviews, and summaries
and statements of effectiveness for 39 intervention categories the
reviews addressed. Examples of particularly effective interventions
include distribution of educational materials and use of educational
meetings to improve professional practice, as well as use of decision
aids to minimise risks or harms to improve consumers’ use of medicines.
Research gaps are evident in 11 intervention categories. Conclusions:
Rx for Change is an internationally recognised, publicly available
intervention research database. It provides up-to-date evidence to guide
healthcare decision makers towards effective intervention strategies.
Guidelines and other policy, program and research initiatives can
potentially be informed by this resource.
The Canadian Association of Pediatric Surgeons
Evidence-Based Resource: improving patient
care and maximizing the use of research
Nasr A, Wayne C, Chan E
Children’s Hospital of Eastern Ontario, Canada
Background: There is a lack of good-quality, empirical evidence in
the field of pediatric surgery. Even when such evidence exists, it must
be disseminated, accepted and applied in order to improve the care of
pediatric surgical patients. Objectives: Our objective is to encourage
evidence-based practice and direct research efforts to areas where
evidence is lacking in the field of pediatric general surgery. We will
do this by establishing a regularly-updated resource summarizing the
best available evidence in this field, accessible by medical students,
residents, fellows, and surgeons worldwide through the Canadian
Association of Pediatric Surgeons (CAPS) website. Methods: 1.
Identify areas of controversy in the field of pediatric surgery using
the Delphi method. 2. Conduct an extensive literature search for
primary research and reviews in each identified area. 3. Summarize the
available evidence for each area. 4. Classify the amount and quality
of evidence for each area. 5. Suggest research topics where good
evidence is sparse. 6. Regularly update the website as new evidence
emerges. 7. Measure the impact. Progress: Data collection began
in November 2012. We have completed one topic and have begun
gathering evidence for another. We will continue to cover topics, in
an order determined by the average number of each type of surgery
performed by residents each year (i.e., more common surgeries will
be covered first). The website where we will present the evidence
will be available to the public shortly as a link on the main page
of the Canadian Association of Pediatric Surgeons (CAPS) website:
http://www.caps.ca/. Impact: This website will improve patient care
by providing an up-to-date, evidence-based educational resource for
students, residents, fellows and surgeons. It will also help to identify
areas where further research is needed, facilitating the formation of
good research questions and preventing duplication of research efforts.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Experiences and attitudes toward
evidence-informed policy-making among
Canadian research and policy stakeholders
working at the interface of agri-food and public
Young I1 , Gropp K2 , Pintar K2 , Waddell L2 , Marshall B3 , Thomas K3 ,
McEwen SA1 , Rajic A1
Department of Population Medicine, University of Guelph, Canada;
2 Laboratory for Foodborne Zoonoses, Public Health Agency of Canada,
Canada; 3 Centre for Food-Borne, Environmental and Zoonotic Infectious
Diseases, Public Health Agency of Canada, Canada
Background: Policy-makers working at the interface of agri-food and
public health often deal with complex and cross-cutting issues that
have broad health impacts and socio-economic implications. They have
a responsibility to ensure that policy-making based on these issues
is accountable and informed by the best available scientific evidence.
Objectives: We conducted a qualitative descriptive study of agri-food
public health policy-makers and research and policy analysts in Ontario,
Canada, to understand their perspectives on how the policy-making
process is currently informed by scientific evidence and how to facilitate
this process. Methods: Five focus groups of three to seven participants
and five one-to-one interviews were held in 2012 with participants
from federal and provincial government departments and industry
organizations in the agri-food public health sector. We conducted
a thematic analysis of the focus group and interview transcripts to
identify overarching themes. Results: Participants indicated that the
following six key principles are necessary to enable and demonstrate
evidence-informed policy-making in this sector: (1) Establish and
clarify the policy objectives and context; (2) Support policy-making
with credible scientific evidence from different sources; (3) Integrate
scientific evidence with other diverse policy inputs (e.g. economics,
local applicability, and stakeholder interests); (4) Ensure that scientific
evidence is communicated by research and policy stakeholders in
relevant and user-friendly formats; (5) Create and foster interdisciplinary
relationships and networks across research and policy communities;
and, (6) Enhance organizational capacity and individual skills for
evidence-informed policy-making. Conclusions: Ongoing and planned
efforts in these areas and a supportive culture in both research and policy
realms are important to facilitate evidence-informed policy-making in
this sector.
Effects of decision aids on the accuracy
of patient knowledge of outcome probabilities:
an investigation of sources of heterogeneity
Gentles SJ1 , Walter SD1 , Stacey D2 , Bennett C3
McMaster University, Canada; 2 School of Nursing, University of Ottawa,
Canada; 3 Ottawa Hospital Research Institute, Canada
Background: Interpretation of prior meta-analysis of randomized
controlled trials (RCTs) evaluating patient decision aid effects on the
accuracy of knowledge of outcome probabilities is complicated by high,
unexplained heterogeneity. Objectives: To explore effect modification
Cochrane Database Syst Rev Suppl 1–212 (2013)
from three possible sources of heterogeneity: the type of control
intervention, decision aid quality, and patients’ baseline knowledge of
probabilities. Methods: A sub-analysis of studies identified in the
2011 Cochrane Review on decision aids for people facing treatment
and screening decisions was conducted. Additional unpublished data
were requested from relevant study authors to maximize the number
of eligible studies. RCTs (to 2009) comparing decision aids with
standardized probability information to control interventions (lacking
such information), and assessing accuracy of patient knowledge of
outcome probabilities were included. Proportions of patients in
each group with accurate knowledge of outcome probabilities were
converted to relative effect measures. Instrument quality was assessed
using the IPDAS instrument. Results: Main effects analysis of 17
eligible studies confirmed decision aids significantly improve accuracy
of patient knowledge of outcome probabilities [RR = 1.80 (1.51, 2.16)],
with substantial heterogeneity (87%). Meta-regression indicated the
control event rate (CER, reflecting baseline knowledge) is a significant
effect modifier (p = 0.001), with over half the variability in ln(OR)
explained by the linear relationship with logit Control (R2 = 0.52); this
relationship was slightly strengthened after correcting for dependence
of the effect measure on CER. The decision aid quality measure
suggests potential effect modification (p = 0.037) accounting for
some variability (R2 = 0.28). Conclusions: Patients’ baseline rate of
knowledge of outcome probabilities is an important variable explaining
heterogeneity of decision aid effects on improving accuracy of this
knowledge, with greater relative effects observed when patients’
baseline rate of knowledge is low. This may indicate that decision aids
are most effective in populations with low awareness.
Profile of overviews published by the Cochrane
Costa MB, Martimbianco ALC, Porfı́rio GJM, Silva V, Grande A, Torres MFS,
Carvalho MR, Fioretti B, Riera R, Torloni MR, Atallah Á
Brazilian Cochrane Centre, Brazil
Background: Cochrane Overviews present a new concept for facilitate
the access to results of multiple Cochrane Reviews about a particular
medical condition, being considered a ‘friendly front end’ to The
Cochrane Library. Given the growing number of Systematic Reviews
(SRs) published, researchers’ interest to conduct Overviews tends to
increase in coming years. The Cochrane Collaboration is pioneer
in conducting Overviews with rigorous methodology as proposed
in Chapter 22 of Cochrane Handbook for Systematic Reviews of
Interventions. Objectives: To conduct a survey and analysis of the
number of Overviews and Overview’ protocols published to date in the
Cochrane Library. Methods: A search was conducted in The Cochrane
Library with the term ‘Overview’ and 77 studies were identified. The
titles and abstracts were evaluated by two authors (MBC e ALCM). The
data of completed Overviews were extracted according to: Editorial
Group, year of publication, number of included SRs and the tool utilized
to analyze the methodological quality of these. Graphs with numbers
and dates of publication of Overviews and of protocols were made
in order to ascertain the number of this study so far. Results: We
selected 9 completed Overviews and 20 protocols. The data extracted
from published Overviews are shown in Table 1. Eight Cochrane
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Editorial Groups have nine Overviews published, with first publication
in 2009. Six Overviews included only Cochrane SRs. Eight Overviews
used the AMSTAR tool for methodological quality assessment of SRs
included. The analysis of production of Overviews and its protocols
is presented in Figures 1 and 2. Conclusions: According to the
last 4 years, the development of Overviews is on the rise. Given the
practicality and relevance of conducting Overviews for decision making
in health problems, its methodology should be disseminated to check
which interventions are scientifically proven with clinical significance
to health care.
Attachments: Table 1.pdf, Figure 1.pdf, Figure 2.pdf
The theory of planned behaviour applied
to shared decision making behaviours:
a systematic review
Thompson-Leduc P1 , Clayman M2 , Légaré F3
Université Laval, Centre de Recherche du CHU de Québec; 2 Division of
General Internal Medicine, Northwestern University; 3 Department of Family
Medicine and Emergency Medicine, Université Laval
Background: Adoption of shared decision making (SDM) requires
behaviour changes in health professionals. The Theory of Planned
Behaviour (TPB) widely used to provide theoretical underpinnings
for understanding such behavioural changes. Objectives: We
systematically reviewed studies that used the TPB to assess SDM-related
clinical behaviours in health professionals. Methods: We searched
PsycINFO, MEDLINE, EMBASE, CINAHL, Index to Theses, ProQuest
dissertations and Current Contents for all years up to April 2012.
The search terms were (Planned behaviour OR intention) AND (Health
professional). We included all studies in French or English that used
the TPB and/or the TRA to assess SDM behavioural intentions or
performance of behaviours in health professionals. We extracted study
characteristics, type of SDM behaviour based on the Makoul & Clayman
integrative SDM model, and theory-based determinants of the SDM
behaviour. Results: Out of 12 388 titles, we assessed 136 full-text
articles for eligibility. We kept 20 eligible studies, all published in
English between 1996 and 2012 (Cohen’s kappa = 0.78). Studies were
conducted in Canada (n = 8), the USA (n = 6), the Netherlands (n = 3),
the United Kingdom (n = 2) and Australia (n = 1). The SDM behaviours
most often measured in a clinical context were ‘sharing knowledge and
making recommendations’ (n = 9) and ‘clarifying the patient’s values
and preferences’ (n = 8). The most frequently reported psychosocial
determinants of the intention to perform a behaviour were subjective
norm (n = 11), perceived behavioural control (n = 11) and attitude
(n = 10). Six studies measured behaviour alongside intention. Great
variability was observed in regression coefficients between psychosocial
variables and theoretical constructs of intention (range = 0.05–0.75)
and behaviour (range = 0.28–0.56). Conclusions: The TPB is a
valid theoretical framework for understanding health professionals’
behaviour in the context of SDM. Further research is needed to
understand how intention is linked to behavioural change in this
Cochrane Database Syst Rev Suppl 1–212 (2013)
Better values clarification methods for better
Scherer LD1 , Angott AM2 , Ubel PA2 , Dickson M3 , Holtzman L3 , Exe N3 ,
Zikmund-Fisher BJ3
1 University of Missouri, USA; 2 Duke University, USA; 3 University of
Michigan, USA
Background: Shared decision making requires that decisions be
grounded in patients’ values and preferences. However, people
frequently express preferences and make choices that are at odds
with their stated values. This suggests that, for shared decision
making to reach its full potential, better values clarification methods
are needed. Objectives: To test whether interactive online values
clarification exercises developed through user-centred design could
help better align treatment preferences with stated values. Methods:
We conducted a between-subjects online randomized experiment in a
demographically diverse US-based population (n = 2033, 46% male,
82% white, age range 18–68, 57% no college degree.) We first
asked participants about their values relevant to colostomy versus
death: if they had to choose, would they rather die or have a
colostomy? Participants were then asked to imagine that they had
been diagnosed with colon cancer. We presented evidence about
two hypothetical treatment options differing only in that one had
a 4% chance of colostomy while the other had an additional 4%
chance of death. Participants in the control arm were immediately
asked their treatment preference; participants in the other four arms
first interacted with either a standard values clarification exercise,
an interactive exercise, or one of two partially-interactive exercises.
Exercises had been previously developed through user-centred design.
Results: Consistent with our prior research, in the control arm, 22%
of people expressed treatment preferences that were discordant with
their previously stated values. After interacting with a standard values
clarification exercise, discordance was not significantly changed at
23%. Partially-interactive exercises reduced discordance to 17–18%;
the most interactive exercise lowered discordance to 14% (Chi-squared
(4) = 13.90, p = 0.003). Conclusions: An interactive online values
clarification exercise can help people better align treatment preferences
with stated values. This method may help better incorporate patient
values into health decisions.
Patient-centered care: Is there a state of the art?
Holmes-Rovner M, Benares K, Kelly-Blake K, Mavis B, Patel N
Michigan State University, USA
Background: A 2012 Cochrane systematic review of patient-centered
care (PCC) training by Dwamena et al, shows effectiveness in
transferring skills to providers. The review found positive impact
on provider skill measures (clarifying patients’ concerns and beliefs;
communicating about treatment options; levels of empathy; patients’
perception of attention to concerns as well as diseases). Meta-analysis
showed mixed effects on patient outcomes (satisfaction, health
behavior and health status). Objectives: Secondary data analysis
to (1) investigate intervention characteristics associated with success
and (2) evaluate relative success of shared decision making (SDM)
vs. communication skills interventions. Methods: Qualitative analysis
of included studies classified interventions by training technique(s)
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
and presence of SDM. Univariate analyses were used to evaluate
relationship(s) to patient outcomes. Results: Of 42 trials, all
used combinations of readings, presentations, demonstration, role
play, standardized patients, small group discussion and/or personal
feedback. SDM was present in 20/42. Theoretical models were
heterogeneous; all focused on interviewing skills to support active
listening. For providers, demonstration was the only training technique
positively related to successful transfer of skills. Short training
(dichotomized at 10 hours) was as effective as long among all provider
types and to patient satisfaction (p < 0.05). Patient satisfaction was
associated with inclusion of patient readings, but not inclusion of a
decision aid or other problem-specific educational material (included
in 17/42 trials). SDM-related skills training was not associated with
success. Variable use of terminology for patient education materials
(PEMs) limits conclusions. Conclusions: Our results support the
published review conclusion that PCC training is successful across
trials. No training technique appears critical to success. Brief training is
effective and appropriate for health care settings. Further investigation
is required to differentiate the impact of SDM vs communication models
with and without PEMs.
Patient-centered care and shared
decision-making: challenges and proposed
Rodrigues C
National Regulatory Agency for Private Health Insurance and Plans (ANS)
Introduction: Patient-centered care allows a shared and active
involvement of patients and their families in clinical decisions, where
individual patient characteristics, preferences, needs, and values are
considered. Big challenges have been faced worldwide to enable the
patient-centered care to become a common practice in private and
public healthcare systems. Challenges and Proposed Approaches:
Some authors consider that most evidence-based approaches must be
at odds, as it focus on populations, and not on individual needs
and values. Outcomes based on these attributes must be defined.
Another challenge is how to minimize the information asymmetry.
Clinical guidelines, technical reports, systematic reviews, and modeling
results must be synthesized and translated to a friendly/accessible
language. Risks, benefits and economic implications of each option
for treatment should be clearly presented. By this way, the patient
becomes more compromised with the consequences of his choice.
Another challenge pointed by many authors is the poor relationship
between patients and physicians. Physicians must be encouraged to
improve the quality of relationship with their patients, which greatly
determines both treatment outcomes, patient’s satisfaction, adherence
to treatment and involvement, and costs. A crucial challenge implies
in an dramatic change of paradigms. Shared decision-making should
be systematically encouraged in public and private healthcare. For the
former, new healthcare models should be designed and implemented
through an active engagement of patients and consumers. Conversely,
for the latter, all stakeholders, including the patients, should have
active voice during the discussion of new reimbursement and coverage
policies. Conclusions: A few countries have already found ways to
face most of these challenges, but we’re still far away from an ideal
world where sparse resources are rationally allocated in healthcare
through a participative, shared, and patient-centered way.
Cochrane Database Syst Rev Suppl 1–212 (2013)
The Grading of Efficacy-Effectiveness in Clinical
Trials (GEECT): a modified PRECIS tool
El Dib R1 , Jorge E2 , Kamegasawa A2 , Daher S2 , Spagnuolo RS2 , Teixeira
M2 , Pereira G2 , Volpato E2 , Módolo N2 , Betini M2 , Valle A2 , Corrêa I2 ,
Bazan R2 , Almeida R2 , Weber S2 , Molina S2 , Yoo H2 , Villas Boas P2 ,
Mathew J3 , Braz L2 , Nascimento P2
Botucatu Medical School, Unesp - Univ Estadual Paulista, Brazil and
McMaster Institute of Urology, McMaster University, Hamilton, Canada;
Botucatu Medical School, Unesp - Univ Estadual Paulista, Brazil;
Advanced Pediatrics Centre, PGIMER, Chandigarh, India
Background: When discussing treatment and talking about evidence,
we refer to effectiveness (treatment that works under real-world
conditions) and efficacy (treatment that works under ideal conditions).
However, the use of these terms seems to be randomly chosen by the
investigators who design clinical trials not reflecting the true purpose
of the study. In addition, renowned educational institutions involved
in Evidence-Based Medicine disseminate a very vague definition of
these terms. The PRECIS tool was developed in 2009 with the aim
of identifying the characteristics of clinical trials that distinguishes
from pragmatic (effectiveness) and explanatory (efficacy) issues and to
assist researchers in preparing their clinical trials. It is worthy to say
that according to PRECIS, the classification of a clinical trial is not a
dichotomy, i.e., there is a gradient between effectiveness and efficacy,
therefore it is very difficult to conduct a clinical trial ‘purely’ pragmatic or
‘purely’ explanatory. However, it is unclear whether investigators when
designing a clinical trial use PRECIS to help policy makers and health
professionals to apply its results into their clinical practice. Objectives:
To assess (i) whether clinical trials published in high impact journals in
the last 3 years used the criteria proposed by PRECIS to differentiate
between effectiveness and efficacy; (ii) to consider whether the clinical
trials’ authors have made appropriately use of the terms effectiveness
and efficacy according to a new score (0–10) and classification (high
or moderate efficacy, high or moderate effectiveness) proposed by us,
called the Grading of Efficacy-Effectiveness in Clinical Trials (GEECT).
Methods: A cross-sectional study of published randomized clinical
trials from high impact journals mentioning the term effectiveness
and/or efficacy was performed. We added to the PRECIS tool a score
ranging from 0 (more efficacious) to 10 (more effective). Results:
842 randomized trials were analyzed by 19 investigators from different
expertise areas. No clinical trials published in high impact journals in
the last 3 years used the criteria proposed by PRECIS to differentiate
between effectiveness and efficacy. The majority of the trials was
classified as moderate effectiveness (51–75) and, they often did
not matched the term chosen by their own clinical trials’ authors.
Conclusions: The GEECT classification based on the 0–10 score
system facilitated the identification of a clinical trial’s application
related to real or ideal conditions, although the modified PRECIS tool
is still highly subjective and can be easily misunderstood in their all
domains according to each investigator’s own experiences, knowledge,
and values. Furthermore, most clinical trials published in high impact
journals in the last 3 years mistakenly use the terms effectiveness and
efficiency, according to the GEECT tool, to illustrate the application
of results in clinical practice making it difficult the development of
health policies. More research are needed to establish the easiest
and useful tool to (a) facilitate the applicability of the results in
clinical practice; b) distinguish between pragmatic (effectiveness) and
explanatory (efficacy) results and; (c) assist researchers in preparing and
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
planning clinical trials. We also suggest that after the establishment of
an ideal tool to determine the specific application of a clinical trial’s
results (i.e., more about effectiveness or more efficacious), journals all
over the world that publish clinical trials should request authors the
submission of a quantitative score related to effectiveness or efficacy
along with their full research article and, also publish a note with
regards the effectiveness and efficacy scores to accompany the main
text of a clinical trial.
Is clinically significant decisional conflict
prevalent in primary care? A scoping review
Ferron Parayre A1 , Thompson-Leduc P1 , Robitaille H2 , Légaré F1
Université Laval - CRCHU de Québec, Canada; 2 CRCHU de Québec,
Background: Clinically significant decisional conflict (CSDC) refers to
a decisional conflict that is likely to have harmful effects on a patient.
Objectives: We aimed to explore the prevalence of CSDC reported in
primary care studies by systematically reviewing published literature.
Methods: We searched PubMed and Web of Science using the
keywords ‘decisional conflict AND/OR decisional conflict scale’ up to
February 2012. We included original studies conducted in primary
care published in English or French. Eligible studies had to specify
a threshold on the Decisional Conflict Scale (DCS) at which they
considered a decisional conflict to be clinically significant, and the
proportion of patients scoring above or below this threshold. Two
reviewers identified eligible studies independently. We extracted study
characteristics, the DCS version used (10 or 16 items), the threshold for
CSDC and the proportion of patients above this threshold. Results:
We found 386 potentially eligible studies, of which 262 had used
the DCS. Only 12 studies (4.6%) met all inclusion criteria (Kappa
coefficient = 0.87). All studies were published between 2006 and
2011, and were conducted in Canada (n = 4), the USA (n = 3), the UK
(n = 2), Australia (n = 2) and Japan (n = 1). Most were conducted in
English (n = 8) and used the 16-item DCS (n = 10). The most common
clinical settings were maternal-fetal health (n = 5), vasectomy (n = 2)
and cancer screening (n = 2). Seven studies used a DCS threshold of
25/100 to establish the prevalence of CSDC, while five used a threshold
of 37.5/100. Reported prevalence of CSDC ranged from 1.9% to 72%,
although the prevalence in most studies was between 20% and 60%
(n = 9). Conclusions: Although decisional conflict is widely assessed
in primary care, very few studies report the prevalence of CSDC in their
population. Further studies are needed to explore the epidemiology of
CSDC in primary care and establish a clear threshold for CSDC.
Decision aids from current systematic reviews
for the clinical encounter
Agoritsas T1 , Brandt L2 , Heen AF2 , Kristiansen A2 , Alonso- Coello P3 , Akl
EA4 , Neumann I1 , Tikkinen KA1 , Montori VM5 , Guyatt GH1 , Vandvik PO2
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; 2 Norwegian Knowledge Centre for the
Health Services, Oslo, Norway; 3 Iberoamerican Cochrane Center, Instituto
de Investigación Biomédica (IIB Sant Pau), Barcelona, Spain; 4 Department
of Internal Medicine, American University of Beirut, Lebanon; 5 Knowledge
and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
Cochrane Database Syst Rev Suppl 1–212 (2013)
Background: Although decision aids help communicate evidence to
patients, their production is time consuming and often not based on
the best available evidence. Linking decision aids to credible, current
recommendations, such as those using the GRADE framework (Grading
of Recommendations Assessment, Development and Evaluation), could
both overcome these limitations and enhance dissemination of the
evidence at the point of care. Objectives: To test the feasibility of
automatically translating evidence summaries from systematic reviews
into generic and interactive decision aids accessible on tablet computers
for clinicians and patients in the clinical encounter. Methods: As
part of the DECIDE project (http://www.decide-collaboration.eu/), we
developed a framework consistent with the International Patient
Decision Aid Standards for translating evidence summaries from
systematic reviews using the GRADE framework into decision aids.
Using recently published evidence profiles, we implemented this
framework in the MAGIC (MAking Grade the Irresistible Choice)
application—a prototype electronic guideline authoring tool and
publication platform, developed by our group, that can automatically
display recommendations in multilayered formats. We are refining
the presentation formats for the decision aids using an iterative
process of brainstorming, stakeholder feedback, and user-testing
in real clinician-patient encounters. Results: Our prototype can
automatically translate a large number of GRADE recommendations
and their supporting evidence summaries into electronic and interactive
decision aids. Preliminary results of user-testing in real patient-clinician
interactions suggest that these tools can be used at the point of care to
facilitate communication of estimates of treatment effects, confidence
in those estimates, and burden of treatment, resulting in decisions
consistent with patients’ values and preferences. Conclusions:
This study provides a proof-of-concept that evidence summaries using
the GRADE framework can be automatically translated into
interactive decision aids for the clinician encounter. These tools offer a
potentially revolutionary method for enhancing shared decision-making
using best current evidence from systematic reviews.
Online access to personal health information as
a key component of shared decision-making: a
pilot study in severe mental illness
Menkes DB1 , Kidd J1 , Southey K2 , Orr M3 , Christini-Crawford D4 ,
Fitzgerald J4
Waikato Clinical School, NZ; 2 Waikato District Health Board, NZ;
3 University of Auckland, NZ; 4 The Psychology Centre, Hamilton, NZ
Background: To pursue shared decision making, patients often
request access to their medical records, yet doing so can be frustrating.
E-health has the perceived advantages of cost efficiency, improved
access and participation, and better service provision, but this is yet to
be convincingly demonstrated in severe mental illness. Objectives: We
aimed to test how a new software (Smartmed Medifile) affects access
to medical records, and perceived benefits of such access. Methods:
We recruited volunteers with severe mental illness and asked their
clinicians to confirm suitability and safety to participate. With training
they could view HoNOS scores, medication details, treatment plans
and lab results. Kaupapa Maori research methods were used to ensure
effective collection of data from Maori participants; these included a
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
focus on individual and collective Maori identity in relation to accessing
and sharing information. Results: Recruitment proved difficult. After
8 months of vigorous advertisement to over 600 eligible patients,
19 consented to participate, and of these only 4 completed the
protocol of 6 months access. Most withdrawals were due to worsening
mental health. Participants were chiefly interested in prescriptions,
progress notes, details about involuntary hospitalisation, and direct
communication with their clinicians. Conclusions: Access to personal
health information is a patient priority and, in combination with
evidence, optimizes informed participation in decisions regarding health
care. Despite stated interest in access to their records, recruitment
of patients to this study was difficult, with identified obstacles at
the organisational, practitioner, and consumer levels. Although the
current software system is easy to use and visually attractive, patients
with severe mental illness appear to have limited use for it. Despite
refinements in facilitating access, mistrust of researchers and a clinician
culture of protecting consumers from ‘too much information’ is likely
to retard adoption of such technology.
New teaching and research activities
of the Brazilian Cochrane Center
Carvalho MR, Fioretti BTS, Torloni MR, Riera R, Martimbianco ALC, Grande
AJ, Porfı́rio GJM, Costa MB, Torres MFS, Silva V, Costa CS, Silva EMK,
Macedo CR, Melnik T, Puga MES, Atallah Á
Brazilian Cochrane Centre, Brazil
Background: The Brazilian Cochrane Centre (BCC) has increased its
efforts to disseminate the culture of evidence-based health (EBH) to
the general public. Objectives: To report new activities implemented
by the BCC. Methods: Over the last months, volunteer collaborators
of the BCC have held meetings to implement, upscale or improve the
activities described below. Results: • Basic Workshop: monthly, 1-day
activity that introduces 20 students to the Cochrane Collaboration
and how to develop systematic reviews (SR). • Advanced Workshop:
monthly, 1-day workshop that helps 20 participants to advance their
SRs, guiding them through title registration and protocol development.
• Online course: introduces students to the main concepts of a
SR (12 modules). • Improving translations: aiming to increase
the proficiency of volunteers involved in the Portuguese translation
of Cochrane abstracts and Plain Language Summaries • Beginners’
Manual: based on our online course and the Cochrane Handbook,
this booklet, written in Portuguese, guides researchers through the
main steps involved in a Cochrane Sr. • Cochrane abstracts and Plain
Language Summaries. • Handsearch: volunteers are being trained to
manually review Brazilian journals not indexed looking for trials to
be uploaded to CENTRAL. • New workshops: based on the demand
of our workshop participants, the team is planning new workshops:
Introduction to Clinical Research, Basic Biostatistics, Statistics for
Metanalyses, Critical appraisal, Assessing risk of bias, Cochrane Library
for consumers, Using Revman and GRADE. • Improving teaching:
The team is being trained to improve communication and didactic
performance to upgrade the quality of our workshops. Conclusions:
These activities are promoting increased visibility and interaction of
the BCC with different publics, more participants in our workshops,
recognition of the BCC as a research center and a highly motivated
and qualified team of professionals capable of both performing SR and
transmitting their knowledge and experience to others.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Participants in the online course ‘Handsearching:
identifying and classifying controlled trial
Ervin A1 , Dickersin K2
Cochrane Eyes and Vision Group, US satellite, USA; 2 US Cochrane
Center, USA
Background: To conduct a systematic review, one must find all
reports of randomized controlled trials (RCTs) and possible randomized
controlled trials (CCTs). Although most RCTs are identified from
searching electronic databases, some RCTs are found only by
handsearching. The US Cochrane Center developed and maintains
a free online course to train individuals in classifying clinical studies
as RCTs or CCTs. Objectives: To describe handsearching course
participants. Methods: Students are asked to provide location,
demographic information and affiliation with the Cochrane
Collaboration at registration. Information is collected on modules
completed by students and scores on self-assessment and knowledge
assessment tests. Results: As of March 21, 2013, 249 students had
registered for the course. They were located in North America (n = 101),
Europe (n = 63), Asia (n = 40), Central/South America (n = 17),
Australia (n = 12), Africa (n = 5) and the Middle East (n = 12).
Of participants responding to the online questionnaire, half (50/100)
claimed a Cochrane affiliation; 41 with a Group, 6 with a Field, and
3 with a Center. 21 respondents revealed a Cochrane role, including
author (n = 6), handsearcher (n = 4), Trial Search Coordinator (n = 5)
and other (n = 6). 64 of 101 of respondents had found the course on a
Cochrane website, and 13 through word-of-mouth. The most common
reason for taking the course was ‘personal growth’ (64/106, 60%). All
self-assessment tests were completed by 32 students with 67 students
completing at least one. The final test for the course, handsearching
6 months of the British Journal of Ophthalmology for RCTs and CCTs,
was attempted by 23 participants and completed by 21, with a median
score of 92.7%. Conclusions: The handsearching course continues
to be an information source for the Cochrane Collaboration and others
across the world to learn to classify clinical studies as RCTs or CCTs.
Teaching searching in an intensive systematic
review course: ‘how many citations should I
expect to review?’
Rosman L, Twose C, Li M, Li T, Saldanha I, Dickerson K
US Cochrane Center; Cochrane Eyes and Vision Group US Project
Background: We offer an intensive 8 week systematic review course in
a School of Public Health. The course is unique, requiring student groups
to complete all steps of a systematic review on intervention effectiveness
(randomized controlled trials, RCTs) or etiology (observational studies,
OBS). Informationists oversee searching techniques. One challenge
is teaching students to create a high quality search that produces a
manageable number of results; only 3 weeks is allocated for searching
and title abstract review. Although there has been research on the
number of databases needed to search, data are sparse on the number
of citations needed to review for systematic reviews of RCTs and OBS.
Objectives: To calculate number needed to be reviewed and read for
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
RCT and OBS reviews. Methods: Using 2 years of data from 19 groups
we abstracted data on total number of citations and full text reports
retrieved and reviewed, databases from which they were identified,
and number ultimately included. We analyzed frequency statistics
overall (mean, median, range) and by database and type of review.
We investigated whether included studies were in PubMed, EMBASE,
or CENTRAL. Results: The 19 systematic reviews retrieved on average
4464 unique citations ranging from 1060 to 16 747 (median: 3720).
Students retrieved and reviewed on average 183 full text reports
(range: 31–357) and abstracted data from on average 23 articles
(range: 19–27). Thus, about 200 citations and 5 full text reports need
to be reviewed to include 1 study in data abstraction. Results were
generally similar for RCTs and OBS. Almost all included studies from
11 reviews analyzed to date are indexed in EMBASE. Conclusions:
The wide range of citations reviewed reveals a discrepancy in workload
between student groups. We plan to investigate factors contributing
to this wide range and the surprising similarity of results for RCT and
OBS reviews.
Brazil’s growing production of scientific review
Guimaraes JA, Almeida ECE
CAPES Brazilian Agency for Support and Evaluation of Graduate Education,
Background: Publications are vital for the advancement of science
because they disseminate new findings and stimulate interaction
between researchers. In the last decades, the Brazilian government has
financed initiatives to promote the country’s scientific production and
its international dissemination. This has led to an improvement of the
performance of Brazil in the international in the international ranking
of scientific publications. Objectives: To assess the contribution of
Brazilian authors to the production of scientific reviews. Methods: We
performed a search for review articles published 2000–2010 in Web of
Science, National Science Indicators, Scopus and GeoCapes. All those
whose corresponding author was affiliated to a Brazilian institution
were retrieved. Results: The number of articles went from 12 434
in 2000 to 34 634 in 2010. The mean annual growth of Brazilian
scientific publications was 10.7%, which is 5 times higher than the
world average and Brazil is now the 13th country in the world in terms
of annual scientific publications. The number of reviews went from
196 in 2000 to 1209 in 2010 and Brazil now holds the 15th place in
the world in terms of review publications. The number of reviews grew
5 times more than that of original scientific articles. Almost all authors
were from public universities. The director of the Brazilian Cochrane
Centre (Atallah Á) was second in the list of Brazilian authors with the
largest number of reviews published and two research assistants of the
Centre (Saconato H, Soares BGO) ranked 19th and 20th. Conclusions:
The number of Brazilian review publications has grown remarkably over
the last decades. This growth is directly related to the number and
quality of post-graduate courses and also to the dissemination of the
culture of evidence-based health and the importance of systematic
reviews in this context.
Attachments: Note.pdf
Cochrane Database Syst Rev Suppl 1–212 (2013)
Translating one million words into two languages:
process approach and lessons learnt from the
translation of a comprehensive international
guideline database
Van de Velde S1 , Vanneste K2 , Bauwens T2 , Goossens C2 , Huyghe S2 ,
Fauquert B3 , Vanschoenbeek J4 , Heselmans A5 , Goossens M5 , Buysschaert
J6 , Aertgeerts B5 , Vander Stichele R4
1 EBMpracticeNet, Belgian Centre for Evidence-based Medicine, Belgium;
Iscientia IVS, Belgium; 3 EBMpracticeNet, Cebam Digital Library for Health,
Belgium; 4 EBMpracticeNet, Belgium; 5 EBMpracticeNet, Department of
Public Health and Primary Care KU Leuven, Belgium; 6 Faculty of Applied
Language Studies Hogeschool Gent, Belgium
Background: A Belgian national electronic point-of-care information
service was initiated in September 2011 to optimise quality of care
by promoting evidence-based decision-making. All Belgian healthcare
professionals get free access to a comprehensive international database
of clinical practice guidelines, in addition to the national guidelines.
Objectives: Translating a set of 938 concise international clinical
practice guidelines from English to Dutch and French. Methods:
The translation process was set up by a broker company for scientific
information, an academic institution of Applied Language Studies and
the editors of the national point-of-care information service. In a
first step, the translation software SDL Trados Studio (www.sdl.com/
products/sdl-trados-studio) was used. This program combines machine
translation with a translation memory database, as well as a terminology management system to ensure the consistent use of terms. This first
translation was post-edited by human translators, verified by medical
proofreaders and approved by validators. This working process was
written down in Business Process Modelling Notation with the Open
Source software Bizagi. The process was coordinated in a Microsoft
Sharepoint work flow and task list. Results: The total word count
of the international guidelines database was the equivalent of nearly
one million words. It took 15 months to undertake this translation
project. Per language 2000 translation hours, 500 proofread hours
and 200 validation hours were needed. The validated versions of
the translated guidelines were re-entered in the translation memory
database, which will improve the quality of the translation when
future updates of the international guidelines have to be translated.
Conclusions: Translating a comprehensive set of clinical practice
guidelines presented a huge challenge. Details on the working process,
lessons learnt and future directions for the updating process will be
presented during the conference.
Disseminating information on medicines and
health interventions in Brazilian Portuguese
using a internet-based resource: the Cemeds’
Junqueira DRG1 , Cândido RCF2 , Moraes AVSM2 , Pádua CAM2 , Lima MG2 ,
Perini E2
1 Centro de Estudos do Medicamento, Universidade Federal de Minas
Gerais, Brazil; Faculty of Health Science, The University of Sydney, Australia;
2 Centro de Estudos do Medicamento, Universidade Federal de Minas
Gerais, Brazil
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: The Centro de Estudos do Medicamento (Cemed) is
a Brazilian centre dedicated to research and knowledge translation
activities to support informed decisions regarding pharmacological
interventions. Recently, communicating evidence has become a central
core of the Cemed activities due the lack of updated high quality
scientific information published in Brazilian Portuguese language.
Objectives: We present the experience of the Cemed in settling up an
internet-based resource to deliver evidence-based health information
to lay people and health professional in a practical, consistent and
accessible way to Brazilian readers. Methods: A team consisted of
a pharmacist researcher trained in epidemiology and working with
the Cochrane Collaboration, three epidemiologists, a pharmacist with
large experience in pharmacy practice, and pharmacy students, were
established. The weblog, an internet resource known by its dynamism
and interaction possibilities, was chosen because of its resemblance
with an electronic journal and its functionalities of ease access and
update. Results: The Cemeds’ Blog was officially launched in February
25, 2012 at http://cemedmg.wordpress.com. In 1 year, we published
100 posts. We accumulated 17 224 hits (average of 50 hits/day),
a total of 10.019 visits (average of 106.6 visits/post) and a median
of 1.5 page views/visitor/day. Despite of the language restriction,
visitors from a number of 47 countries on the five continents have
accessed the weblog. After Brazilian readers, our major public with
14 843 hits, we have been followed by readers in Portugal (328 hits),
Australia (165 hits), US (157 hits), Spain (102 hits) and Argentina
(78 hits), among others. Conclusions: The establishment of this
multidisciplinary team has been proved a fascinating and fruitful
didactic experience for training graduate students. The audience
reached by the Cemeds’ Blog demonstrates the power of this internet
resource in disseminating information worldwide and the relevance
of translating knowledge on health care outcomes and the use of
Attachments: Figure1.png
The Italian IN-DEEP project - integrating and
deriving evidence, experiences and preferences:
developing research-based health information
applicable to decision making and
self-management by people with multiple
Colombo C1 , Filippini G2 , Confalonieri P3 , Baroni I4 , Traversa S4 , Hill S5 ,
Synnot A5 , Battaglia M4 , Mosconi P1
1 Istituto di Ricerche Farmacologiche Mario Negri - IRCCS, Milan, Italy;
Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous
System Review Group, Unit of Neuroepidemiology, Fondazione IRCCS
Istituto Neurologico ‘‘Carlo Besta’’ Milan, Italy; 3 U.O. Neurologia IV Centro Sclerosi Multipla, Fondazione Istituto Neurologico ‘‘Carlo Besta’’,
Milan, Italy; 4 Italian MS Society, Genova, Italy; 5 Centre for Health
Communication and Participation, Australian Institute for Primary Care and
Ageing, La Trobe University, Melbourne, Australia
Background: Patients increasingly want to know the evidence behind
treatments and how the research relates to them. People with multiple
sclerosis (PwMS) increasingly search for information on the Internet.
Cochrane Database Syst Rev Suppl 1–212 (2013)
This creates a challenge for providing high quality health information
online. The IN-DEEP project is a collaboration between teams in
Australia and Italy, developing parallel projects involving researchers,
neurologists, PwMS, MS societies, communication experts. Here we
present the Italian project findings. Objectives: To make high
quality evidence accessible and meaningful to PwMS and their families,
starting from their information needs to develop an online resource of
evidence-based health information. Evidence from Cochrane Reviews
of MS treatments was the initial focus. Methods: Six focus groups and
an online forum were conducted to analyse the experience of PwMS
and their families in finding, assessing, integrating health information
with personal values. Drawing from people’s experience, a template
for an evidence-based online resource was developed by the research
team and PwMS. After pilot testing, the online resource was launched
with an online evaluation questionnaire. Results: 40 PwMS and 20
family members participated in the focus groups and online forum.
Information needs covered MS causes, drugs’ adverse events, new
drugs and quality of life. Attitudes towards the Internet were variable:
for some it was useful, others were cautious or stopped searching over
time. For many, the neurologist remained the preferred information
source. A modular multi-page template was developed and interferon
was the first topic covered. Benefits and adverse events were included,
with practical information, information on research methodology, tools
to evaluate health information and personal stories. 433 respondents
completed the evaluation questionnaire. Overall the website was well
received. Conclusions: The online resource is considered readable,
understandable and useful by PwMS and their families. Other findings
and the challenges to disseminate Cochrane Reviews will be discussed.
Using a scoping review to identify promising
gender-sensitive health promotion interventions
for women
Pederson A, Liwander A, Fang ML, Julieta G
BC Centre of Excellence for Women’s Health, Canada
Background: Gender, as a social determinant of health, affects
an individual’s health and social outcomes. Initiated within the
field of HIV/AIDS, gender-sensitive health promotion interventions
(GSHPI) are programs and policies designed to address gender-related
health and social inequities among and between women and men.
It is important to develop methods for incorporating the analysis
of sex and gender within scoping reviews and to explore how
gender-sensitive elements are being incorporated in current health
promotion interventions to identify promising practices. Objectives:
Conduct a scoping review to identify promising GSHPI for women
in the fields of tobacco, alcohol, physical activity and sedentary
behaviour, and assess the extent to which they have considered
sex, gender, diversity and equity. Methods: A systematic search
was conducted in 47 bibliographic databases and 16 websites for
studies published between 2001 and 2012 that (1) explicitly targeted
girls and/or women; (2) incorporated an understanding of sex and/or
gender; (3) engaged with the determinants of women’s health; and
(4) sought to reduce gender-related social and health inequities. The
method was enhanced through consultations with key stakeholders to
guide the overall review process and to verify our preliminary results.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Results: The scoping review helped identify and categorize a large
volume of academic and grey literature and allowed for categorization
of findings to explore how the interventions considered sex, gender,
diversity and equity. The review also highlighted gaps in the existing
literature and our results suggest that few interventions met the criteria
for gender-sensitive interventions. Conclusions: Findings highlight
gender-sensitive features of health promotion interventions in tobacco,
alcohol, physical activity and sedentary behaviour, including how
gender roles may affect health behaviours. However, current literature
is only at the early stages of documenting GSHPI and enhanced
methods are required to further define and measure GSHPI.
The DECIDE frameworks for going from evidence
to recommendations and decisions
Oxman A1 , Glenton C1 , Lewin S1 , Alonso P2 , Flottorp S1 , Davoli M3 ,
Rosenbaum S1 , Moberg J1 , Gulmezoglu AM4 , and other members of the
DECIDE Collaboration5
Norwegian Knowledge Centre for the Health Services, Norway;
2 Iberoamerican Cochrane Centre, Spain; 3 Lazio Regional Health Service,
Italy; 4 World Health Organization, Switzerland; 5 Varied
Background: Evidence about benefits and harms of interventions is
essential but not sufficient for making healthcare decisions. Additional
factors must be considered, including values (the relative importance
of benefits and harms), resource use, equity, and the intervention’s
acceptability and feasibility. These factors are not always considered in
a balanced or transparent way. Objectives: DECIDE frameworks aim
to help people systematically think through each factor (criterion) that
is relevant for a particular recommendation or decision. These include
clinical recommendations, coverage decisions, and health system
and public health recommendations and decisions. Results and
Conclusions: Each framework includes a set of criteria, judgments
about each criterion and the evidence informing those judgments. The
frameworks enable people to systematically consider all the important
factors leading to a recommendation or decision. Their conclusion,
with the evidence and judgments leading to it, becomes transparent.
The frameworks are being developed by DECIDE (a project funded by
the European Union’s 7th Framework Programme) and the GRADE
Working Group.
The reporting of research design of diagnostic
test accuracy (DTA) studies in abstracts
of Cochrane Diagnostic Test Accuracy Reviews
Hunt H, Zhelev Z, Hyde C
University of Exeter
Background: The abstract of a scientific publication helps readers to
gain an overall idea of the study and to decide whether or not they
should read the full text. Within diagnostic test accuracy studies, the
reporting of research designs within the abstract section is commonly
inconsistent or absent. This has implications for screening on the
Cochrane Database Syst Rev Suppl 1–212 (2013)
basis of study design as well as for study identification in terms of
keywords and indexing. We recently conducted an analysis of DTA
studies published in English within EMBASE between 2012 and 2013
(N = 200) and found a great deal of heterogeneity in reporting of
research design. On this basis, we thought it would be useful to carry
out a similar analysis on DTA studies published in the Cochrane Library.
Objectives: We aim to analyse different ways in which the research
design terminology of DTA studies is reported in Cochrane DTA Reviews,
and to explore potential inconsistency in the terminology used to refer
to different DTA designs. Methods: We will investigate all full reviews
and abstracts published by the Diagnostic Test Accuracy Working
Group within the Cochrane Library to identify (a) study design reporting
variation within abstracts; (b) the range of research design terms used;
and (c) any inconsistency in their use. Results: We have initiated
the analysis by identifying all full reviews and abstracts published
by the Diagnostic Test Accuracy Working Group within the Cochrane
Library (N = 60), and results will be forthcoming. Conclusions:
As part of our analysis, we will create a frequency and distribution
map of the research design reporting within titles and abstracts of all
full reviews and abstracts published by the Diagnostic Test Accuracy
Working Group within the Cochrane Library, with recommendations for
future practice in reporting study design within diagnostic test accuracy
reviews published in the Cochrane Library.
Measuring and reporting of statistical
heterogeneity in reviews of diagnostic accuracy
Ochodo EA1 , Leeflang MMG1 , van Enst WA2 , Hooft L2 , de Groot JA3 ,
Bossuyt PM1 , Moons KGM3 , Reitsma JB3
1 Academic Medical Center, University of Amsterdam, Amsterdam, The
Netherlands; 2 Dutch Cochrane Centre, Academic Medical Center, The
Netherlands; 3 Julius Center, University Medical Center, Utrecht, The
Background: In the majority of diagnostic reviews there is more
variability in accuracy measures than can be expected due to chance
alone. As a variety of approaches exist for how reviewers examine,
measure, report and interpret their results in such circumstances,
more guidance is urgently needed. Objectives: To describe the
methods currently used in diagnostic reviews to visualize, quantify,
and report statistical heterogeneity in accuracy results between
primary studies and to explore how the results of this examination
influence subsequent analysis decisions and formulation of conclusions.
Methods: Systematic reviews on diagnostic tests published in
MEDLINE-indexed journals between May and September 2012 were
identified using a systematic search. Using a standardized form,
information was extracted on the clinical context and methods applied
from the main meta-analysis in each review. Results: 53 meta-analyses
met inclusion criteria. These meta-analyses contained a median of 14
primary studies (IQR = 9.5–20.5). Statistical tests for heterogeneity
were used in only 72% of the meta-analyses. The most common
tests were I2 (29), followed by χ2 (26), and τ 2 (5). Heterogeneity
was represented visually in all but 5 studies; 40 plotted sensitivity and
specificity in ROC space and 34 presented forest plots. Data on how the
investigation of statistical heterogeneity influenced subsequent analysis
decisions (i.e. whether to investigate sources of heterogeneity) and
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
the formulation of conclusions will be available before the colloquium.
Conclusions: The exploration of statistical heterogeneity in diagnostic
accuracy meta-analyses is increasing, although not yet universal.
However, there is a lack of consistency in which heterogeneity
tests are used, how these tests are interpreted, and how these
results influence subsequent analysis decisions and conclusions. In a
diagnostic meta-analysis, because mean values are difficult to interpret
and translate to clinical practice and because confidence intervals
and ellipses do not accurately reflect the amount of between-study
variation, identifying sources of variability becomes important.
The DEPRESsion Screening Data (DEPRESSD)
registry: a protocol for a registry to support
individual patient data meta-analyses of the
diagnostic accuracy of depression screening
Levis B, Thombs B
McGill University, Canada
Background: Major depressive disorder may be present in 10–20% of
patients in medical settings. Routine screening for depression has been
recommended to improve depression management. However, studies
that have examined the diagnostic accuracy of depression screening
tools typically have used data-driven, exploratory methods to select
optimal cutoffs. Typically, these studies report results from a small
range of cutoff points around whatever cutoff score is most accurate
in that given study. When data from these published studies are
combined in meta-analyses, estimates of accuracy for different cutoff
points are often based on data from different studies, rather than
having data from all studies for each possible cutoff point. As a result,
traditional meta-analyses can generate grossly exaggerated estimates
of accuracy. Individual patient data (IPD) meta-analyses can be used
to address this problem by synthesizing data from all studies for each
cutoff score to obtain precise, unbiased diagnostic accuracy estimates.
Objectives: The DEPRESsion Screening Data (DEPRESSD) Registry
was created as a data repository for IPD meta-analyses of depression
screening accuracy. The Registry is accumulating datasets from original
studies with diagnostic accuracy data for common depression screening
tools, which will result in large enough samples to accurately
estimate accuracy across all relevant cutoff scores. It will also allow
analyses of moderating factors that may influence accuracy (e.g., age,
gender, diagnosis). Methods: Authors of eligible published studies are
being invited to contribute original data to the Registry. Datasets will
be eligible for this project if they include a DSM or ICD diagnosis of MDD
based on a validated structured or semi-structured diagnostic interview
administered within two weeks of the administration of one or more
depression screening tools included in the Registry. Conclusions:
This Registry will provide a mechanism to obtain realistic estimates
of depression screening tool accuracy, which currently appears to be
substantially exaggerated.
Cochrane Database Syst Rev Suppl 1–212 (2013)
The assessment of reporting quality on
systematic reviews or meta-analyses of
diagnostic test published by Chinese authors
Ge L1 , Liang L1 , Liu YC1 , An N1 , Shi XT1 , Xu JF1 , Tian JH2
The First Clinical College of Lanzhou University, China; 2 Evidence-Based
Medicine Center, School of Basic Medical Sciences, Lanzhou University,
Background: The quality of reporting on diagnostic systematic reviews
(SRs) or meta-analyses (MAs) published by Chinese authors is unclear.
Objectives: The research aims to evaluate the quality of reporting on
diagnostic SRs or MAs, using the PRISMA statement and determine
whether there has been a improvement. Methods: According to
the inclusion and exclusion standard, we searched Chinese Biomedical
Literature Database, PubMed, EMBASE, the Cochrane Library, Web of
knowledge five databases to identify SRs/MAs on diagnostic test. The
searches were implemented in July 2012 and the cut off for inclusion
of the SRs/MAs was December 31, 2011. The PRISMA statement
was applied to assess reporting quality. Analyses were performed
using Excel, SPSS17.0 and Meta Analyst soft. Results: A total of
312 studies were included. Fifteen diseases systems were involved.
According to the PRISMA checklist, the score range of the study quality
was 4–26, the average score was 17.14 ± 4.18 (Table 1). Figure 1
showed that there has been some improvement in total score after the
PRISMA publishing. The reporting quality of researches published by
University is better than by Hospital. Funding theses compared with
Non-funding theses, funding theses has been some improvement in
total score. SRs/MAs werewritten by 3 authors and 2 cooperating
unit compared with 1–2 authors and one unit, the reporting quality
improves distinctly. The report quality of CSCD these and SCI these was
better than Non-CSCD these and Non-SCI these. And the difference in
total score to all stratified factors was statistically significant (P < 0.05).
Conclusion: The number of diagnostic SRs/MAs is increasing annually.
The quality of reporting has measurably improved over the previous
years. Unfortunately, there are still many deficiencies in protocol and
registration, search, risk of bias across studies, additional analyses.
Future SRs/MAs should pay attention to these aspects.
Figure 1 Stratified analysis of reporting quality of
included studies.pdf, Tab 1 The results of reporting quality assessment
(n = 312).pdf
The study of reporting quality of randomized
controlled trials in systematic reviews
of acupuncture
Liu Y1 , Huang J2 , Zhang R2 , Mai Y3 , Zhao X3 , Sun W3 , Wei M1 , Li YP1 ,
Huo X4 , Ke W2 , Yang KH2
Evidence-Based Medicine Center, School of Basic Medical Sciences,
Lanzhou University, China; 2 Evidence-Based Medicine Center, The First
Clinical Medical College, Lanzhou University, China; 3 Evidence-Based
Medicine Center, The Second Clinical Medical College, Lanzhou University,
China; 4 The First Clinical Medical College of Lanzhou University, Lanzhou
University, China
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: The reporting quality of randomized controlled trials
(RCTs) is one of the factors during developing a systematic review
(SRs)/meta-analysis(MAs). It is significant to know which information
was ignored by reviewers in RCTs which were included in SRs/MAs.
Objectives: To evaluate the reporting quality of RCT in SRs/MAs of
acupuncture. Methods: We searched PubMed, EMBASE, Web of
Science and Cochrane Database of Systematic Reviews (CDSR), the
Chinese Biomedicine Literature Database(CBM), Traditional Chinese
Medicine database (TCM database), Chinese Journal Full-text Database
(CJFD), Chinese Scientific Journal Full-text Database (CSJD) and
Wanfang Database, until Deccember 2011. The RCTs in English and
Chinese were identified from those SRs/MAs. The random samples
were selected from these RCTs in 2001–2010. Data was extracted
into excel spreadsheets according to pre-prepared data extracted
forms. The reporting quality was assessed based on CONSORT (27
items) and STRICTA checklists (17 items) statements by two reviewers,
respectively. Results: A total number of 327 SRs/MAs of Acupuncture
& Moxibustion and a random sample of 363 RCTs were identified and
selected in this study. It showed that the reporting quality of 363
Chinese and English RCTs of acupuncture was poor. The scores of
CONSORT of RCTs in 2006–2010 were higher in English than in Chinese
(P = 0.000). However, scores of STRICTA in 2006–2010 of English
RCTs were similar to Chinese RCTs (P = 0.440). Compared with these
in 2001–2005, scores of CONSORT in 2006–2010 were significantly
higher than in both English (P = 0.011) and Chinese RCTs (P = 0.001).
Besides, scores of STRICTA in both English (P = 0.317) and Chinese
RCTs (P = 0.853) in 2006–2010 were similar to RCTs in 2001–2010.
Conclusions: The RCTs from the SRs/MAs of acupuncture have not
comprehensive reporting of relevant information based on CONSORT
and STRICTA statements. The researchers should be pay attention to
comprehensive report of RCTs on acupuncture.
Has completeness and quality of systematic
review and meta-analysis reporting in major
radiology journals changed since publication of
the PRISMA statement? Subtitle: is completeness
of reporting associated with study quality?
Tunis A1 , McInnes M2 , Hanna R1 , Esmail K1
University of Ottawa, Canada; 2 University of Ottawa/Ottawa Hospital
Research Institute, Canada
Background: The Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) statement guides completeness of
reporting of systematic reviews (SR) & meta-analysis (MA). The
completeness of reporting in major radiology journals is unknown.
Additionally, the association of completeness of reporting with study
quality [measured by the Assessing the Methodological Quality of
Systematic Reviews (AMSTAR) tool] has also not been evaluated.
Objectives: The purpose of our study is to determine whether the
completeness of reporting of systematic reviews & meta-analysis in
major radiology journals has changed since publication of the PRISMA
statement. A secondary objective is to evaluate whether completeness
of reporting (PRISMA) is associated with study quality (AMSTAR).
Methods: SR & MA published in high impact radiology journals were
identified by searching Medline using the modified Montori method.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Studies were reviewed independently by two investigators and assessed
for adherence to the AMSTAR & PRISMA checklists. The average results
were analysed to assess for change pre and post PRISMA publication,
and to evaluate for any association between PRISMA and AMSTAR
results. Results: 130 studies from 11 journals were included. Average
PRISMA and AMSTAR results were 21.8 (out of 27) and 7.2 (out of
11) respectively. The average result was higher post publication of
PRISMA; with PRISMA reported items of 22.6 vs. 20.9 and AMSTAR
result of 7.7 vs. 6.7. Strong positive correlation (r = 0.86) between the
PRISMA and AMSTAR results was present. There was high variability
between journals. Radiology had the highest PRISMA reported items
of 24.7, and AJNR had the lowest at 19.6. Two major areas for
improvement include study protocol registration and assessment of
risk of bias across studies (publication bias). Conclusions: There
has been modest improvement in completeness of reporting of SR
and MA in major radiology journals. Improved completeness of
reporting (PRISMA) was strongly associated with higher study quality
Attachments: Figure 1.tif, Figure 2.tif, Figure 3a.tif, Figure 3b.tif,
Figure 4a.tif, Figure 4b.tif
Methodological quality of systematic reviews
and meta-analyses on interventional in leading
Chinese evidence-based medical journals
Li YP1 , An N2 , Xu JF2 , Ge L2 , Liang L2 , Shi XT2 , Tian JH3
The Second Clinical College of Lanzhou University, China; 2 The First
Clinical College of Lanzhou University, China; 3 Evidence-Based Medicine
Center, School of Basic Medical Sciences, Lanzhou University, China
Background: More and more Systematic Reviews (SRs) and
Meta-analyses (MAs) with different angles and opinions were emerging
published in Chinese leading evidence-based medical journals.
However, the current situation on methodological quality of SRs/MAs
published is not clearly yet. Objective: To critically assess the
methodological quality of SRs/MAs on interventional published in
Chinese leading evidence-based medicine journals. Methods: To
Chinese Journal of Evidence-based Medicine, The Journal of
Evidence-Based Medicine, Chinese Journal of Evidence Based Pediatrics
and Chinese Journal of Evidence-Based Cardiovascular Medicine
web-based database for data sources, to select SRs or MAs of
interventional strictly up to December 2011 based on the inclusion and
exclusion criteria. Data were extracted by two reviewers independently.
The methodological quality of the trials was assessed by the AMSTAR
tool. We discussed the factors may affect methodological quality on
five aspects: publication year, number of author(s), financial support,
author affiliation. All analyses were undertaken in Meta-analyst 3.13
and Microsoft Excel 2003. Results: A total of 487 studies were
included. The Table 1 showed that AMSTAR checklist score range from
1.5 to 9.5, the average score was 5.94 ± 1.05. AMSTAR publishment
greatly increased the total score statistically. There were no significant
differences among the other groups (Fig. 1). Conclusion: The results
from multivariate analysis showed that the methodological quality of
SRs/MAs of interventional published in Chinese leading evidence-based
medicine journals had problems in different levels, which required to
be further improved. The lack of the details of retrieval strategies and
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
single type of document retrieval should be noticed. There remained
a pretty low rate of usage on grey literature and a poor report on
publication bias. We sincerely hope that analysts will take this as a
warning and produce high-quality SRs/MAs in future.
Attachments: Figure 1 Stratified analysis on AMSTAR assessment for
included 487 studies.pdf, Table 1 The result of methodological quality
assessment (n = 487).pdf
Quality appraisal of clinical practice guidelines
on the treatment of hepatocellular carcinoma or
metastatic liver cancer: a systematic review
Wang Y1 , Li YP1 , Deng S2 , Wei S3 , Luo Q4 , Li XL1 , Yu J1
The Chinese Cochrane Centre, China; 2 West China Hospital, Sichuan
University, China; 3 West China Medical School, Sichuan University, China;
National Chengdu Center for Safety Evaluation of Drugs, West China
Hospital, Sichuan University, China
Background: Objectives: This study was supported by Ministry
of Science and Technology of China to quality appraisal the current
available clinical practice guidelines (CPGs) for hepatocellular
carcinoma (HCC) and sum recommendations of strongly recommended
guidelines, so as to provide a policy-making evidence for clinical
practice. Methods: The databases of MEDLINE, Web of science,
CBM and CNKI and the relevant CPGs websites were systematically
searched until August 2012. The quality of CPGs was appraised
by AGREE II instrument, and data and graphics were performed by
SPSS 13.0 and SigmaPlot 12.0, respectively. Results: Total 19
evidence-based guidelines and 10 expert consensuses were included.
The mean percentage of six domains score of clarity of presentation,
scope and purpose, stakeholder involvement, rigor of development,
editorial independence and applicability were 89%, 84%, 64%, 49%,
37% and 20% respectively.The two domains of rigor of development
and clarity of presentation in evidence-based guidelines were superior
to expert consensus (p < 0.05).We finally strongly recommended and
recommended five and nineteen guidelines, respectively. However, five
guidelines were not recommended due to poor quality. Conclusions:
The overall methodological quality of CPGs for HCC is moderate, but
with poor applicability and potential conflict of interest. The quality
of evidence-based guidelines are significantly superior to consensus;
however, it is also need to further increase the transparency of quality
appraisal of evidence, recommended process and the involved conflict
of interest.
Interventions for age-related macular
degeneration: What is the quality of the
Ssemanda E1 , Ugarte Gil C2 , Li T1 , Dickersin K1
Cochrane Eyes and Vision Group, USA; 2 Johns Hopkins School of Public
Health, USA
Background: Systematic reviews on interventions for age-related
macular degeneration (AMD) are essential for making informed clinical
inferences and providing evidence-based care. Objectives: This report
Cochrane Database Syst Rev Suppl 1–212 (2013)
examined the quality of systematic reviews on interventions for AMD
using modified versions of the Critical Appraisal Skills Program (CASP),
the Assessment of Multiple Systematic Reviews (AMSTAR), and the
Preferred Reporting Items for Systematic Reviews and Meta-Analysis
(PRISMA). Methods: PubMed/Medline, EMBASE and CENTRAL were
searched for relevant reviews in 2009 and updated in 2012. We
selected reviews, which asked a focused clinical question, used
explicit, pre-specified scientific methods, and examined the efficacy
of an intervention for AMD. Two authors independently extracted
and assessed the characteristics and methodological quality of each
review. Results: Out of 7676 citations, 36 systematic reviews met
our inclusion criteria. 36% of systematic reviews were classified as a
Cochrane Review. Most of the systematic reviews targeted neovascular
AMD and investigated anti-VEGF interventions, dietary supplements
or photodynamic therapy. Although the majority of systematic reviews
presented a search description, 56% searched non-English journals,
47% included unpublished data, and 39% searched for ongoing
studies. 56% and 56% reported at least two data abstractors screened
abstracts and full-texts respectively. 53% of systematic reviews
assessed the risk of bias independently. 94% of systematic reviews
appraised the included studies qualitatively. Nearly all systematic
reviews explored the limitations at the study and outcome levels, while
42% discussed limitations at the review level. Only 36% did not report
the source of monetary or material support of the review. 47% of
reviews were judged to be reliable. We found Cochrane systematic
reviews to be more reliable than non-Cochrane systematic reviews.
Conclusions: We identified areas for improvement in systematic
review conduct. The quality of systematic reviews varied, with better
quality found in Cochrane Reviews as compared to non-Cochrane
Assessment of the quality of reporting for
treatment components in Cochrane Reviews
of acupuncture
Kim KH1 , Kang JW2 , Lee MS3 , Shin B4 , Lee JD2
1 Department of Acupuncture and Moxibustion Medicine, Korean Medicine
Hospital, Pusan National University, South Korea; 2 Department of
Acupuncture and Moxibustion, College of Korean Medicine, Kyung Hee
University, South Korea; 3 Korea Institute of Oriental Medicine, South Korea;
Department of Rehabilitation Medicine, School of Korean Medicine, Pusan
National University, South Korea
Background: Highquality reporting of treatment details can aid
replication of study results in real-world clinical practice. The revised
Standards for Reporting Interventions in Clinical Trials of Acupuncture
(STRICTA) is a reporting guideline for key elements of acupuncture
interventions in clinical trials. Objectives: This study used STRICTA
to investigate whether Cochrane Reviews of acupuncture adequately
report important treatment details. Methods: Cochrane Reviews
of acupuncture were identified from The Cochrane Library (Issue 7,
2012). Randomized controlled trials (RCTs) included in the reviews
and published after 2005 were obtained. Using STRICTA, we extracted
acupuncture-related information from both the Cochrane Reviews and
the RCTs. The Characteristics of included studies table was the
major source of intervention information from Cochrane Reviews.
Reporting quality of acupuncture interventions in Cochrane Reviews
was assessed and compared to the respective RCTs. Results: In
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
total, 25 Cochrane Reviews of acupuncture and 92 RCTs met the
selection criteria. Cochrane Reviews were 16% less likely to report
the acupuncture-related items of STRICTA than RCTs (risk ratio 0.84,
95% confidence interval 0.79–0.88, I2 = 8%) (Fig. 1). Information
was significantly better reported for 10 of the 15 treatment-group
items of STRICTA in RCTs than in Cochrane Reviews (p < 0.05), while
four items did so without statistical significance. One item related to
practitioner background was significantly better reported in Cochrane
Reviews. Conclusions: Reporting quality of treatment details in
Cochrane Reviews of acupuncture was insufficient with regard to
STRICTA, even though such information was readily reported in RCTs.
The overall quality of reporting of the RCTs, while better than the
reviews, was also often suboptimal. Use of the STRICTA guideline
during the review process is recommended to adequately report the
key treatment components in Cochrane Reviews of acupuncture. The
potential impact of STRICTA to the external validity and generalizability
of reviews needs to be investigated.
Attachments: Forest plot.png
Assessment of the quality of clinical trials
Wong C1 , Wu M1 , Tam K2
1 Taipei Medical University - Shuang Ho Hospital, Taipei, Taiwan; 2 Taipei
Medical University, Taipei, Taiwan
Background: Clinical trial registration is known to improve research
transparency and will ultimately strengthen the validity and value of the
scientific evidence base. Through clinical trials registration, it should
be possible to take steps to ensure that registered data about health
care are informed by all of the available evidence. However, previous
evaluations of registered records of clinical trials have shown that
registered information is often incomplete and non-comprehensive.
Objectives: The study is aimed to evaluate the quality of clinical
trials registries. Methods: The quality of 14 primary registries
in the World Health Organization (WHO) Registry Network and the
ClinicalTrials.gov registry (http://clinicaltrials.gov/) was evaluated by
comparing the completeness of WHO 20-item Trial Registration Data
Set items. Results: Among the 15 clinical trials registries included in
the study, 40.0% (6/15) of the clinical trials registries ignored the item
of ‘date of first enrollment’, 26.7% (4/15) trials registries neglected the
item of ‘secondary identifying numbers’, 20.0% (3/15) trials registries
unnoticed of ‘Secondary Sponsor(s)’ and ‘Countries of Recruitment’
items. Only four clinical trials registries fulfilled all the 20 items in
the WHO Trial Registration Data Set. Conclusions: Clinical trials
registration has the potential to improve clinical trial transparency and
reduce publication bias and selective reporting. These potential benefits
are currently undermined by deficiencies in the provision of information
in key areas of registered records. The missing or uninformative entries
of key information could be reduced by improving the quality of clinical
trial registries.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Quality appraisal of clinical practice guidelines
on glioma
Tian HL1 , Gou Y2 , Wang Z2 , Niu X3 , Dang W2 , Yang KH4
Evidence-Based Medicine Centre of Lanzhou University, The First Cinical
Hospital of Lanzhou University, China; 2 The First Cinical Hospital of Lanzhou
University, China; 3 The Second Cinical Hospital of Lanzhou University,
China; 4 Evidence-Based Medicine Centre of Lanzhou University, China
Background: Clinical practice guidelines (CPGs) play an important
role in healthcare. The guideline development process should be
precise and rigorous to ensure that the results are reproducible and
not vague. To determine the quality of guidelines the Appraisal
of Guidelines and Research and Evaluation (AGREE) instrument was
developed and introduced. Objectives: To assess the methodological
quality of clinical practice guidelines for neurological disease on glioma.
Methods: Eight databases (included MEDLINE and EMBASE) were
searched till to December, 2012. The methodological quality of
the guidelines was assessed by two authors independently using
the AGREEII instrument. Results: From 940 citations, 15 relevant
guidelines were included. The overall agreement among reviewers was
moderate [ICC = 0.83; 95% confidence interval (CI), 0.66–0.92]. The
mean scores were moderate for the domains ‘scope and purpose’ 60%
and ‘clarity of presentation’ 65%, however there were low for the
domains ‘‘stakeholder involvement’44%, ‘rigor of development’ 39%,
‘applicability’ 32%, ‘editorial independence’ 31%. Only 1/3 guidelines
described the systematic methods for searching and selecting the
evidence, nearly half of the 7(47%) guidelines didn’t give a specific
recommondation. None described a procedure for updating the
guideline. None used the Grading of Recommendations Assessment,
Development and Evaluation (GRADE) system. Conclusions: The
quality and transparency of the development process and the
consistency in the reporting of glioma guidelines need to be improved.
The quality of reporting of guidelines was disappointing. Many other
methodological disadvantages were identified. In the future, glioma
CPGs should based on the best available evidence and rigorously
developed and reported. The quality of glioma guidelines in China is
low. Greater efforts are needed to provide high-quality guidelines that
serve as a useful and reliable tool for clinical decision-making in this
The use of Cochrane SR in the development
of clinical practice guidelines. The case of
syndromic management of sexually transmitted
infections and other infections of the genital
tract. 2012
Gaitan H1 , Torres M2 , Rodriguez A3
1 Coordinating Editor STI Group, Clinical Research Institute, Universidad
Nacional de Colombia, Colombia; 2 STI Group, Alianza CINETS, Universidad
Nacional de Colombia, Colombia; 3 Clinical Research Institute, Universidad
Nacional de Colombia, Colombia
Background: In recent years, the GRADE approach has been broadly
accepted by many GDG. The use of SR for GDG is highly expected.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
There is a lack of information about the relationship between the
types of evidence with the strength of recommendations using GRADE.
Objectives: To present the evidence mapping of the literature used to
develop recommendations in the Guideline for Syndromic management
of the Genital Tract Infections, with emphasis in the use of Cochrane SR.
Methods: The evidence of each recommendation was reviewed and
was classified according to the type of evidence, quality, quantity and
strength of the recommendation. A descriptive analysis was performed
as well as a cross-analysis to identify the relationship between the
strength of the recommendation and the quality of the evidence. The
quality of the SR was assessed with AMSTAR. Results: SR supported
the 29.1% of the recommendations, 52% of them were Cochrane
SR, RCT 25.6%, observational studies 5.9%, guidelines 9.3% and
expert opinion 30.1%. The quality of the evidence was high (14%),
moderate (15%), low (16%) and very low (55%). 63.7% of the
recommendations were strong in favor. 14% of the strong in favor
recommendations came from high quality evidence and 49% came
from very low quality evidence. Not all the Cochrane SR had the same
level of quality. Conclusions: The evidence shows a similar percentage
of systematic reviews, RCT and expert opinion in the guideline. 15%
of the recommendations were supported by RS Cochrane. The GRADE
approach allows weighting other factors beyond quality of the evidence
which are relevant for clinical practice. Research needs to be done on
the most important factors in grading recommendations and how the
collaboration can support GDG worldwide in order to become a source
of high quality evidence for guideline developers.
Clinical practice guidelines manuals and toolkits.
Are they different among languages, countries
and developers?
Flórez ID, Pérez AV, Peña E, Prieto LC, Cañón LA
Health Technology Assessment Institute- IETS, Colombia
Background: Manuals and Toolkits (MT) are standards for developing
Clinical Practice Guidelines (CPG). Most developers have their own
MT. There isn’t enough information about characteristics of MT
in other languages than English. Objectives: To assess the
characteristics of MT for developing CPG from different developers
in English and Spanish. Methods: We searched electronic databases,
national clearinghouses and non-electronic sources such as guidelines
developer’s sites. Epidemiologists independently assessed MT retrieved.
Information about scoping, development group, Conflict of Interests
(COI), updating, evidence systems among others, were extracted.
Results: Twenty MT were retrieved, 8 in Spanish, and 12 in English. It
is not clear how COI is declared and handled in most of the MT. GRADE
and SIGN were the most recommended systems for assessment of
quality of evidence, nevertheless many didn’t recommend any system.
Only two MT had a complete explanation about patient’s participation.
Three years is the most common recommendation for updating CPG.
Only a few include an economic component. There isn’t clarity in how
recommendations are reported and how should be the external review
of MT. Conclusions: There is heterogeneity in CPG development.
Spanish MT are less specific than English ones. It is important
to improve quality of Spanish-language MT’s, in order to enhance
quality of Spanish CPG. There is an important lack of information
Cochrane Database Syst Rev Suppl 1–212 (2013)
about patient’s participation and drafting of recommendations. It’s
important to improve the contents and quality of MT in order to achieve
high quality standards on CPG development for both developed and
developing countries.
Reducing unnecessary cervical cancer screening:
achieving more by doing less
Koster M, Schottinger J
Kaiser Permanente Southern California, USA
Background: Too-frequent screening for cervical cancer can increase
costs, lead to unnecessary invasive procedures associated with
overtreatment, and shift resources away from the one in five women
who do not receive recommended routine screening. Objectives:
A large, U.S.-based integrated healthcare system with centralized
evidence services and eight independent regions developed and
implemented an evidence-based guideline for cervical cancer screening.
Novel implementation strategies and performance monitoring in one
region led to significant improvements and are described below.
Methods: Graded systematic reviews were conducted by a centralized
analytic unit, and recommendations developed by a guideline team with
representation from each region. In one large region with more than
3.5 million patients, interventions aimed at the practitioner, patient and
systems levels were implemented for routine Pap and HPV cotesting.
Practitioner interventions included electronic distribution of guidelines,
point-of-care electronic prompts, and workflow support. Patient-level
interventions included point-of-care education, and inreach/outreach
activities. System-level interventions focused on centralized patient
outreach letters and reminder calls, computerized decision support, and
unscreened cancer lists for panel management. Monthly performance
monitoring on a measure of ‘overpapulation’ was reported at medical
center, department and provider levels. Results: In a 5-year period,
over 100 000 fewer unnecessary Pap tests were performed, while
screening rates increased by 7%. Conclusions: Centralized systematic
evidence review and guideline development, coupled with coordinated
implementation and performance monitoring, can reduce unnecessary
screening and invasive procedures, focus resources on appropriate
routine screening in underscreened populations, improve patient access
and reduce costs.
Meeting end-user needs through rapid evidence
reviews: a partnership case study
Barker SJ
Institute for Safety, Compensation & Recovery Research (ISCRR), Monash
University, Australia
Background: Barriers to using traditional systematic reviews in
the ‘real-world’ policy setting have led to a growth in accelerated
approaches to evidence reviewing. Those that expedite the process
whilst maintaining high quality and rigour show promise, however
achieving a one-size-fits-all accelerated approach may not be suitable.
Transparency in reporting, application to other disciplines, and lack
of impact assessment are some limitations of current accelerated
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
approaches. A new partnership in compensation health between
academic research and government groups created the need for a
tailored evidence review program that could inform decision-making
as well as other activities such as strategic planning and stakeholder
engagement. Objectives: To develop and implement an accelerated
review approach that is robust, transparent and delivers reviews
that meet end-user needs. Methods: We reviewed existing external
accelerated review programs, conducted stakeholder interviews
(researchers and end-users), and also evaluated evidence reviews
conducted during the establishment phase of our partnership. Through
a separate project impact and return on investment was assessed
for three earlier evidence reviews. Our Research Translation model
was also an input to the framework. Results: Two accelerated
evidence review ‘products’ have been developed—‘snapshot reviews’
and ‘rapid reviews’. They share the same eight high-level stages and
differ according to the depth and breadth of process, timelines, and
the expertise required to conduct the review (researcher network). The
way in which evidence will be used is a key factor in determining which
product is most appropriate. Tools have been developed to inform and
guide the review, such as the evidence review plan and stakeholder
meeting protocol. Conclusions: Our snapshot and rapid reviews
deliver a unique and collaborative approach that can be applied across
disciplines. The potential impact of accelerated evidence reviews is
highlighted through our impact assessment work.
Summarizing evidence for policy: some
limitations of rapid and systematic reviews
Blanquaert I1 , Laberge A2 , Deck W3 , Dufort P4 , Rousseau J4
Institut National de Santé Publique du Québec, Montreal, Canada; 2 Service
de Génétique Médicale, CHU Ste-Justine, Montreal, Canada; 3 Agence de
la santé et des Services Sociaux de la Gaspésie, Gaspesie, Canada; 4 Institut
National de Santé Publique du Québec, Quebec, Canada
Background: The increasing demand for evidence-informed
policymaking may translate into pressures on scientific advisory bodies
to produce rigorous and timely assessments. Several constraints may
force health agencies to opt for rapid reviews, the quality of which
depends on previous evaluations and the applicability of results to
the local context. Objectives: To share some observations on the
conformity of systematic reviews and health technology assessment
(HTA) or evidence-based (EB) reports to standard quality guidelines
and on the pros and cons of rapid reviews to inform policy decisions.
Methods: The observations derive from a rapid review of reviews on
cystic fibrosis (CF) newborn screening (NBS), diagnosis and treatment.
This review included a formal systematic review on the impact of
CF NBS, for which the methods applied in systematic reviews, HTA
or EB reports published between 1995 and 09/2011 were critically
analyzed. Feedback on the quality of this assessment was obtained
through formal peer review, a deliberative forum and a web-based
consultation process. Results: Five reports on the impact of CF
NBS were identified. Their methodological quality was acceptable but
not optimal. Considerable heterogeneity was noted between reports
with respect to data selection, description and appraisal. Authors’
conclusions were less concordant for clinical outcomes for which
evidence was less conclusive. Their scope sometimes went beyond the
quality of the reviewed evidence and was predominantly based on the
Cochrane Database Syst Rev Suppl 1–212 (2013)
benefits of NBS. Conclusions: A thorough review of reviews was less
time-consuming than a systematic review but did not prove sufficient to
derive final conclusions on CF NBS benefits at the population level or to
gauge the balance between the benefits and risks in the local context.
The focus of reviews on the benefits of CF NBS to the detriment of
other aspects, including test performance, limited the scope of evidence
readily available to support decision-making.
What’s more important - timeliness or accuracy
of results in providing evidence? Preliminary
results on a research program on rapid reviews
Tricco A1 , Antony J1 , Hutton B2 , Moher D2 , Ciliska D3 , Straus S1
Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Canada; 2 Ottawa
Hospital Research Institute, Canada; 3 McMaster Evidence Review and
Synthesis Centre, Canada
Background: Health decision-makers (including clinicians, patients,
and policy-makers) need timely access to health information.
Frequently, this information can be obtained from a systematic review;
however, the amount of time it takes to complete a systematic review
may not suit the needs of some decision-makers. Instead, they may
be forced to rely on expert opinion or the results of single studies to
make important decisions. Rapid reviews are a form of knowledge
synthesis in which components of the systematic review process are
simplified or omitted to produce information in a timely manner. Yet
rapid reviews might be susceptible to biased results as a consequence
of streamlining the systematic review process. Objectives: To develop
a comprehensive list of rapid review methods and categorize each
method by feasibility, timeliness, comprehensiveness, and risk of bias.
Methods: Two previous systematic reviews on rapid review methods
will be updated by searching electronic databases (e.g., MEDLINE,
EMBASE, the Cochrane Library) and conducting targeted Internet
searches (e.g., Google). Citations (titles/abstracts) and full-text articles
will be screened, and data abstraction will be conducted by two
reviewers independently. This list will be supplemented by an electronic
survey of international rapid review programs. A comprehensive list
of all rapid review methods will be compiled and categorized by
feasibility, timeliness, comprehensiveness and risk of bias. Results:
Our research proposal was funded by the Canadian Institutes for
Health Research and is currently underway. Preliminary results will
be presented at the conference. Conclusions: Our results will be
a first step to understanding how rapid reviews can be used to
balance decision-makers’ need for accuracy, as well as timeliness. By
advancing the methods used in rapid reviews, the quality of health care
decision-making will be enhanced, and researchers can better ensure
that decisions are based on the best possible evidence.
Attachments: Cochrane abstract Rapid reviews 26MAR2013.pdf
Usability of Cochrane-based evidence summaries
in point-of-care guidelines
Jousimaa J, Alenius H, Kunnamo I
Duodecim Medical Publications Ltd, Finland
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: Evidence-based Medicine Guidelines (EBMG) is a
collection of concise point-of-care guidelines produced by Finnish
Medical Society Duodecim. The EBMG collection of almost 1000
guidelines is completed with Evidence Summaries indicating the level of
evidence and some also the strength of recommendation. An Evidence
Summary can be (1) directly linked to a specific point in guideline
text; (2) linked to the guideline general topic (in a separate document
named ‘Related Resources’), or (3) a lone summary not linked to any
guideline. Objectives: To assess the usability of Cochrane-Based
Evidence Summaries attached to guidelines by assessing how they
have been linked with guidelines. Methods: A database search
was done to find the number and type of EBMG Evidence Summary
links. Special attention was paid to ‘lone summaries’ - whether they
were actually not usable in this type of guideline of if there were
other reasons for non-linking. Results: Currently, there are 4355
EBMG Evidence Summaries, almost 3000 of them based on Cochrane
Reviews. Of these 3000, 1000 are directly linked with guidelines, 1500
are linked to guideline topics, and 500 are lone summaries without
links to guidelines. The distribution of linked summaries in different
clinical specialties is presented. Conclusions: Evidence summaries
are most likely to influence clinical decisions, if they are clearly visible
to guideline users. Summaries attached to ‘Related Resources’ and
especially lone summaries are less likely to influence practices. In
this presentation, possibilities to enhance evidence summary impact by
developing their general appearance, visibility and concordance with
guideline texts are discussed with practical examples in a live demo;
and gaps in Cochrane evidence are identified.
No RCT is an island: how often do RCTs cite
relevant existing Cochrane Reviews?
Middleton P, Binnion C, Shute E
The University of Adelaide, Australia
Background: Randomised controlled trials (RCTs) need to place
themselves in the context of other studies, ideally through making
reference to any existing systematic review in completed RCT
publications. Objectives: To assess the extent of RCTs citing
relevant Cochrane Reviews in existence before publication of the RCT
and the nature and purpose of these cites. Methods: All Cochrane
Reviews including > 50 RCTs, updated at least once, as at January
2013 were assessed for trials included since the previous version(s) of
the review. These trials were then checked to see if and how they
had cited the previous review version. Results: Of the 100 Cochrane
Reviews estimated to fulfil the above criteria, results are presently
available for 40 reviews. Just under half (19/40) included at least one
RCT which cited previous versions of the Cochrane Review—median 2
(range 1–28) per review. On a per RCT basis, nearly 77% of eligible
trials (258/334) failed to cite a previous Cochrane Review where an
update of the review now includes that trial. When RCTs did cite a
Cochrane Review, this was generally a statement of review results. Six
trial reports described research gaps and three mentioned that they had
used the Cochrane Review to help design their trial. Full results will be
available for the Colloquium. Conclusions: Most new RCTs included
in updates of Cochrane Reviews should be able to cite the previous
version of the review, yet less than a quarter do so. This may be due
Cochrane Database Syst Rev Suppl 1–212 (2013)
to lack of knowledge that a Cochrane Review exists or a preference for
citing individual RCTs addressing similar questions. Either way, failure
to use a relevant Cochrane Review at design stage may decrease the
risk of the RCT addressing the most pertinent questions.
The publishing characteristics of Cochrane
Reviews for health policy research
Xiu-xia L1 , Jia-hua Z2 , Yao-long C2 , Zong-jiu Z2 , Ke-hu Y2
Evidence-Based Medicine Center, School of Basic Medical Sciences,
Lanzhou University, China; 2 Evidence-Based Medicine Center, School of
Basic Medical Sciences, Lanzhou University, China
Background: With the propagation of the evidence-based health
policy-making, the systematic reviews of health policy research have
become increasingly popular. However, due to the complexity of the
Health Policy Research, they are facing challenges. Objectives: To
describe the publishing characteristics of the Cochrane Reviews of
Health Policy Research. Methods: We searched the Cochrane library
by the topic on ‘Effective practice/health systems’, and retrieved the
Advanced Search as a supplement in March 2013. The search terms
were health, policy and strategy. The EndNote X4 and Excel were used
for data description and analysis. Results: 112 Cochrane Reviews
of health policy research were included out of the 927 identified,
accounting for 1.23% of the total Cochrane Reviews, of which there
were 13 (11.61%) Protocols, 12 (10.71%) New Searches, 5 (4.46%)
Conclusions Changed, 2 (1.79%) Withdrawn, 2 (1.79%) Overview,
and 1 (0.89%) Methodology, Comment and Major Change; there were
7 Reviews included 0 studies, 45 included 1∼10, others included more
than 10. They were published online in 2005 (1, 0.89%), 2006 (1,
0.89%), 2008 (5, 4.46%), 2009 (41, 36.61%), 2010 (17, 15.18%),
2011 (17, 15.18%), 2012 (24, 21.43%) and 2013 (6, 5.36%). They
focused on the Implementation Strategies (84, 75.00%), Financial
Arrangements (17, 15.18%) and Governance Arrangements (11,
9.82%); involved Public Health (41, 36.61%), Theoretical Exploration
(21, 18.75%), Hospital Management (16, 14.29%), Medical Insurance
(14, 12.50%), Pharmaceutical Policy (9, 8.04%), Community Health (9,
8.04%) and Rural Health (2, 1.79%). Conclusions: Although many
Cochrane Reviews of Health Policy Research have been published,
the quantity and quality of the evidence should be improved, we
should pay more attention to the Financial Arrangements and the
Governance Arrangements involved Rural Health, Community Health
and Pharmaceutical Policy and so on.
Analysing the impact factor of the Cochrane
Database of Systematic Reviews (CDSR)
Stewart G
Wiley, United Kingdom
Background: The Impact Factor of the Cochrane Database of
Systematic Reviews (CDSR) is calculated and published as part of
the Journal Citation Reports (JCR) by a commercial company, Thomson
Reuters, each year in June. From 2007 to 2010, the Impact Factor of
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
the CDSR increased by an average of 10% annually. For the first time
in 2011, the CDSR Impact Factor decreased. The CDSR is currently in
the top 10 of the Medicine, General & Internal category of the JCR.
Objectives: To establish the reason(s) why the Impact Factor for the
CDSR decreased in 2011 by analysing the citation data from 2010 to
2011 and the 2012 data when available, and to look for methods
to minimize the risks of this becoming a trend. Methods: Citation
data taken from the ISI Web of Science covering the years 2009–2012
will be analysed using a macro created in Microsoft Excel in order to
identify the factors contributing to an increase or decrease in the CDSR
Impact Factor. Results: Is the CDSR Impact Factor reliant on a small
number of highly cited articles? Has there been a large increase in the
number of citable items published? Are more reviews being published
that are not cited? Which subject areas, individual articles and Review
Groups have contributed most to the Impact Factor of the CDSR?
Conclusions: Conclusions will be drawn from the analysis once the
data is made available from Thomson Reuters in June 2013.
Making Cochrane Reviews more clinically
accessible: Cochrane Clinical Answers
Pettersen K
Cochrane Clinical Answers, UK
Background: Research among clinicians in the USA conducted by
Wiley publisher in 2008 suggested that, although Cochrane systematic
reviews are widely used and highly regarded, there is a need for evidence
translation to make Cochrane Reviews more immediately useful at the
point of care (e.g. before, during and after a patient consultation).
Objectives: To create a user-friendly entry point to the high-quality
evidence from Cochrane Reviews; Cochrane Clinical Answers (CCAs).
Methods: Step 1: Initial subject areas for development decided
in collaboration with Cochrane Review groups and reviews selected
as source material for CCAs based on currency of search date and
clinical utility. Step 2: Editorial team recruited to oversee strategic
development, develop CCA editing protocols, and source appropriate
CCA authors. Step 3: Population, Intervention, Comparison, and
Outcome (PICO) data agreed as core content required to allow the
results of a review to be individualized to the patient and thus be
useful at the point of care. PICOTron data extraction program designed
to automatically extract as much of these data as possible directly
from Cochrane Reviews. Step 4: Additional data required to inform
PICO manually extracted from text of Cochrane Reviews, primarily
using Characteristics of Included Studies tables. Step 5: Practicing
clinicians commissioned and trained to author CCAs and their output
approved by editorial team. Results: Cochrane Clinical Answers
website (http://cochraneclinicalanswers.com/) has been designed and
market tested and to date 100 Clinical Answers based on single
Cochrane Reviews have been published Conclusions: Translating
Cochrane Reviews into bite-sized, quickly digestible Clinical Answers
is challenging but rewarding. A key challenge relates to the lack
of standardized presentation of PICO data within Cochrane Reviews.
Good progress has been made on developing CCAs based on single
Cochrane Reviews and further development will focus on synthesising
the evidence from more than one Cochrane Review.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Cultures of evidence among decision-makers
in non-health fields: systematic review
Lorenc T1 , Tyner E1 , Petticrew M1 , Duffy S2 , Martineau F1 , Phillips G1 ,
Lock K1
London School of Hygiene & Tropical Medicine, UK; 2 Centre for Reviews
and Dissemination, University of York, UK
Background: Many non-health public policy sectors may have
impacts on population health outcomes. Decision-makers’ views
about research evidence are less well understood in these sectors than
in healthcare or public health. Objectives: To systematically review
data on decision-makers’ views about research evidence in non-health
sectors. Methods: Systematic review of qualitative evidence. A
range of database sources were searched. Studies were included
if: they included local policy-makers or practitioners in transport,
housing, urban planning and regeneration, crime and policing, or
licensing; and reported qualitative data on views, beliefs or experiences
regarding research evidence. Study findings were synthesized using
a grounded-theory thematic analysis approach. Results: Sixteen
studies were included. Several factors are reported to impact on
decision-makers’ use of evidence. These include practical issues such
as capacity and organisational factors. However, the relevance and
usefulness of research studies appear to be more important. The
scope of decision-making is often constrained by political feasibility
or acceptability, or by legislation or guidance, which mean that
the use of evidence may not be practicable. Local decision-makers
appear to mainly use evidence tactically to support policy choices,
and are often sceptical about the evidence-based policy agenda.
Discussion: Compared to healthcare or public health, cultures of
evidence in non-health sectors present distinct issues. The findings of
this review indicate the need for a broader perspective on evidence
use, which takes into account the whole decision-making process, and
the interaction of academic research with more informal and situated
forms of knowledge. Linear models of ‘knowledge translation’ may not
capture the complexity of potential relations between knowledge and
practice, and the wide variation in decision-makers’ understandings of
the concept of evidence. The findings call into question the assumption
that increasing the uptake of research evidence is likely to lead to
better decisions.
The limitation of word count in Chinese journals:
a potential impediment for implementing the
CONSORT statement
Zhang Z1 , Wang XH2 , Zhang Q2 , Tian JH1
1 Evidence Based Medicine Center of Lanzhou University, Lanzhou, China;
Tumor Hospital of Gansu Province, Lanzhou, China
Background: Though improvement in recent years, the reporting
quality of randomized controlled trials (RCTs) is still poor in China
according to the CONSORT (Consolidated Standards of Reporting
Trials) statement. Poor reporting quality may make RCTs less credible
in clinical application and lower value in further study. Generally, good
reporting quality needs certain number of article words. The limitation
of word count in Chinese journal may be a possible hindering factor for
the application of the CONSORT statement in China. Objectives: To
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
assess the current situation about limitation of word count in Chinese
journals. Methods: ‘Instructions to Authors’ of Chinese clinical
journals indexed by ‘Chinese Science Citation Database, CSCD’ were
systematically collected in January 2013. The data of word limitation
was extracted by two reviewers independently. The data were analyzed
in Excel 2007. Results: Overall, 219 journals were eligible. In the 219
journals, 57 journals didn’t mention any information about limitation of
word in ‘Instructions to Authors’. And no maximum limitation of words
account was claimed only in 4 journals. Limited to a maximum words
account of 10 000, 8000, 7000, 6000, 5000, 4000, 3000 Chinese
characters were claimed in 3, 10, 2, 33, 76, 30, 4 journals respectively.
4000–6000 words were still the common maximum limitation (63.5%).
And there were only 5 journals which claimed that RCTs should be
reported according to the CONSORT statement (2.3%). Conclusions:
The limitation of word count in RCTs was still widespread in Chinese
clinical journals, and limited to 4000–6000 Chinese characters was
most common. Though there was no unambiguous evidence about
appropriate words for good reporting of RCTs in Chinese, word
limitation may played a hindering factor on the application of the
CONSORT statement in China. The minimum of Chinese characters
count which is sufficient for good reporting is still unproved.
A family of different dissemination products
from one Cochrane Review
Rosenbaum S, Glenton C, Lewin S
Norwegian Knowledge Centre of the Health Services
Background and Objectives: For several years, the Norwegian
Cochrane branch and the Norwegian EPOC satellite have participated
in the development of dissemination products derived from systematic
reviews, aimed at audiences using evidence for different tasks. All
products use the Summary of Findings table as a core starting point.
In this presentation we will demonstrate how the tables and other
elements make up critical building blocks for creating products tailored
to specific and different uses. One parent, many children: The Cochrane
Review on the effect of lay health workers was first published in 2005
and has been updated twice since then. We aimed to increase its impact
by re-representing the results in the following formats: (1) Structured
plain language summary format. In addition to including the summary
in the review, elements from this summary were also reused in parts
of the remaining products. (2) SUPPORT summary format, aimed
at policy makers in low and middle-income countries. This review
summary was made available through several websites, including the
WHO’s Reproductive Health Library, where it was the most downloaded
document of 2012. (3) Video version of the SUPPORT summary. This
was made available on YouTube, and has so far been viewed 7800
times. (4) As part of a SURE policy brief format. This was developed
by Ugandan colleagues in response to a specific request from national
policy makers for evidence on task shifting. (5) As part of the
DECIDE evidence to recommendation frameworks that were developed
to support a WHO Guideline panel. Conclusions: The Summary of
Findings table is the core starting point for all our dissemination work.
Without it, creating a consistent and precise message across different
media and contexts would be an overwhelming task. You can read
more about these formats on www.cochrane.no.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Moving from evidence to implementation for
childhood vaccination communication strategies:
synthesising programme experience from low
income countries
Lewin S1 , Hill S2 , Ames H3 , Bensaude de Castro Freire S4 , Bosch-Capblanch
X5 , Cliff J6 , Glenton C3 , Kaufman J2 , Lin V7 , Muloliwa A8 , Oku A9 , Oyo-Ita
A9 , Rada G10
Norwegian Knowledge Centre for the Health Services and MRC South
Africa, Norway; 2 Centre for Health Communication and Participation,
La Trobe University, Australia; 3 Norwegian Knowledge Centre for the
Health Services, Norway; 4 International Union for Health Promotion and
Education, France; 5 Swiss Tropical and Public Health Institute, Switzerland;
Eduardo Mondlane University, Mozambique; 7 School of Public Health,
La Trobe University, Australia; 8 Ministry of Health of Mozambique,
Mozambique; 9 University of Calabar, Nigeria; 10 Pontificia Universidad
Católica de Chile, Chile
Background: Caregivers’ knowledge and perceptions regarding
vaccination are key determinants of childhood vaccination status,
and communication interventions are therefore important in providing
information. A key challenge for policy makers in low income
countries (LICs) is how best to integrate evidence-based communication
strategies into vaccination programme delivery at scale. To address
this challenge, the ‘Communicate to vaccinate 2’ (COMMVAC 2)
project will develop guidance for policy makers on how to strengthen
vaccine delivery and increase vaccination uptake in LICs through
the integration of evidence-based communication strategies that are
adapted for local conditions. Aim To describe how the ‘Communicate
to vaccinate 2’ (COMMVAC 2) project will improve knowledge
translation for childhood vaccination communication efforts in LICs.
Methods: COMMVAC 2 has two components: firstly, to extend
earlier work on mapping the evidence on communication (see:
www.commvac.com/publications.html) to include mass vaccination
campaigns; and then to develop a taxonomy of these strategies and
a framework for outcomes associated with vaccination communication
interventions. Secondly, we will build an evidence base to guide the
implementation of these strategies. This will involve a systematic review
of factors affecting the successful implementation of communication
interventions at scale and then integrating this evidence with that from
systematic reviews of the effectiveness of vaccination communication
interventions. The synthesized product will be the starting point for
developing a range of best practice options with local applicability issues
factored in, and which can be applied to routine and supplementary
immunization activities. Conclusions: This project will contribute
to improving childhood vaccination coverage in LICs by building the
evidence needed to implement effective vaccination communication
interventions. The systematic reviews will provide a deeper understanding of the range of vaccination communication interventions being
delivered in LICs and the factors associated with their implementation
at scale. The project will also translate this evidence into guidance for
Development of knowledge brokering
intervention model based on a systematic review
Ban J
University of Oxford, UK and Providence Health and Services, USA
Background: Health care policy decisions are often made without
careful consideration of best available research evidence. A knowledge
brokering intervention may be useful in addressing the disconnect
between research evidence and policy decision. Objectives: This
study aims to construct a conceptual model for knowledge brokering
intervention using information obtained by conducting a systematic
review. Methods: Randomized controlled trials evaluating the
effectiveness of knowledge brokering intervention were searched in
MEDLINE, EMBASE and the Cochrane library. Observational and
descriptive studies of knowledge brokering intervention were identified
using MEDLINE, EMBASE, CINAHL, Implementation Science and Google
Scholar. A narrative synthesis was carried out to summarize the
evidence. Results: Two randomized controlled trials (RCT), two
cross-sectional surveys, two case-studies, four qualitative studies and
two mixed methods studies were identified. Based on limited number
of RCTs with poor methodological quality, the knowledge brokering
intervention appears to be effective in improving evidence use in clinical
and policy decision. The methodological quality of observational
and descriptive studies varied widely. Even though the knowledge
brokering intervention was explained with similar theoretical concepts,
there were significant heterogeneities in the description of knowledge
broker’s role.The knowledge brokers tend to; (a) Build network with
decision makers and researchers, and assess their needs, (b) Access,
appraises and summarize relevant research evidence, (c) Adapt the
evidence to local context and advocate the use, (d) Monitor evidence
use and identify new challenges, (e) Summarize priorities of decision
makers and generate research question and (f) Communicate research
needs to researchers. Using these description of knowledge broker’s
role, a conceptual model for knowledge brokering intervention was
constructed (Fig. 1). Conclusions: An intervention using knowledge
brokering intervention appear to be effective in improving evidence
use in health care policy decision. A conceptual model for knowledge
brokering intervention was constructed using information summarized
by conducting a systematic review.
Attachments: Figure 1.pdf
An updated review of the development
of Evidence-based pharmacy: definition, practice
and research
Liang Y, Zhang L, Liu YL, Song J
Department of Pharmacy, West China Second University Hospital, Sichuan
University, China
Background: In 1990s, Evidence-based Medicine (EBM) was introduced into the field of Pharmacy, leading to the emergence of
Evidence-based Pharmacy (EBP). Although, many professionals in
concerned filed are promoting EBP, there was no study focusing on the
concepts and development of EBP. In 2010, we systematically reviewed
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Cochrane Database Syst Rev Suppl 1–212 (2013)
the definition and literatures of EBP and updated this review in 2012.
Objectives: To provide updated evidence on the definition, practice
and research of EBP. Methods: We searched PUBMED, EMBASE, four
local Chinese journal databases and Google with pre-designed search
strategy. We extracted definitions of EBP and other information from
included articles. We compared the existing definitions of EBP on three
domains (who, how and where to practice). We consulted experts in
concerned fields in and outside China to raise a new one if the existing
definitions failed to reach a consensus. We descriptively analyzed
the existing literatures on EBP practice and research. Results: The
current five definitions of EBP varied a lot on three domains and we
raised a new one based on expert consulting and available evidence.
Included articles reported that EBP was practiced in clinical pharmacy,
drug treatment recording, prescription verification and pharmaceutical
management. The current practice model follows the model of EBM.
There are EBP practice training program both in and outside China.
45% of the included articles were published between 2011 and 2012.
57% of the authors are majored in Hospital Pharmacy. Conclusions:
A definition of EBP was raised based on current evidence and expert
consensus. The practice model of EBP follows the model of EBM, and
there is EBP practice training in and outside China. Number of studies
on EBP increased dramatically in recent 2 years. Researchers in EBP
are mainly hospital pharmacists, which is consistent with the previous
Engaging nurses in the work of the Cochrane
Collaboration: a field’s account
Stern C, Pearson A
Cochrane Nursing Care Field, Australia
Background: Getting nurses to access, understand, and use Cochrane
Reviews can be challenging. Developing innovative strategies to
disseminate the findings of reviews may help with this problem and
subsequently assist in improving patient outcomes. Objectives: To
establish a series of activities to increase the use and ease of the
Cochrane Library by nurses involved in delivering care. Methods:
The Cochrane Nursing Care Field (CNCF) has undertaken a number
of activities to engage the nursing community with the Cochrane
Collaboration. The Evidence Transfer Program (ETP) consists of two
components - Review Summaries and Podcasts. Review summaries of
nursing-care-relevant Cochrane Reviews are developed by the CNCFs
membership base and are subsequently published in a range of
international journals. Following the completion of a review summary a
podcast is developed and where possible both resources are translated
into languages other than English. Additionally the CNCF is involved
in identifying and tagging Cochrane Reviews that are of relevance to
nursing care. Results: Since its establishment in 2010 the Field has
seen over 175 summaries published in more than 20 international
journals. Over 25 podcasts are freely available and translations have
commenced in German and Chinese. Review tagging has led to
the development of a classification system that has seen over 500
Cochrane Reviews identified as relevant to the nursing community.
Conclusions: The importance of the Cochrane Collaboration and its
role in providing an evidence base for nursing care is fully supported
by the CNCF. The Field has undertaken a range of activities to assist
with this work which has proven popular.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
The PRISMA evaluate the reporting systematic
reviews and meta-analyses’ abstracts
of cost-effectiveness of pregnancy mortality
Qiu J1 , Zhang S2 , Zhou Y2 , Yao Q3 , Song G3 , Yan B3 , Zhou R3
Maternal, Child and Adolescent Health Care Center, School of Public
Health, Lanzhou University, Lanzhou 730000, China; 2 Maternal and Child
Care Hospital of Gansu Province, Lanzhou 730000, China; 3 School of
Public Health, Lanzhou University, Lanzhou 730000, China
Background: Systematic reviews (SRs)/Meta-Analyses (Mas) of
cost-effectiveness about pregnancy mortality become increasingly
popular, which could provide direct decision basis for managers.
However, not all SRs/Mas reported the important information, and the
SRs/Mas quality is unknown. It is significant to know which information
was ignored by reviewers in structured summary in SRs/Mas of
cost-effectiveness about pregnancy mortality. Objectives: To evaluate
the reporting quality in SRs/Mas’ abstracts on cost-effectiveness about
pregnancy mortality accuracy published. Methods: We searched the
Cochrane Database of Systematic Reviews (CDSR), Web of science
and PubMed, from 2002 to March 2013. Using the following text
and keywords in combination both MeSH terms and text words, the
search strategy was (meta analysis OR meta analyses OR systematic
review* OR over review) AND pregnancy. Details of the relevant
aspects of items as reported in these SRs /MAs were extracted from
the abstract structure. Reporting quality was assessed independently
by two reviewers using the PRISMA for abstract. Results: 49 SRs/MAs
were included, 40 (81.6%) studies stated the backgrounds. 46 (95%)
studies represented research objectives. 39 (79.6%) studies reported
data sources.19 (38.8%) studies provided eligibility criteria. 44
(89.8%) studies reported interventions. 40 (81.6%) studies provided
participants. 23 (46.9%) studies stated the study appraisal and
synthesis methods. 37 (75.5%)studies described results. 19 (38.8%)
mentioned limitations.42 (85.7%)studies provided the conclusions and
25 (51%) implications of key findings. 36 (73.5%) studies reported
systematic review registration numbers. These reviews were reported by
thirteen Countries, and majority from USA 23 (46.9%). Conclusions:
The reporting quality of SRs/MAs of cost-effectiveness was better in
these studies, but authors still should improve reporting quality in field
of ‘provided eligibility criteria’, ‘study appraisal and synthesis methods’
and ‘report limitations’ in the SRs/Mas. All countries should increase
the studies on cost-effectiveness of pregnancy mortality to improve
public health level.
How to explore user experience when
developing communication products
Rosenbaum S
Norwegian Knowledge Centre for the Health Services
Background: Many teams worldwide are developing products for
communicating evidence from systematic reviews for different contexts,
such as shared decision making, clinical support, priority setting,
guideline and policy development, mass media reporting. These
projects can benefit from incorporating methodology from a user
Cochrane Database Syst Rev Suppl 1–212 (2013)
centered design approach, in order to create products that are more
useful and usable for their intended audiences and tasks. Objectives:
In this presentation I will describe some of the principles and pragmatic
considerations for ‘user testing’ - a method of observing and exploring
users’ experiences of a product under development, in order to improve
the design for the end user and their tasks. Presentation: I will cover
the following points: • What is user testing? • Why is it important?
• How can you carry it out? • What are some of the challenges?
• How can it be modified for different products, stages of development
or resource limitation? Getting started with user testing: I will make
available downloadable instructions and materials for user testing.
A novel approach to presenting adverse effect
Results: a case study
Dryden D, Sumamo Schellenberg E, Vandermeer B, Rowe B
University of Alberta Evidence-based Practice Center, Canada
Background: We conducted a systematic review of randomized
controlled trials (RCTs) on the comparative effectiveness and safety
of drugs for acute migraine headache in the emergency department.
Safety is poorly reported and often the same adverse effects (AEs)
are not reported for similar interventions, so traditional pair-wise
meta-analysis of data is not possible. We proposed an alternative
comprehensive safety report for these treatments. Objective: To
describe a novel approach to presenting AE results in the absence
of traditional pair-wise meta-analyses. Methods: A priori AEs were
grouped into categories (e.g., vomiting, sedation). After mapping the
interventions and AE categories, a traditional pair-wise meta-analysis
was not possible. Therefore, we analyzed AEs for individual arms of
trials. When an intervention had more than one study reporting on any
AE, the results were pooled using a standard inverse variance random
effects meta-analysis. The risks (i.e., incidence) for each AE category
are presented as a summary estimate and 95% confidence interval.
Results: From a comprehensive search, 39 RCTs investigating 9 drug
classes reported specific AEs. Summary tables present the risk of each
AE category for specific active agents and placebo. Graphs for each
AE category were created using Excel. The horizontal axis shows the
active agents or placebo that resulted in an AE; the vertical axis shows
the risk of an AE associated with each agent. Specific examples of
tables and graphs for AE categories will be presented. Conclusion:
A traditional pair-wise meta-analysis of AEs was not possible since
multiple RCTs testing the same drugs failed to report common AEs.
Instead, we present a summary of AEs by treatment arm that provides
an overall picture of which interventions had a high risk of specific AEs.
‘Discussion sections’: are we ignoring valuable
insights into intervention effectiveness?
Campbell F, Blank L, Messina J, Day M, Buckley-Woods H, Nick P,
Elizabeth G
University of Sheffield, UK
Background: Synthesizing the evidence for the effectiveness of
complex interventions requires an understanding of contextual factors
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
that influence; why, when, for whom and in what circumstances
interventions may or may not work. Various methodological
developments are evolving to enable a greater understanding of the
mechanisms that influence intervention effectiveness, such as inclusion
of qualitative evidence and realist synthesis approaches. This study
sought to explore the value of a qualitative assessment of the discussion
section in the included RCTs in a review. Frequently this section allows
the authors to describe why the results of the study were or were
not as expected, yet it’s frequently overlooked in data extraction.
Objectives: To compare the insights from discussion sections of
included RCT’s with the results of a synthesis of qualitative research
studies. Methods: We undertook a review of brief interventions to
promote physical activity. To understand the barriers and facilitators
of such interventions we conducted a synthesis of qualitative studies
alongside a synthesis of RCTs. We also conducted a qualitative analysis
of the discussion sections of the RCTs to see if they also identified
barriers and facilitators and how these compared to the findings of
the qualitative studies. Results and Conclusion: The value of the
discussion sections was they were reliable in terms of being directly
relevant to the studies on which they were commenting. Qualitative
studies may have been conducted indifferent cultural contexts and
findings maybe inappropriately used to interpret findings of RCTs.
There were some themes that occurred in both the discussion sections
and in the analysis of qualitative studies. However, the perspectives
of participants were rarely given voice in discussion sections of RCTs.
Nonetheless, discussion section provide useful insights that can inform
understanding of why certain results were obtained.
Patient-important outcomes reported in
randomized clinical trials (RCTs) of
neuromuscular electrical stimulation (NMES) in
mechanically ventilated patients: a systematic
methodologic review
Kho ME1 , Duffett MC2 , Koo KK3 , Dodek P4 , Herridge MS5 , Lamontagne
F6 , Needham DM7 , Cook DJ8
School of Rehabilitation Science, McMaster University, Canada;
Department of Physical Medicine and Rehabilitation, Johns Hopkins
University, USA; 2 Clinical Epidemiology and Biostatistics, McMaster
University, Canada; 3 Department of Medicine and Division of Critical Care,
University of Western Ontario, Canada; 4 Center for Health Evaluation and
Outcome Sciences, St. Paul’s Hospital and University of British Columbia,
Canada; 5 Interdepartmental Division of Critical Care Medicine, University
of Toronto, Canada; 6 Centre de Recherche Clinique Étienne-Le Bel,
Université de Sherbrooke, Sherbrooke, Canada; 7 Division of Pulmonary &
Critical Care Medicine, Department of Physical Medicine and Rehabilitation,
Johns Hopkins University, USA; 8 Medicine and Clinical Epidemiology and
Biostatistics, McMaster University, Canada
Background: NMES is an emerging rehabilitation therapy to prevent or
reduce intensive-care unit acquired weakness. Objectives: To contrast
the outcomes reported in RCTs of NMES in mechanically ventilated
patients against authors’ interpretations of NMES effectiveness and its
role in clinical practice. Methods: We searched MEDLINE, EMBASE,
LILACS, CINAHL, SCOPUS, and Web of Science for RCTs of NMES
in mechanically ventilated patients. Independently, in duplicate we
Cochrane Database Syst Rev Suppl 1–212 (2013)
identified studies and abstracted descriptive data. We classified
outcomes according to the International Classification of Function:
body structure (e.g., protein turnover, muscle size), body function (e.g.,
muscle strength), activity (e.g., walking), and participation (e.g., return
to work). We also identified safety and feasibility outcomes and the
authors’ interpretations about NMES effectiveness and its role in clinical
practice through textual assessment of study conclusions. Results:
Of 428 citations, we identified 13 unique RCTs; 5 of these were
pilot trials. Seven studies randomized patients by treatment group, 4
randomized by body side, and 2 were crossover studies. The median
[minimum, maximum] numbers of patients enrolled and evaluated per
study were 19 [7, 142] and 15 [7, 52], respectively. Authors reported
33 different outcomes (Table 1), with a median [interquartile range] of
5 [3, 6] per study. Most studies reported measures of body structure
(n = 11) or function (n = 7); only 2 reported activity, and none
reported participation. Authors reported safety, feasibility, and other
outcomes in only 6, 5, and 5 studies, respectively. Most authors [10
(78%)] concluded that NMES was an effective intervention and half [7
(54%)] suggested that NMES could be used in clinical practice. Of all
favorable conclusions regarding effectiveness or usefulness in clinical
practice, only 2 studies reported measures of activity. Conclusions:
There are at least 13 RCTs of NMES in critical care, but these studies
are small and include few patient-important outcomes. To inform
clinical practice, more studies reporting patient-important outcomes
are needed.
Attachments: Table (Apr-03-2013).pdf
Are claims of interventional benefit in clinical
trial abstract conclusions justifiable? A case
report of pharmacological and complementary
therapies for chronic asthma
Toone R1 , Sinha I2
Department, Royal Manchester Children’s Hospital, UK;
Respiratory Unit, Alder Hey Children’s Hospital, Liverpool, UK
1 Respiratory
Background: Conclusions in abstracts of randomised controlled trials
(RCTs) should accurately reflect study results, as people may only read
this section of the report. Authors sometimes use strategies (‘spin’)
to suggest therapies are beneficial, even if results suggest otherwise.
We examined how often, when abstracts of RCTs of interventions for
asthma suggest an intervention has benefit, this claim is justifiable.
To suggest interventional benefit, we felt studies must recruit the
pre-specified sample size, and demonstrate statistically significant
between-group differences for the primary outcome (p < 0.05).
Methods: Studies were identified from Cochrane Reviews of chronic
asthma therapies. We included RCTs, of pharmacological and
non-pharmacological/complementary interventions, in which the
abstract conclusion suggested interventional benefit. The abstract
conclusion of each RCT was categorised: (1) suggesting benefit
without uncertainty; (2) suggesting benefit with uncertainty (eg
more studies required); (3) not suggesting benefit. We identified
whether the trial report presented a required sample size, primary
outcome, and between-group comparison for this. For abstracts
suggesting benefit without uncertainty, we evaluated whether the
claim was (1) justified (sufficient participants, and primary outcome
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
between-group comparison p < 0.05); (2) unjustified (not all criteria
met); (3) non-evaluable (insufficient information). As an exploratory
evaluation of ‘spin’, we evaluated how often, when abstract conclusions
suggest benefit with uncertainty, this claim appeared based on
secondary outcome/within-group comparisons. Results: Of 153
abstracts screened, 42 full RCT reports were evaluated. 26/42
abstracts suggested benefit with no uncertainty. This was justified in
11/26, unjustified in 3/26, and non-evaluable in 12/26. 16/42 abstracts
suggested benefit with uncertainty. In 11/16, the suggested benefit was
felt to be based on secondary outcome/within-group comparisons (ie
‘spin’). Non-evaluable claims of benefit, and ‘spin’, were particularly
common in RCTs of non-pharmacological/complementary therapies.
Conclusion: When abstracts of RCT reports suggest benefit of
experimental treatment, the full report frequently includes insufficient
information to justify this claim. Spin is commonplace in RCT abstracts.
Cross-over trials—are they doing it right? Are
we doing it right?
Dwan K
The University of Liverpool, UK
Background: Previous work by Elbourne et al. (2002) indicated that
the description in the methods section of systematic reviews regarding
how cross-over trial data were to be included was insufficient and
recommendations were made for improvement. Recent work found
that reports of cross-over trials often omit important methodological
issues in design, presentation and analysis. Objectives: To assess
review methodology for including cross-over trials in reviews published
by the Cochrane Cystic Fibrosis and Genetic Disorder (CFGD) Group and
to investigate whether there has been an improvement compared to
the Elbourne results published over 10 years ago. To assess the quality
of reporting of cross-over trials within the trial reports themselves and
subsequently, within Cochrane Reviews. To determine whether MECIR
conduct and reporting standards for cross-over trials are adhered
to. Methods: CFGD reviews (published to September 2012) were
accessed. Reviews which did not include cross-over trials were excluded.
The methods sections of reviews were checked to identify how review
authors planned to manage cross-over trial data. Cross-over trial
reports were accessed and the quality of the reporting of the results
assessed and compared to the data included in the review by review
authors. Results: There were 104 published CFGD reviews, 82 (79%)
included or planned to include cross-over trials; 39% of trials actually
included were cross-over. However, 48% of reviews made no statement
in their methods regarding including cross-over trials, or only referred to
the work by Elbourne with no further details. Full results regarding the
quality of reporting within the trial reports and how results were actually
included in the reviews will be presented. Conclusions: Guidelines
are needed for reporting of cross-over trials. Review authors and
groups should be more aware of the inclusion of cross-over trials within
reviews and ensure the methodology is correct and data are included
Cochrane Database Syst Rev Suppl 1–212 (2013)
Using bivariate meta-analysis and
meta-regression to investigate the effects
of exercise on pain and disability in osteoarthritis
Uthman O1 , van der Windt D2 , Jordan J2 , Dziedzic K3 , Healey E2 , Jordan
K2 , Foster N2
1 University of Warwick, UK; 2 Keele University, UK; 3 Keele University, UK
Background: Previous reviews have documented that exercise
interventions are more effective than no exercise control for osteoarthritis (OA) however effect estimates vary widely. Objectives: To
estimate effectiveness of exercise interventions and explore trial-level
characteristics that may be associated with effect size estimates of
exercise for OA. Methods: Pain and functional limitations are both
key outcomes in OA. Bivariate random effects meta-analysis was used
to simultaneously synthesize effects on pain and function, taking the
correlation between the two outcomes into account. We calculated
95% prediction intervals which incorporate between-study variability.
A series of unadjusted bivariate meta-regression analyses was carried
out to investigate the impact of trial-level characteristics on treatment
effect size estimates. Results: A total of 43 trials involving 4466
patients met the inclusion criteria. The results of the bivariate
meta-analysis showed that exercise interventions significantly reduced
pain ( = −1.35 cm; 95% CI −1.75 to −0.95 cm, 10 cm visual
analogue scale) and improved function (1.03 units; 95% CI −1.60
to −0.80 units, WOMAC disability scale from 0 to 10). There was
statistically significant strong correlation (0.740, p < 0.001) between
pain relief and improvement in function. The prediction intervals
suggest that exercise interventions applied at population level may not
always be beneficial in all settings, about 15% future trials are likely
to show exercise not to be effective for pain and function. Exercise
tended to be more effective among younger adults; in hospital-based
settings, and when supervised and standardized. Trials with low risk of
bias showed less promising results. Conclusions: This review provides
insight into some of the sources of variability in effect estimates of
exercise interventions for OA. In this bivariate meta-analysis, effect
estimates for pain and function were pooled simultaneously in a single
analysis in order to reduce reporting bias due to outcome measures
‘borrowing strength’ from each other.
Measurement harmonization in
individual-participant-data meta-analysis
Galindo-Garre F1 , Hidalgo MD2
1 VU University Medical Center, The Netherlands; 2 University of Murcia,
Background: Our project stands to advance measurement harmonization a great deal by carefully developing statistical methods to
support the practice of individual participant data meta-analysis. Some
statistical harmonization approaches have been already developed to
integrate different measures but there is not a compromised solution
in a meta-analytic context with complex health behavior constructs.
Objectives: To review the methodological approaches to combine
different measures of the same construct, and, finally, compare one of
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
the most common ones, standardization with a moderated nonlinear
factor analysis (MNLFA). Statistical performance of each one will be
evaluated under different circumstances to, and finally, apply to a
real dataset. Methods: For this study we review the statistical
harmonization techniques that have been used in the literature and
we compared simple standardization to a method can be applied
to the dichotomous, ordinal, and sometimes continuous measures,
MNLFA. We used Monte Carlo simulations and real archival data
from seven HIV prevention intervention trials. Different measurement
scales and distributions were created using parameters and scales
derivate from the real HIV prevention interventions individual data.
In order to evaluate the robustness of the measurement scales
under different conditions the percentage bias of the estimate was
calculated as well as the efficiency as the variability of the estimate
across replications. Results: The MNLFA was more efficient and
unbiased in most of the circumstances and it did not make a
difference from a simple standardization when the measures were
all continuous and normal regardless the sample sizes and the number
of studies. Conclusions: The moderate nonlinear factor analysis
is more generalizable harmonization technique when individual data
needs to be integrated than just standardizing the metrics. The
most important limitations are that requires at least some items
to overlap within studies and the data needs to be independent
within study.
Challenges in conducting a systematic review
of predictors and moderators of outcome: an
example in psychological therapies for OCD
Knopp J1 , Knowles S1 , Bee P2 , Lovell K2 , Bower P1
NIHR School for Primary Care Research, Centre for Primary Care,
Manchester Academic Health Science Centre, The University of Manchester,
UK; 2 School of Nursing, Midwifery, and Social Work, The University of
Manchester, UK
Background: Psychological interventions play an increasingly
significant role in treating mental and physical health problems.
However, treatment effectiveness varies across conditions and
individuals. The systematic assessment of predictors and moderators
of outcome in trials has the potential to help understand this
variability and provide treatments focussed on the needs of individual
patients. Objectives: We sought to synthesize current evidence on
predictors and moderators in psychological therapies for adults with
Obsessive-Compulsive Disorder (OCD). Methods: Relevant trials of
any language were identified through electronic database searches
(CENTRAL, MEDLINE, PsycINFO and EMBASE), key author contact and
searches of systematic reviews. We assessed quality of predictor and
moderator analyses using published criteria - predictors measured via a
validated pre-randomization measure, < 5 predictors assessed, using
a test of interaction, and a-priori hypotheses of anticipated predictor
effects. Results: 55% (38/69) of trials reported baseline factors
associated with outcome. Predictors were commonly assessed via
a validated pre-randomization measure, though few trials adopted
existing guidelines by stating a-priori hypotheses or conducting the
appropriate test of interaction. Inadequate data reporting prevented
the use of meta-analytic procedures; the analysis was restricted to a
Cochrane Database Syst Rev Suppl 1–212 (2013)
variant of the box-score. None of the common predictors showed a
consistent association with outcome. Commonly reported variables,
showing a lack of association comprised medication use, age of onset,
OCD-related beliefs, and educational level. Conclusions: Whilst
analyses of predictors and moderators are common, their utility is
limited by methodological weaknesses. Advances in this field require
the implementation of existing guidelines and full reporting of the
planning and conduct of predictor analyses; explicitly, the use of gold
standard statistical procedures in assessing moderators, the reporting
of a-priori hypotheses of anticipated predictor effects, and increased
consideration of statistical power in predictor analyses.
Statistical simulation to assess results
of meta-analyses using post-intervention,
change from baseline and mixed methods
Silva V, Grande AJ, Porfı́rio GJM, Puga MES, Martimbianco ALC, Torres
MFS, Costa MB, Carvalho MR, Fioretti BTDS, Costa CS, Peccin MS, Riera
R, Torloni MR, Atallah Á
Brazilian Cochrane Centre, BR
Background: Meta-analyses of continuous outcomes can be
performed by post-intervention, changes from baseline and also by
a mixture of these methods (Fig. 1a). General recommendations
are available in the Cochrane Handbook for Systematic Reviews of
Interventions in chapters 7 (Section, 9 (Section
and 16 (Section, however, the impact of the choice of a
methods has not been assessed. Objective: To assess the impact in
estimated effect (effect size and confidence interval) in meta-analyses
performed by post-intervention, change from baseline and by a mixture
of these methods. Methods: We produced 20 theoretical randomized
controlled trials (RCT) (10 small-trials and 10 mega-trials) through
statistical simulation using Software R (version 2.15.3) (Fig. 1b). The
function was developed based in a random number generation for
the normal distribution. Continuous outcome data were produced;
mean and standard deviation were calculated for the experimental
and control groups of the post-intervention and change from baseline
from each RCT. The theoretical RCTs analyzed by post-intervention
and change from baseline were randomized for mixture of methods.
Random-effects meta-analyses of mean difference and standardized
mean difference were performed, followed by the 95% confidence
interval, using the inverse-variance method. Sensitivity analyses were
conducted. Results: Differences in the effect sizes ranged from 0.10
to 9.01 and differences in the width of the confidence intervals ranged
from 1.16 to 18.04 (Fig. 2 and Table 1). Conclusions: Despite
the lack of significant differences in this statistical simulation, there
were changes in the effect sizes and confidence intervals indicating
that meta-analyses using post-intervention, change from baseline and
mixture of methods can produce different conclusions especially if the
effect estimated is close to accepting or rejecting the null hypothesis.
Sensitivity analyses are recommended when the methods were mixed.
Attachments: Silva V, et al. Statistical simulation to assess results of
meta-analyses using post-intervention, change from baseline and
mixed methods.pdf
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Which journals have cited Cochrane Systematic
Sun X, Ma JC, Zhao Y, Tian JH
Evidence Based Medicine Center, School of Basic Medical Sciences of
Lanzhou University, China
Background: Cochrane systematic reviews (CSRs) are systematic
reviews of primary research in human health care and health policy, and
are internationally recognized as the highest standard in evidence-based
health care. Objectives: To investigate which journals have cited
CSRs and articles in which groups are more likely to be cited by other
journals. Methods: All CSRs published in the Web of Science from
inception to December 2012 were retrieved and information extracted
about the published year, group, the citation frequency of each CSR,
journals citing CSRs. Two reviewers independently performed data
extraction. Results: Of 5647 CSRs from database searching, 3874
CSRs were cited in other articles. Until December 2012, each CSR
published in 2007 has been cited 16.94 times on average, followed by
CSR published in 2006 (15.67 times), 2008(14.98 times) and others
were shown on Table 1. A CSR published in 2006 has been cited as
much as 320 times.Table 2 showed that of 1794 journals which have
cited CSRs, Cochrane database of systematic reviews (CDSR) has cited
793 (11.7%) CSRs, followed by American family physician 93 (1.37%),
Plos one 89 (1.31%), European journal of physical and rehabilitation
medicine 83 (1.22%) and Pediatrics 58(0.86%).4 journals has cited
51–100 CSRs, 21 journals has cited 21–50 CSRs, 103 journals has
cited 11–20 CSRs, 180 journals has cited 6–10 CSRs and 843 journals
has cited only one CSR.Table 3 showed that every CSR in Methodology
Review Groupp has been cited 17 times on average, followed by
Consumers and Communication Group (7.58), Back Group (7.38),
Tobacco Addiction Group (6.76), Drugs and Alcohol Group (6.65).
Conclusions: This survey showed that except for CDSRs, CSRs also
have been widely cited by other journals. But the citation of different
groups was imbalanced. Therefore, efficient measures should be taken
by some groups to improve the quality of CSRs, so as to provide
evidence for more articles.
Attachments: Table 1 the number of articles citing CSRs from 2005
to 2012.pdf, Table 2 the citation frequency of CSRs in different journals from 2010 to 2012.pdf, Table 3 average citation frequency of CSRs
in different groups from 2010 to 2012 fy.pdf
Which is more generalizable, powerful
and interpretable in meta-analyses, mean
difference (MD) or standardized mean difference
Takeshima N1 , Furukawa TA1 , Sozu T2 , Tajika A1 , Ogawa Y1 , Hayasaka Y1
1 Department of Health Promotion and Human Behavior, Kyoto University,
Japan; 2 Department of Biostatistics, Kyoto University, Japan
Background: When the outcome is continuous, the effect size is
commonly represented either as a mean difference (MD) or as a
standardized mean difference (SMD). When the outcome is measured
Cochrane Database Syst Rev Suppl 1–212 (2013)
in different units across trials in the meta-analyses, we have no other
choice than to use SMD to combine the outcomes. When the outcome
is measured in the same unit in every trial, we can use either MD or
SMD. In this latter case, there appears currently to be no agreement
about which effect size to prefer. Few quantitative assessments
have been conducted with regard to their relative generalizability and
statistically power. Objectives: To empirically examine which index
is more generalizable and statistically powerful in meta-analyses when
the same unit is used. Methods: From the Cochrane Database, we
included all the meta-analyses in which the continuous outcome was
contributed by at least 3 trials. We examined percentage agreement,
I-squared statistics and z-scores of MD and SMD in fixed-effect and
random-effects models. Generalizability was assessed as percentage
agreement, when one study was taken from each meta-analysis
and MD and SMD of that individual trial was compared with the
meta-analytically pooled MD and the SMD of the remaining trials. The
agreement was defined when the point estimate of MD or SMD of
the individual trial is included within the 95% confidence interval of
the pooled MD or SMD of the remaining trials. This procedure was
repeated for all the trials, and the overall percentage agreement was
calculated. I-squared statistics, which index heterogeneity among the
combined trials, relate to the generalizability, and z-scores represent
the statistically power. Results: We are currently conducting the
analysis. We will present the results at the colloquium.
The feasibility and reliability of using restricted
mean survival time in aggregate data
meta-analysis of time-to-event outcomes
Wei Y, Royston P, Tierney J, Parmar M
MRC Clinical Trials Unit Hub for Trials Methodology Research, MRC Clinical
Trials Unit, UK
Background: Meta-analyses of time-to-event trial outcomes
commonly use the hazard ratio (HR) as the treatment effect measure.
For aggregate data reviews, this relies on extracting or estimating
HR from published analyses. Use of the HR implicitly assumes
proportional hazards (PH), which may be violated for some or all trials
in a meta-analysis. An alternative treatment effect measure is the
between-arm difference in the restricted mean survival time (RMST).
For a given arm, the RMST is the expected time-to-event up to t* and
may be estimated as the integrated survival function S(t), RMST =
integral 0’t* (S(t)) dt , where t* must be chosen by the analyst. The
RMST relaxes the need for PH assumption and allows treatment effect
to vary with time. However, the RMST analysis relies on having IPD
or reconstructing survival data from published curves. Objectives &
Methods: We aim to assess the feasibility and reliability of estimating
the restricted mean survival time for aggregate data meta-analysis of
randomized trials. We compare the non-PH test results and estimates of
the RMST differences from the individual participant data (IPD), survival
curves reconstructed from this IPD, and from published survival curves.
Results: Based on a meta-analysis of neo-adjuvant chemotherapy for
invasive bladder cancer (6 trials), testing of the non-PH assumption,
the estimated HR and difference in RMST are similar for IPD and curves
reconstructed from it. However, the ability to use published survival
curves to assess non-PH and estimation of the RMST was limited to
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
3 trials. Conclusions: Reconstructed survival curves enable non-PH
testing and good approximations of the difference in RMST, offering
an alternative to the HR for meta-analysis of time-to-event outcomes.
Better approximations could be achieved if good quality Kaplan Meier
curves, including the number of participants at risks were regularly
Comparison between Autocad and Draftsight
in data extraction
Li Z1 , Mi D2 , Yang KH1 , Cao N3 , Tian JH1 , Ma B1 , Liu Y1
Evidence Based Medicine Center of Lanzhou University, China; 2 First
Clinical Medicine College of Lanzhou University, China; 3 Second People’s
Hospital of Gansu Province, China
Background: None included studies in Systematic reviews can be lost
to perform meta-analysis. We can use autocad and draftsight software
to gain the data we needed when published figures as the only source
of outcome data. Draftsight is more convenient for using to extract data
than autocad. However, is it accurate and reliable enough performing
draftsight for data extraction? Objectives: To analyze and compare
the precision of autocad and draftsight software for data extraction
from figures by performing meta-analysis. Methods: We prepared ten
figures together with original data from published papers, which would
be used for the precision test. Mean, 95% confidence interval (CI)
and standard deviations (SD) were used as statistical parameters from
figures to elevate the data extraction. Autocad and draftsight were
performed by different researchers, and data analysis was implemented
by the third researchers, which were designed with blind method to
avoid bias. Differences in data extraction between researchers with the
same software were previously compared and adjusted. Meta-analyses
were performed to compare precision between the two software,
using original data from papers and the data extracted with autocad
and draftsight. Results: We gained the data exactly from figures
using the software. As result of the meta-analysis, there was no
statistically significant difference of precision between autocad and
draftsight software for data extraction; and both of them showed
their satisfactory precision. Conclusions: There is no difference of
accuracy between the two software; however, draftsight is small and
exquisite in the practicality, which is more convenient than autocad.
So we would prefer to recommend draftsight in general. With the
draftsight software, we can always get the data exactly when papers
were published with figures as the only source of outcome data. Then
we can perform meta-analysis without data lost of included studies.
Why 196 Cochrane Systematic Reviews were
withdrawn in Cochrane Database of systematic
Ma JC, Sun X, Zhao Y, Tian JH
Evidence Based Medicine Center, School of Basic Medical Sciences of
Lanzhou University, China
Background: Cochrane Systematic Review (CSRs) is the leading
resources of the medical care systematic evaluation.The number of
CSRs published has increased steadily over the past decade, at the same
Cochrane Database Syst Rev Suppl 1–212 (2013)
time, the number of withdrawal CSRs has also increased too. What
led to the CSRs withdrawan from Cochrane Database of Systematic
Review? Objectives: To access the reasons of withdrawn of CSRs,
so as to search countermeasures to reduce quantities of withdrawn
reviews and improve the quality of CSRs. Methods: An electronic
literature search of all CSRs from inception to December 2012 was
conducted using the Cochrane Library, with clicking the following search
terms ‘By Review Group’. Two reviewers independently determined
CSRs eligibility and extracted the withdrawal reviews information and
search details. Disagreements were resolved by the third author.
Results: 196 studies were included, which account for 2.74% of the
whole CSRs (7143) ;The CSRs are composed of 53 review groups,
of which 6 groups have more than 6 withdrawn reviews, 12 groups
have 3–5 withdrawn reviews; 15 groups have 1 to 2 withdrawn
reviews, and 18 groups have no withdrawn reviews. Table 1 shows
that the largest proportion of withdrawn reviews group is: Prostatic
Diseases and Urologic Cancers Group (8.89%); followed by Menstrual
Disorders and Subfertility Group (8.84%), Pregnancy and Childbirth
Group (8.45).There were seven reasons for withdrawn, 43.88% of
the withdrawn CSRs were out-of-dated reviews, and 29.08% of the
withdrawn CSRs were updated by other CSRs (Table 2). Conclusions:
This survey showed that the whole reasons of withdrawn of CSRs.
The main reason for the withdrawn is because the reviews were
out-of-dated, and some of CSRs were withdrawn owing to the absence
of abstract or detection of errors, which can be avoided by frequent
update and strict check. Therefore, efficient measures should be taken
to reduce the portion of withdrawn reviews.
during conducting the review. Other supplementary tables could be
summarized in the Results section. ‘Components of the herbal medicine
in relevant trials’ (Fig. 5) summarize the prescription with dosage and
using method by studies. ‘Summary of point selection in included trials’
(Fig. 6) presents the name and frequency of the points for specific
disease. ‘STRICTA checklist for included trials’ (Fig. 7), or ‘checklist of
elaborated CONSORT statement for trials with herbal interventions’,
helps to evaluate the reporting quality of trials. Furthermore, table of
‘adverse events’ (Fig. 8) is needed to reveal the potential side-effect
of HM or acupuncture and the comparison result of occurrence rate of
adverse events between groups.
Attachments: Fig.1 Searching strategy and result.jpg, Fig.2 Literature screening form.jpg, Fig.3 Contact information with the authors.
jpg, Fig.4 Data extraction form.jpg, Fig.5 Components of the herbal me
dicine in relevant trials.jpg, Fig.6 Summary of point selection in included trials.jpg, Fig.7 STRICTA checklist for included trials.jpg, Fig.8 Adverse events.jpg
A hybrid approach for automating citation
screening process
Zhang D, Lei J, Robinson KA
Johns Hopkins School of Medicine, USA
Attachments: Table1 List of withdrawal CSRs in review group.pdf,
Table2 List of main reasons for withdrawal CSRs.pdf
Supplementary tables for systematic reviews
of herbal medicine or acupuncture
Cao H1 , Li XL1 , Klupp N2 , Liu J1
Beijing University of Chinese Medicine, China; 2 University of Western
Sydney, Australia
Background: In a systematic review, tables play an important part
to clearly and intensively present the essential information of the
included studies. The commonly used tables are known to show
‘characteristics of included/excluded trials’, ‘risk of bias assessment’,
and ‘summary of finding’. However, during the study, more tables
might be generated and they would be a valuable media to record and
reveal the study process. It would be meaning to explore supplementary
tables to present details of the characteristics or quality-related items
for specific intervention, especially for the interventions with more
variability such as herbal medicine (HM) or acupuncture. Objective:
To introduce some useful supplementary tables for systematic reviews of
HM or acupuncture for the usage during the literature searching, trials
selection, data extraction or results presenting process. Description:
There are some tables help efficiently record the process of the review
but may be hardly presented in the text, such as ‘searching strategy
and result’ (Fig. 1) for each literature source, ‘screening form’ (Fig. 2),
‘contact information with the authors’ (Fig. 3), and ‘data extraction
form’ (Fig. 4). Recording and presenting this additional information
encourage review authors to perfect the details, and improve the quality
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: Building a classification method to facilitate screening of
search results is an explicit way to enable more efficiency in systematic
review process. We propose to use a hybrid approach to optimize the
collection of features used to characterize the citations (feature space)
by combining Independent Component Analysis (ICA) and Sequential
Forward Floating Search (SFFS), and by using Support Vector Machine
(SVM), Perceptron voting (VP), and BayesNet (BN) for both comparison
and achieving the best outcome as possible. Objectives: To optimize
the feature space by utilizing ICA and SFFS, as well as through the
comparison and adjusting the results from SVM, VP and BN. Methods:
We used the search results and listings of eligible studies from three
systematic reviews: First, we built three feature spaces: (i) MeSH terms
(ii) title keywords (iii) keywords from abstracts. We used ICA to extract
500 ‘relevant’ feature types from 5000+ types among these three
spaces mentioned above for three projects; Further we used modified
SFFS method to select ‘most relevant’ feature type for individual
project, through machine training/test with SVM, BN, and VP; Then
we used SVM, VP and BN for classifying the citation collections. For
comparison purpose, we also run the process without ICA process,
and without both ICA/SFFS process. Results: The preliminary result
shown the sensitivity has increased to 90.23%, 84.67% and 88.02%
for each projects from 55.02%, 58.4%, and 53.21% after ICA/SPSS
optimization. The specificity rates are from 56.32%, 67.34%, and
84.34% to 77.98%, 80.04% and 83.74% after ICA/SFFS optimization.
High sensitivity means we do good job including ‘right’ documents;
High specificity means we do good job excluding ‘wrong’ documents
so we don’t waste time. Conclusions: The preliminary results shown
that optimizing the feature space is an important route to improve
classification. With improvement, we could achieve 100% sensitivity
while still maintain high specificity.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Underreporting of conflicts of interest among
authors of clinical drug trials: cross sectional
Rasmussen K, Schroll JB, Gøtzsche PC, Lundh A
The Nordic Cochrane Centre, Denmark
Background: Conflicts of interest (COI) may influence how the benefits
and harms of treatments are interpreted. Knowledge about individual
author COI is therefore important when reading an article. However,
some COI may be undisclosed by authors. Objectives: To determine
the prevalence of conflicts of interest among non-industry employed
Danish physicians who are authors of clinical trials and determine
the number of undisclosed conflicts of interest in trial publications.
Methods: We searched EMBASE for articles with at least one Danish
author. Two assessors included the 100 most recent articles of drug
trials published in international journals that adhere to the ICMJE’s
manuscript guidelines. For each article, two assessors independently
extracted data on trial characteristics and author COI. We determined
the prevalence and type of disclosed COI among non-industry employed
Danish physician authors. We compared the COI reported in the articles
to those reported on the publicly available Danish Health and Medicines
Authority’s disclosure list in order to identify undisclosed COI. Results:
A pilot study of ten articles included seven with industry sponsorship,
one with mixed sponsorship and two with non-industry sponsorship.
Twenty-eight (26%) out of 107 authors were non-industry employed
Danish physicians. Eleven out of 28 authors disclosed one or more
COI in the journal. We found that among the 28 authors 7 had
undisclosed COI related to the trial sponsor or manufacturer of the
drug being studied. Nine of the 28 authors had undisclosed COI related
to competing companies manufacturing drugs for the same indication
as the trial drug. Full data analysis of all 100 trials and further
exploration of data will be presented at the conference. Conclusions:
Our preliminary results suggest that there is substantial underreporting
of COI in clinical trials. Publicly available disclosure lists may assists
journal editors in ensuring that all COI are disclosed.
Publication bias in randomised trials
of duloxetine for the treatment of major
depressive disorder
Maund E, Tendal B, Hróbjartsson A, Jørgensen KJ, Lundh A, Schroll JB,
Gøtzsche PC
The Nordic Cochrane Centre
Background: In order to reduce publication bias, researchers have
called for many years for clinical study reports submitted in licensing
applications to the regulatory authorities to be made publicly available.
In 2010 an important precedent was set when the European Medicines
Agency (EMA) granted researchers at The Nordic Cochrane Centre
access to full clinical study reports and corresponding protocols.
Objectives: To assess and compare selective reporting in full clinical
study reports and published articles in a cohort of RCTs submitted
to the EMA for marketing approval. Methods: Unredacted clinical
study reports and the corresponding protocols, approximately 13 500
pages, for all nine placebo controlled trials used in the regulatory
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
submission for duloxetine for the treatment of major depressive
disorder were obtained from the EMA in May 2011. Published
articles, including pooled analyses, were identified through searching
relevant literature databases; contacting the manufacturer; and through
reference checking. Data of interest were: primary outcome (including
type of analysis, and analysis population), and harms (deaths, serious
adverse events, drug related serious adverse events, suicides, attempted
suicides, number of discontinuations due to adverse events, and total
number of adverse events). Relevant data were extracted from protocols
and clinical study reports by one set of independent observers, and
from published articles by a second set of observers. These data
were then compared. Results: No major discrepancies were identified
between protocols and clinical study reports. Sixty published articles
were identified. There was evidence of both publication bias and
selective reporting. Harms, in particularly serious adverse events and
discontinuation emergent adverse events, were poorly reported in
published articles (see Table 1). Conclusions: Whilst there was no
evidence of selective reporting in clinical study reports, there was
evidence of publication bias and selective reporting in publications.
Clinical study reports contained important data on harms that were not
available in publications.
Attachments: Table 1 revised Emma Maund Abstract Cochrane Colloquium .pdf
Publication bias in clinical trials on monoclonal
antibodies: a cross-sectional study
Marin dos Santps DH, Riera R, Atallah Á
Brazilian Cochrane Center, Brazil
Background: Publication bias can affect the reliability of systematic
reviews. This study investigated the problem from the perspective
of biologicals, with high aggregate economic value, in order to
assess whether the nature of the medical supply may change the
patterns of publication and dissemination of results. Objectives:
To evaluate the characteristics (indices and ratios) of publication and
dissemination of results of clinical trials on monoclonal antibodies
adalimumab, bevacizumab, rituximab, trastuzumab and infliximab
registered at ClinicalTrials.gov. Methods: Cross-sectional study. In
the first stage of the research, the sample included every protocols of
interventional clinical trials, phases III–IV, completed and registered
at ClinicalTrials.gov on the above mentioned monoclonal antibodies
(n = 243). Set the initial sample, we evaluated the patterns of
publication and result’s disclosure at ClinicalTrials.gov, through a
search strategy that considered Pubmed, Embase, Lilacs, Cochrane
Central and Google Scholar. Results: Among the 243 trials that
comprised the initial sample, 169 (≈ 69.5%) were published and 61
(≈ 25.1%) had their results disclosed at ClinicalTrials.gov. The industry
sponsored, wholly or partially, 169 trials (≈ 69.5%). Considering the
subsample of unpublished studies (n = 74), 51 (≈ 69%) were fully
or partially funded by industry. The prevalence of placebo controlled
or single arm studies is greater in trials funded by industry (≈
59.41%) rather than in studies not supported by industry (≈ 40.64%).
Conclusions: Publication bias in clinical trials is intense, despite the
nature of intervention (in this study, monoclonal antibodies). The
source of funding (involving or not the industry) did not change the
Cochrane Database Syst Rev Suppl 1–212 (2013)
patterns of publication, suggesting that publication bias occurs similarly
in all cases. However, studies involving placebo or single arm studies
(therefore, with a poor design) were more common in the sample
financed by industry.
Barriers and facilitators in the implementation
of interventions to prevent publication bias
Nussbaumer B, Kien C, van Noord M, Thaler K, Griebler U, Gartlehner G
Danube University Krems, Austria
Background: Non-publication of clinical trial results may decisively
reduce the benefit of systematic reviews. Because the results from the
research that is available differ from the results of all the research that
has been completed in an area, this may lead to wrong conclusions
about benefits and harms of medical interventions. As awareness has
grown about the problem of publication bias, preventive measures
have been implemented—but without much success. Objectives: To
identify factors acting as barriers or facilitators in the implementation
of interventions to prevent publication bias. Methods: We chose
two qualitative approaches to identify influencing factors: A thematic
analysis of 42 articles identified through a literature search in MEDLINE,
the Cochrane Library, EMBASE, CINAHL, PsycINFO, AMED, Web of
Science and a hand search (Fig. 1) and 33 semi-structured interviews
with different stakeholders. We focused on the following interventions
to overcome publication bias: (1) prospective trial registration; (2) peer
review; (3) open access policies; (4) monitoring of ethics committees
and funding agencies on the publication of trial results; and (5) conflict
of interest statements. Results: We identified 22 barriers and 14
facilitators. Competing interests of different stakeholder groups and
reluctance to publish sensitive data or negative results were identified
as main barriers, as well as lack of provided resources, mechanisms
to enforce the proper implementation of these interventions, and
lack of awareness of the problem of publication bias. Facilitators
include international harmonization of prospective trial registration and
raising awareness of publication bias among the scientific community.
The results of the interviews will be available at the end of May.
Conclusions: Given the plurality of barriers, it will not be enough
to count on the voluntariness of stakeholders to make sure that
interventions to prevent publication bias are implemented. Therefore
the implementation of these interventions should be mandatory and
enforcement mechanisms should be installed.
Attachments: Fig. 1 Lit.Search.png
Full publication of studies presented
at biomedical meetings—updated systematic
review of follow-up studies
Scherer R1 , Meerpohl JJ2 , Schmucker C2 , Schwarzer G2 , von Elm E3
Bloomberg School of Public Health, Johns Hopkins University, Baltimore,
USA; 2 German Cochrane Centre, Institute of Medical Biometry and Medical
Informatics, University Medical Center, Freiburg, Germany; 3 Cochrane
Switzerland, Institute of Social and Preventive Medicine, Lausanne
University Hospital, Lausanne, Switzerland
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: Studies presented at scientific meetings are hard to
identify in electronic literature searches. As part of the ‘grey literature’
they are often not used in systematic reviews. If full publication
is dependent on factors such as magnitude or direction of results,
reporting bias may occur. This potentially invalidates the results of
meta-analyses aiming at an unbiased evidence base. Objectives: To
determine the full publication rate of studies presented at biomedical
meetings and the time elapsed until full publication. To identify
factors associated with full publication. Methods: We searched major
electronic databases through 11/2012 without language restriction for
follow-up studies using cohorts of abstracts of biomedical meetings.
We extracted data if publication rates were reported for a minimum
follow-up of 24 months. Using random effects models, we calculated
weighted estimates of publication rates and pooled odds ratios (OR;
Mantel-Haenszel method) for factors associated with publication.
Results: A total of 264 studies following 147.529 abstracts from
667 individual meetings were included. The median publication
rate after presentation was 42.3% (range 2.6–90.7). The weighted
publication rate was 39.5% (95%CI: 37.4–41.6); individual estimates
were heterogeneous (I2 = 98.3%, p < 0.0001). Publication activity
starts to diminish after 60 months (Figure). In 20 studies including
only RCT abstracts the weighted publication rate was 64.2% (95%CI:
56.7–71.0). Study characteristics associated with subsequent full
publication were: significant vs. non-significant results (OR 1.9; 95%CI:
1.6–2.2), clinically relevant vs. not relevant results (1.6; 1.3–2.0); basic
vs. human research (1.5; 1.3–1.7); RCT vs. observational study (1.4;
1.2–1.7). Abstract characteristics associated with full publication were:
accepted vs. rejected for presentation (2.6; 2.2–3.2) and oral vs.
poster presentation (1.7; 1.5–1.8). Conclusions: A sizable proportion
of research presented at biomedical meetings remains unpublished.
Factors associated with full publication suggest that reporting bias is
present even after study results have been presented to peers.
Attachments: SR meeting abstracts figure.pdf
Quantifying bias in randomized controlled trials
in child health
Hartling L, Hamm M, Dryden D, Vandermeer B
University of Alberta, Canada
Background: While randomized controlled trials (RCTs) are considered
the gold standard for evidence on therapeutic interventions, they are
susceptible to bias. There is a growing body of empirical evidence
based on meta-epidemiological methods to quantify biases in RCTs;
however, there are inconsistent findings across studies and clinical
areas. Objectives: To quantify bias related to specific methodological
characteristics in child-relevant RCTs. Methods: We identified
systematic reviews containing a meta-analysis with 10–40 RCTs that
were relevant to child health in the Cochrane Database of Systematic
Reviews. Two reviewers independently assessed RCTs using items
in the Cochrane Risk of Bias tool and other study factors. We
used meta-epidemiological methods to assess for differences in effect
estimates between studies classified as high/unclear vs. low risk of
bias. Results: We included 287 RCTs from 17 meta-analyses. The
proportion of studies at high/unclear risk of bias was: 79% sequence
generation, 83% allocation concealment, 67% blinding of participants,
47% blinding of outcome assessment, 49% incomplete outcome data,
Cochrane Database Syst Rev Suppl 1–212 (2013)
32% selective outcome reporting, 44% other sources of bias, 97%
overall risk of bias, 56% funding, 35% baseline imbalance, 13%
blocked randomization in unblinded trials, and 1% early stopping
for benefit. We found no significant differences in effect estimates
for studies that were high/unclear vs. low risk of bias for any of
the risk of bias domains, overall risk of bias, or other study factors.
Conclusions: We found no differences in effect estimates between
studies based on risk of bias. A potential explanation is the small
number of trials included. It has been postulated that much larger
samples are needed to detect differences; however, this raises the
question of the magnitude of differences if they exist. Until further
evidence is available, reviewers should not exclude RCTs based solely
on risk of bias particularly in the area of child health.
Completeness of outcome specification across
Cochrane Systematic Reviews of three common
eye conditions: time to be more explicit!
Saldanha I, Wang X, Li T, Dickersin K
Cochrane Eyes and Vision Group, USA
Background: Complete specification of outcomes in a systematic
review (SR) is important for promoting reproducibility, minimizing
bias in the SR process (meta-bias), and evaluating time-dependent
treatment effects. A completely-specified outcome has four domains:
outcome title (e.g., visual acuity), technique/instrument used, outcome
measure (e.g., continuous variable such as mean visual acuity), and
time-point(s) for outcome assessment. Objectives: To evaluate the
degree of completeness of outcomes specification across SRs addressing
three common eye conditions: age-related macular degeneration
(AMD), cataract, and diabetic retinopathy (DR). Methods: Using the
four domains, we evaluated completeness of specification for the
most frequently-assessed primary and non-primary outcomes for all
Cochrane SRs addressing the three conditions. Results: We identified
36 completed Cochrane SRs and protocols addressing AMD (n = 16),
cataract (n = 16), and DR (n = 4). All reviews provided titles
for the outcomes they assessed. Time-point(s) was the next most
frequently specified domain; for example 13/16 (82%) SRs on AMD
assessing visual acuity specified time-points at which the outcome
was assessed (Table 1). Outcome measure was the least frequently
specified domain; for example only 1/12 (8%) cataract SRs assessing
quality-of-life specified the outcome measure. For the five most frequent
outcomes across conditions, 16/35 (46%) SRs assessing visual acuity,
2/13 (15%) SRs assessing contrast sensitivity, and none of the 32,
7, and 13 SRs assessing quality-of-life, disease onset, and disease
progression specified all 4 domains. Primary outcomes were more
likely than non-primary outcomes to specify all four domains (46% vs.
5%, p < 0.0001), and specified a higher mean number of domains
(3.24 vs. 1.92, p < 0.0001). Conclusions: Specification of outcomes
was largely incomplete across SRs addressing the three conditions. To
facilitate reproducibility and reduce bias, systematic reviewers should
completely specify the primary and additional outcomes they propose
to examine.
Attachments: Outcomes Abstract-Completeness 2013 Tables.pdf
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Characteristics of the authors of acupuncture
related Cochrane Systematic Reviews
Fei Y, Chai Q
Beijing University of Chinese Meidicine, China
Background: Acupuncture is relatively well accepted in the world.
Many Cochrane systematic reviews of acupuncture were published.
Objectives: To investigate the characteristics of the authors of
acupuncture Cochrane systematic reviews. Methods: Searching
‘acupuncture’ in ‘record title’ in Cochrane Library (January 2013) for
published full Cochrane Reviews. Author information was abstracted
and analyzed. Results: 40 Cochrane Reviews were identified (1
was withdrawn), 39 reviews were included. They were published
in 2008–2013. 39 health conditions, edited by 23 groups, were
identified. 8 groups, including Menstrual Disorders and Subfertility
group (5), Musculoskeletal group (4), Pain, Palliative and Supportive
Care group (4), stroke group (3) etc, published 62% of the reviews.
Authors from 13 countries contributed. The affiliation of contact
authors were from China mainland (10), Australia (8), Hong Kong (6),
United Kingdom (6), United States (4), Canada (3) and Germany (2). 18
(46%) reviews were written by international author groups. Authors of
25 (64%) reviews could not be identified to have acupuncture related
education or practice background judged by the information provided
in the reviews. 6 (15%) first authors published 15 (38%) reviews,
with each of whom 2–4 reviews. Among them, 4 authors published
11 reviews for almost totally different health conditions with different
Cochrane groups. 16 (41%) reviews included less than 5 studies each
(6 reviews didn’t include any study). Only 2 of the 13 reviews that didn’t
involve Chinese language reviewers searched Chinese databases. While
22/26 reviews (having Chinese language authors) searched Chinese
databases. Conclusions: Acupuncture systematic reviews were mainly
written by authors from China (including Hong Kong), Australia, UK,
US, Canada, Germany. Acupuncture education or practice background
of the authors was not provided adequately in the reviews. The
registering of the topics of systematic reviews of acupuncture should
be in accordance with the clinical practice and research of acupuncture.
Would a timely analysis of secondary outcomes
have led to an earlier identification of effective
stroke rehabilitation interventions?
Langhorne P, Editorial Team
Cochrane Stroke Group, UK
Background: Randomised trials often use secondary (or surrogate)
outcomes that are believed to anticipate changes in primary outcomes.
Many surrogate outcomes are used in rehabilitation research in the
belief that recovery patterns are predictable and improved secondary
outcomes will herald improved primary outcomes. Objectives: To
identify if a timely analysis of secondary outcomes would have resulted
in an earlier identification of effective rehabilitation interventions.
Methods: We identified 11 ‘effective’ rehabilitation interventions
(median 10 trials; IQR 6–17) that were supported by a Cochrane
Review and recommended in Clinical Guidelines in 2010. These
were matched with 11 similar ‘neutral’ interventions (13 trials; 5–18)
Cochrane Database Syst Rev Suppl 1–212 (2013)
that are currently not recommended. We then carried out a series of
cumulative meta-analysis against; (a) time before guideline publication,
and (b) total number of participants included in each analysis. The
main outcome was the time (participants) required to achieve a
significant z-score (> 1.96). Results: When comparing the ‘effective’
and ‘neutral’ intervention reviews, the total number of participants
were similar (P = 0.47) but the ‘neutral’ interventions had fewer
available for secondary outcome analyses (median 232 vs. 586;
P = 0.04). The ‘effective’ interventions achieved a significantly higher
median z-score on the primary outcome after the accumulation of 300
participants compared with only 200 participants for the secondary
outcome. Within the group of ‘effective’ interventions both primary and
secondary outcomes achieved significance at the same time (8 years
vs. 9 years; P = 0.79) prior to guideline publication, but the number
of participants required was lower for the secondary outcome (160 vs.
461; P = 0.056). Conclusions: In these rehabilitation reviews
secondary outcome results did achieved statistical significance with
fewer participants than the primary outcomes but this did not translate
into an earlier demonstration of effect because data were often missing.
Secondary outcomes need to be applied in a more standardised and
consistent manner.
Methodological overview: meta-analyses
of adverse effects data from case-control studies
as compared to other observational studies
Golder S1 , Loke Y2 , Martin B3
CRD, University of York, UK; 2 School of Medicine, University of East
Anglia, UK; 3 Department of Health Sciences, University of York, UK
Background: A diverse range of study designs are used in the
evaluation of adverse effects in systematic reviews, including
case-control studies. However, case-control studies do have potential
biases that may lead to divergent findings compared to studies that use
other methods. The extent of any discrepancy or heterogeneity between
the pooled risk estimates from case-control studies and other study
designs is a key concern for systematic reviewers. Objectives: We
aimed to ascertain whether the risk estimates from meta-analyses of
case-control studies differ from that of other study designs. Methods:
Searches were carried out in 10 databases in addition to reference
checking, contacting experts, and handsearching key journals and
conference proceedings. Studies were included where a pooled relative
measure of an adverse effect (odds ratio or risk ratio) from case-control
studies could be directly compared with the pooled estimate for the
same adverse effect arising from other types of observational studies.
Results: We included 82 meta-analyses. Pooled estimates of harm
from the different study designs had 95% confidence intervals that
overlapped in 78/82 instances (95%). Of the 23 cases of discrepant
findings (significant harm identified in meta-analysis of one type of
study design, but not with the other study design), 16 (70%) stemmed
from significantly elevated pooled estimates from case-control studies.
There was associated evidence of funnel plot asymmetry consistent
with higher risk estimates from case-control studies. On average,
cohort or cross-sectional studies yielded pooled odds ratios 0.94
(95% CI 0.88–1.00) times lower than that from case-control studies,
Conclusions: Empirical evidence from this overview indicates that
meta-analysis of case-control studies tend to give slightly higher
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
estimates of harm as compared to meta-analyses of other observational
studies. However it is impossible to rule out potential confounding from
differences in drug dose, duration and populations when comparing
between study designs.
The PRISMA statement for reporting systematic
reviews of China health policy
He S1 , Zhao J1 , Zhang F1 , Tian JH2
Evidence-Based Medicine Center, School of Basic Medical Sciences
of Lanzhou University, China; 2 School of Public Health of Lanzhou
University, China
Background: Publication bias in a systematic review (SR) occurs
mostly during the selection process and a transparent selection process
is necessary to avoid such bias. The Preferred Reporting Items
of Systematic reviews and Meta-Analyses (PRISMA) Statement was
published to help authors improve how they report SRs. Objectives:
To identify SRs of China health policy and evaluate their reporting
quality by PRISMA. Methods: An electronic literature search of all
SRs of China healthy policy from inception to December 2012 was
conducted using the following text and keywords in combination both
MeSH terms and text words, the search strategy was (meta analysis OR
meta analyses OR systematic review* OR overreview) AND (health or
policy) in five Chinese databases. The reporting quality was assessed
independently by two reviewers using the PRISMA. Results: Fifty SRs
were included finally. The result of PRISMA showed in Table 1. The
CSCD or non-CSCD articles, the fund support, the published year and
the number of the author seem to have little impact on the quality of
the SRs. there were more items showing significant difference in the
group of the number of the authors, which indicated that the author
number may influence the reporting quality of SRs in China health
policy. Conclusions: The reporting quality of SRs of China health
policy was poor. The PRISMA statement may give the authors a useful
reference to improve the reporting quality of SRs in this field.
Attachments: Table 1 PRISMA Checklist of Reporting Quality.PDF
The correlation analysis of PRISMA, AMSTAR and
GRADE in systematic review
Yao L, Wei D, Wang Q, Wang XQ, Sun LN, Liang FX, Yang KH, Chen YL
Evidence-Based Medicine Center, School of Basic Medical Sciences,
Lanzhou University
Background: The PRISMA, AMSTAR and GRADE are used to assess
the quality of report, methodology and evidence in systematic reviews
(SRs), but up to now there was no literature had ever studied the
correlation of the quality of report, methodology and evidence in
SRs. Objectives: To assess the correlation of PRISMA, AMSTAR and
GRADE in SRs. Methods: We selected the SRs about complementary
and alternative medicine to respiratory diseases as the sample. Chinese
Biomedical Literature database (CBM) and Cochrane Database of
Systematic Reviews (CDSR) were searched up to Sept 2012. Each
SR was independently identified and evaluated by two reviewers,
and discussed with the third member when disagreement appeared.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Results: (1)79 SRs were included. (2) The most inadequately
reported item in PRISMA was ‘structured summary’ (96%), followed
by ‘objective’ (95%) and ‘search’ (86%). (3) 91% and 85% SRs had
never provided the information of the conflict of interests and the list
of studies (included and excluded) in AMSTAR. (4) A majority of the
SRs had a ‘low’ or ‘very low’ quality of evidence in GRADE. (5) the
correlation of PRISMA, AMSTA and GRADE was showed in Table 1.
Conclusions: The PRISMA and AMSTAR obviously had a positive
correlation (p = 0), but there was no correlation between PRISMA and
GRADE, as well as AMSTAR and GRADE.
Attachments: table1.jpg
Development of the PRISMA harms extension
Zorzela L1 , Moher D2 , Vohra S1
of Alberta, Canada; 2 University of Ottawa, Canada
1 University
Background: Systematic reviews (SRs) of harms can provide valuable
information to help describe adverse events (AEs) but they are hampered
by lack of standardized methods to report these events. A systematic
review undertaken by our team has identified major gaps in reporting in
systematic reviews of AEs, necessitating the need for a new guideline,
The PRISMA Harms Extension. Objectives: To modify PRISMA to
include items specific to harms reporting. Methods: A modified Delphi
process was used. An initial checklist of potential items to be reported
in a SR of AEs was developed and refined by experts. The first phase
of the Delphi process was online, such that 40 potential items were
sent to experts in SRs, guideline development, clinical trials, statistics
and epidemiology, who assigned relevance of each item on a 1–10
Likert scale in two rounds. After the second round, items voted 8 or
higher were kept. Items voted 5 or less were removed, and those that
were indeterminate were carried forward for the next Delphi phase:
the in-person consensus meeting. At this meeting, an invited group
of relevant experts discussed and decided the final list of checklist
items that should be kept in the guideline. Results: The online Delphi
originated significant agreement among participants. Out of the 40
items scored twice by 72 participants, one item was voted ‘excluded’
and 7 items received indeterminate votes. The consensus meeting
had 25 worldwide experts in guideline development and systematic
reviews. After two full day discussions on the relevance of items, it
was decided that 5 items should be mandatory and 14 items should be
considered recommended when reporting harms in systematic reviews.
Conclusions: The ultimate goal of this guideline development is to
improve quality of reporting in systematic reviews, so that both benefits
and harms are discussed.
Systematic reviews in health policy: method,
practice and challenges
Jia L1 , Meng Q2 , Yuan B2
1 Shandong University, China; 2 Peking University, China
Background: Health policy makers need high quality evidences
to make scientific decisions on some important health issues or
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
innovations. How to provide evidences is a big opportunity and
challenge for the researchers. Objectives: Explore systematic review
method and supply evidences which are to satisfy the needs of health
policy makers. Methods: Literature review, key informant discussion
and group discussion were conducted. Key important websites and
organizations were searched to get the materials about how to conduct
systematic review; Six experts on health economics, health policy and
public health were invited to discuss the applicability of the current
methods in health policy; group discussions were conducted once
2 weeks for nearly 1 year. Results: Two-phase systematic review
method in health policy was explored and practiced via three systematic
reviews about health financing. The scoping review is the first step
to get enough information on different angles which showed the
characters of strategies, contexts and outcomes; Evaluative review is
the second phase to get high quality evidences which based on the
scoping review, needs of health policy maker, context of health system
are considered when to select the theme topic. Three systematic
reviews were conducted using this method. Some challenges of
systematic review method in health policy faced by researchers in
the future: searching method to get accurate information about
health policy topic; controlled studies are scare in health policy; the
applicability of the outcomes of the systematic reviews in different
health systems. Conclusions: Two-phase systematic review method
in health policy need to be developed especially some key technologies
such as searching, quality assessment of observational studies and
Modifiable factors influencing recruitment
in clinical trials
Oude Rengerink K1 , Hooft L2 , Bossuyt PM3 , Mol BW1
Academic Medical Center, Department of Obstetrics and Gynaecology;
2 Dutch Cochrane Centre, Academic Medical Center; 3 Academic Medical
Center, Department of Clinical Epidemiology, Biostatistics and
Background: Patient recruitment in clinical trials often takes longer
than expected. Trials with slow recruitment are more costly and an
insufficient sample size leads to indecisive conclusions. At present,
determinants of slow recruitment that could help recruitment of patients
both before and during clinical studies have not been systematically
investigated. Objectives: To identify modifiable factors influencing
recruitment in clinical trials. Methods: We included all 1130 trials
registered in the Netherlands Trial Register with an expected date
of completion between 2005 and 2010. Through a questionnaire
sent to the principle investigators we identified characteristics of the
principal investigator and research group, hospital organization, trial
organization and design. We used logistic regression analysis to assess
which characteristics were associated with (un)successful recruitment.
Results: Of 392 trials (35%) questionnaires were completed. For
these trials 232.707 persons were to be recruited. Half of the trials
did not achieve their original recruitment target (i.e. 80% of the
targeted number of patients within the planned time). Although
42% of the trials were extended for ≥ 6 months, when closing
recruitment 46% still had recruited fewer patients than originally
intended. Factors associated with unsuccessful recruitment were: lack
of clear responsibilities for recruitment, trial coordinator not PhD,
Cochrane Database Syst Rev Suppl 1–212 (2013)
multicenter trial (especially > 10 centres). Factors associated with
successful recruitment were: newsletter and presentation at start for
recruiters, pocket cards, and email at start of the trial. Conclusions:
Investigators overestimate recruitment success in almost half of the
trials. Although we identified factors associated with recruitment, we
are yet unable to make a general checklist for improving recruitment.
A possible limitation of this study is the risk for selective responses and
unmeasured confounders. Nevertheless, trialists and funders should be
aware of potential recruitment barriers and incentives at study design
as well as during the study.
Combining systematic review methods with
philosophical analysis for a research ethics
review: a case study in bridging disciplines
Wright J1 , Wilman E1 , Megone C1 , Gyte G2 , Duley L3 , Oliver S4
Univerisity of Leeds, UK; 2 Cochrane Pregnancy & Childbirth Group, UK;
3 University of Nottingham, UK; 4 Institute of Education, UK
Background: A systematic review of the ethics of conducting research
on preterm and sick neonates was commissioned to feed into the
research project ‘Improving quality of care and outcome at very
preterm birth’. The output was a systematic review of empirical ethics
papers and a systematic review of analytical ethics papers. Review
findings also informed the pilot randomised controlled trial design and
the procedure for ethics review. Medical ethics questions are more
usually addressed by philosophical analysis rather than by systematic
review. We reflected on the benefits and challenges from working
in a multi-disciplinary, multi-method systematic review. Objectives:
To review: • contributions of the different disciplines • comparisons
between philosophical and qualitative social science methodologies
• challenges and solutions in reviewing from different perspectives
• resulting advantages and disadvantages. Methods: We captured
reflections on the process of developing a systematic review for ethics.
Data from diaries, interviews and meetings were collated to map
methods used at each stage of the review and analysed. Results:
Both disciplines used conceptual frameworks and aimed to provide
impartial, unbiased results and conclusions. Philosophical analysis
added informed questioning and detailed critique of the alternative
arguments identified. Systematic review methods contributed explicit
procedures and methodological rigour. The team had to become
familiar with the methods, resources and terminology of other
disciplines. Conclusions: It was possible to apply qualitative synthesis
methods to the ethics review. Involving experts from different disciplines
enabled appropriate use of methods and resources to achieve a robust
review recognised by those disciplines. Developing understanding of
the methods, resources and terminology of other disciplines requires
effective communication and ‘extra’ time. Benefits include insights into
alternative methods that could be applied to disciplines and creating
a wider network of collaborators. Reflections on the review process
improved communication and identified challenges and solutions.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Methodological challenges to assess
effectiveness of treatments with retrospective
studies : the case of localized prostate cancer
Larocque B, Asselin G, Coulombe M, Rhainds M
UETMIS, CHU de Québec, Canada
Background: Radical prostatectomy (RP), external beam radiation
therapy (EBRT), and brachytherapy (BT) are the main curative options
for localized prostate cancer (PCa). However, divergence still remains
between experts about which option should be preferred in terms
of benefits and harms. Objectives: To assess the comparative
effectiveness of treatments for localized PCa. Methods: A systematic
review was conducted in in PubMed, Embase, the Cochrane Library
and the grey literature until October 2012 to identify systematic
reviews (SRs), randomized controlled trials (RCTs), and observational
studies. The primary outcomes were PCa-specific mortality and all-cause
mortality. Selection, quality assessment and data extraction were
performed by two independent reviewers. Synthesis review was shared
with an interdisciplinary group of experts. Results: No RCT comparing
RP to other therapeutic options was found. A total of 12 retrospective
population-based cancer studies, including claims databases and
hospital-based observational studies were included. Results suggest
that patients treated by RP had a lower risk of PCa-specific mortality
(hazard ratio (HR): 0.38–0.67) or all-cause mortality (HR: 0.49–0.63)
than those receiving EBRT. Results concerning BT compared with RP
and EBRT remain unclear. Use of retrospective databases t was
associated with major methodological issues. Limitations include
validity of the causes of death, age-dependant PCa treatment, staging,
individual risk assessment (PSA, Gleason score), treatment description
such as surgical procedures, radiation dose, isotope for BT, inability
to separate EBRT than BT in databases, and change over time for
radiation therapy. Conclusions: Results from retrospective studies
suggest that RP is associated with better survival outcomes compare
with EBRT. However, considering the methodological weakness related
to selection, misclassification and confounding by indication bias, the
level of evidence remains low. Due to the uncertainty of comparative
effectiveness, clinicians should emphasize on patient’s values, quality
of life and side effects to support shared-decision making in PCa.
Evidence mapping: methodological foundations
and application to epidemiologic research on
sugar sweetened beverages and health
Althuis MD1 , Weed DL2
EpiContext, USA; 2 DLW Consulting Services, USA
Background: Evidence maps are a new methodology that systematically characterizes the range of research activity on broad topics
and are used to guide research priorities, systematic reviews, and
meta-analyses. This methodology is underused in epidemiology and
has considerable potential to increase the efficiency of research efforts.
Objectives: We demonstrate the usefulness of evidence mapping as
a tool for organizing epidemiological studies, using as an example
research on sugar sweetened beverages (SSB) and health outcomes:
obesity, type 2 diabetes (T2D), metabolic syndrome (MetSyn) and
Cochrane Database Syst Rev Suppl 1–212 (2013)
coronary heart disease (CHD)/stroke. Methods: We performed a
search of Pubmed, Scopus, and Cochrane databases and a hand search
of references. Studies selected were published reviews and longitudinal
studies (intervention and cohort; January 1, 1966–October 31, 2012).
Results: We identified and mapped 77 studies (18 review, 59 primary
research). Most research focused on obesity (N = 47), with the
numbers of studies reducing to 6–11 when categorized into groups
by age and study type (Fig. 1).The number of cohort studies that
assessed SSB and remaining health outcomes were T2D (N = 9),
MetSyn (N = 4), and CHD/Stroke (N = 4). For all outcomes, more
than 30% (N = 18) of the primary research studies we identified were
not referenced in published reviews. We found considerable variability
among primary research studies of SSB and the four health outcomes
in terms of designs, definitions of SSB, and definitions of outcomes. For
example, we counted 14 different definitions of weight/obesity in 29
cohort studies, with no more than 6 studies reporting use of the same
outcome measure. Conclusions: This map showcases the complexity
of research on this topic. Establishing standards in the study of SSB and
health would facilitate interpretation across research studies, thereby
increasing utility of systematic reviews/meta-analyses and ultimately
efficiency of research efforts. Rapid publication of new data suggests
the need for caution when reading reviews and regular updates.
Attachments: Figure 1. Althuis.pdf
Terminology confused: how to name network
Li L, Tian JH, Yang KH, Tian HL, Sun R
Evidence-Based Medicine Center, School of Basic Medical Sciences,
Lanzhou University
Background: Many synonymous names for network meta-analysis
exist. Objectives: So we conducted this survey to find how they named
a network meta-analysis and why. Methods: Published network
meta-analyses were retrieved by searching databases (Pubmed, the
Cochrane library, Embase, and ISI Web of Knowledge) and
hand-searching other sources (Google engine, HTA websites, references
lists). Two independent reviewers conducted search, select studies,
abstracted data. Statistical analyses were conducted using SPSS
version 15.0 for Windows. Results: 104 network meta-analyses
were included. In the titles, 65.38% (68 studies) used ‘network
meta-analysis’ (NMA), 20.19% (21 studies) used ‘mixed treatment
comparisons’ (MTC), 6.73% (7 studies) used ‘multiple-treatments
meta-analysis’ (MTM), and 7.69% (8 studies) used systematic review
or meta-analysis. Of all these studies, 2.88% (3 studies) mentioned
‘indirect comparison’ in their titles. Of those studies (n = 39) that
acknowledged that NMA, MTM and MTC are the same things, 58.97%
(23 studies) used ‘network meta-analysis’ (NMA), 23.08% (9 studies)
used ‘mixed treatment comparisons’ (MTC), 7.69% (3 studies) used
‘multiple-treatments meta-analysis’ (MTM), and 10.26% (4 studies)
used systematic review or meta-analysis. Conclusions: Although
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
NMA, MTM and MTC were considered as the same things using
different methods combining direct and indirect evidence, and NMA
were the most used name, available studies about used different
names. This might confuse NMA readers, so in the future consensus
must be achieved regarding how to name NMA studies.
How can we improve trials assessing the
effectiveness of Screening, Brief Intervention,
and Referral to Treatment (SBIRT) for substance
use? Methodological issues encountered during
a systematic review
Young M1 , Stevens A2 , Galipeau J2 , Pirie T1 , Garritty C2 , Singh K2 ,
Yazdi F2 , Golfam M2 , Pratt M2 , Turner L2 , Porath-Waller A1 , Grimshaw
JM3 , Moher D3
Canadian Centre on Substance Abuse, Canada; 2 Ottawa Hospital
Research Institute, Canada; 3 Ottawa Hospital Research Institute and
University of Ottawa, Canada
Category: Other topics. Background: Screening, Brief Intervention,
and Referral to Treatment (SBIRT) is a comprehensive, integrated public
health approach to providing early intervention and treatment services
for individuals at risk of substance use-related harms. Evidence exists
to support the use of SBIRT for alcohol use, but no systematic review
has been done for other substances. We conducted a systematic review
on the effectiveness of screening and brief interventions as part of
the SBIRT model for reducing the non-medical use of psychoactive
substances. During our assessment of studies, we uncovered
methodological and reporting issues in this literature. Objectives: We
will present the methodological and reporting issues we identified in
the literature assessing screening and brief interventions for substance
use, as encountered during our systematic review. We will offer
possible solutions to overcome some issues. Methods: We included
randomized controlled trials opportunistically screening adolescents
or adults and then providing a one-to-one, verbal brief intervention
to those at risk of substance use harms. The non-medical use of
psychoactive substances were of interest, excluding alcohol, nicotine,
and caffeine. Interventions were comprised of four or less sessions and
were compared with no/delayed intervention or provision of information
only. Methodological and reporting issues were encountered during
the process of conducting the review. Results: Few studies met the
inclusion criteria. Methodological issues in the literature relate to the
consent process, the screening procedure (i.e., whether opportunistic),
inconsistent measurement and reporting of outcomes, and trial design.
We will discuss possible solutions for some of these issues when
designing future studies in this area. Conclusions: Important
methodological limitations exist in the SBIRT literature, some of which
could be overcome with the design of future studies. This presentation
will be relevant to those conducting methodological assessments of
this or related literature and those involved in trial design in this area.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Variability and completeness of outcome
reporting in studies for low back pain
rehabilitation interventions: a survey of trials
included in Cochrane Reviews
Gianola S1 , Castellini G2 , Pecoraro V1 , Frigerio P3 , Moja L4
1 Clinical Epidemiology Unit, I.R.C.C.S. Orthopedic Institute Galeazzi, Milan,
Italy; 2 COF Lanzo Hospital, Lanzo d’Intelvi, Como, Italy; 3 Spinal Cord Unit,
Niguarda Ca’ Granda Hospital, Milan, Italy; 4 Department of Biomedical
Sciences for Health, University of Milan, Clinical Epidemiology Unit,
I.R.C.C.S. Orthopedic Institute Galeazzi, Milan, Italy
Background: The selection of appropriate outcomes or domains
is crucial when designing clinical trials in order to compare directly
the effects of different interventions in ways that minimize bias.
Objectives: We aimed to assess the frequency and completeness
of outcome measures in randomized controlled trials (RCTs) included
in Cochrane systematic reviews (SRs) focused on rehabilitation interventions for low back pain. Methods: We performed a cross-sectional
study of all RCTs included in 11 Cochrane SRs. Data extraction
exploring frequency and completeness (full, partial or incomplete) was
independently evaluated by two raters. Our outcomes were: the
cumulative frequency of outcomes across RCTs and the proportion
of outcomes rated as fully replicable. Results: The provisional
results are derived from a random sampled of one-third (n = 60)
of the 190 RCTs. Overall forty-two outcomes were investigated.
The outcomes most commonly reported were pain [in 52 RCTs (86,
7%)] and disability [in 49 RCTs (81,7%)] measured respectively by
34 and 15 different measurement instruments. An half of RCTs
described the methodological procedure to assess the outcome as
blinded (50%), in a few less the procedure was unclear (43,3%)
and few reported not blinded (6,7%). For 50% of the RCTs the
outcome description was considered sufficient to allow replication.
Conclusions: In our preliminary results, we reported a large number
of outcome measures and a myriad of measurement instruments used
with better opportunities to the standardization of approaches. Most
times the outcomes reporting was complete. In other cases was partial
or incomplete. Initiatives to ensure quality assurance of outcomes in
rehabilitation trials should be encouraged.
From health to development: a growing centre
of excellence in systematic reviewing
Stewart R1 , Korth M2 , van Rooyen C3 , de Wet T4
Evidence-Informed Policy Team, Centre for Anthropological Research,
University of Johannesburg, and EPPI-Centre, London; 2 Evidence-Informed
Policy Team, Centre for Anthropological Research, University of
Johannesburg, South Africa; 3 Evidence-Informed Policy Team, Centre
for Anthropological Research, and Department of Anthropology and
Development Studies, University of Johannesburg, South Africa;
Evidence-Informed Policy Team, CfAR, University of Johannesburg, South
Background: It is a credit to the Cochrane Collaboration that
systematic reviews are increasingly viewed as gold standard evidence
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
for decision-making in disciplines other than health. Most recently
we have seen a paradigm shift in International Development towards
commissioning and making use of systematic reviews. Our team
from the University of Johannesburg have played an important part
in these developments. Objectives: This poster will report on the
growing centre of excellence in systematic reviewing at the University
of Johannesburg and reflect on how systematic reviews in Development
differ from those in Health. Methods: With experience of Cochrane,
Campbell, EPPI-Centre and CEE systematic review methods, we are in
a unique position to reflect on how reviews in Development build on,
and differ from, Cochrane Reviews. We will draw on our experience
of seeking funding for reviews, conducting them, providing training,
engaging stakeholders and shaping policy. Results: Firstly we note
that ‘Development’ is an externally applied label, and largely refers to
reviews on a wide range of questions with a focus on evidence from lowand middle-income countries. Reviews in Development also currently
address particular kinds of (often very broad) questions and draw on
a wider range of study designs. This has particular implications for
searching, assessing risk of bias and synthesis. Thus far Development
reviews have engaged predominantly with policy-makers rather than
service users, and have incorporated a relatively new emphasis on
causal pathway analysis. Conclusions: There is considerable potential
to influence the nature of systematic reviewing in Development, and
we believe that it is key for Southern academics to play a role. We
therefore welcome the opportunity to share our experiences and invite
input from others experienced in reviewing this evidence.
Identifying underlying mechanisms between
intrinsic and variable prognosticators and
clinical outcomes: a structural modelling
Hermans F1 , Schuit E2 , Mol BW1 , Opmeer B3
Department of Gynecology, Academic Medical Center, Amsterdam,
The Netherlands; 2 Department of Gynecology, UMCU, Utrecht, The
Netherlands; 3 Clinical Research Unit, Academic Medical Center,
Amsterdam, The Netherlands
Background: It is often implicitly assumed in clinical practice as
well as in research that prognosis of outcomes and effect of medical
interventions to improve outcomes are homogeneous across fixed
biological factors, such as gender, ethnicity and age. Thereby the
process and underlying mechanisms, through which fixed and variable
risk factors and subsequent intermediate outcomes result in the final
outcome, are unclear. For instance, risk of preterm birth is different for
boys and for girls, and women of different ethnic origin have different
normalcy curves for pregnancy. Consequently, to appropriately evaluate
interventions aiming at reducing preterm delivery, the definition of
preterm—as abnormal in comparison with at term—should take
these different intrinsic prognoses into consideration. In addition,
it is unclear whether and how intrinsic prognosis and variable risk
factors interact. Knowledge and understanding of such mechanisms
is pivotal to appropriately design clinical trials and interpret their
results. Objectives: To present the rationale and analytical methods
and illustrate this approach with an example from the PRO-TWIN
and AMPHIA studies. Methods: In the PRO-TWIN and AMPHIA
Cochrane Database Syst Rev Suppl 1–212 (2013)
studies, women with a twin-pregnancy were randomized between
pessary versus no-pessary and between progesterone versus placebo,
to evaluate whether they reduce the risk of preterm delivery and poor
neonatal outcome. In doing so, we model the causal chain between
ethnicity, fetal gender, acquired risk factors, cervical length and signs
and symptoms for preterm birth. Relevant variables will be selected
to specify directed acyclic graphs (DAGs) representing causal relations
between prognostic variables and outcome(s) (see example shown in
Fig. 1). Structural equations modeling will be used to statistically test
whether the model adequately fits the data, also allowing specification
of latent (unobserved) variables that represent a combination of several
manifest (observed) variables.
Attachments: Hypothetical SEM for preterm birth.pdf
Reaching certainty: a descriptive study of ‘stable’
Cochrane Reviews and coming to firm conclusions
Bastian H1 , Hemkens L2
National Center for Biotechnology Information, National Library of
Medicine, NIH, USA; 2 Basel Institute for Clinical Epidemiology and
Biostatistics, University Hospital Basel, Basel, Switzerland
Background: According to the Cochrane Handbook, a ‘stable’ review
is ‘one that is highly likely to maintain its current relevance for the
foreseeable future’. Objectives: To monitor the extent and reasons
for Cochrane Reviews (CR) being designated stable, and to describe the
reviews designated by the CR authors as having a conclusion that would
be unlikely to change with new trials (called here a ‘firm conclusion’).
Methods: Stable reviews were identified in the February 2013 Issue
of the Cochrane Database of Systematic Reviews (CDSR). Data on the
year and reasons of the designation ‘stable’ were extracted from the
‘What’s new’ section. When reasons were not clearly reported there,
the abstract, discussion and conclusions sections were searched. Both
authors agreed on categories. The conclusions and body of evidence
of reviews with firm conclusions were described. Results: There were
180 stable reviews among 5137 ‘non-withdrawn’ intervention and
diagnostic CRs in the CDSR (3.5%). The number of reviews being
designated stable has been increasing in recent years. Reasons for
the designation were often not explained in the ‘What’s new’ section,
and a total of 26 reviews gave no clear reason in the review for
the categorizing reviews as stable. Where a reason was given (154
reviews), the most common category was a belief that future trials were
unlikely (36%) (see Table 1). Only 16 reviews are designated as having
firm conclusions, mostly because there was no evidence of benefit, or
any benefits were either clinically unimportant or not sustained (11/16
reviews, 69%). Conclusions: Reasons for the decision to designate
a review ‘stable’ are often poorly reported. Cochrane authors rarely
conclude that new trials would be unlikely to change the conclusions
of their reviews. They may be more likely to do so when there is an
absence of evidence of effect.
Attachments: Table 1-Bastian-Hemkens-Apr-2013.jpg
Methodology of animal studies and impact on
aggregating data: why meta-analyses might be
inappropriate for preclinical studies
Pecoraro V1 , Cappellini G2 , Ciccolallo L3 , Dall’Olmo L4 , Virgili G5 , Garattini
S6 , Moja L7
Clinical Epidemiology Unit, IRCCS Orthopedic Institute Galeazzi, Milan,
Italy; 2 Chiesi Farmaceutici, Parma, Italy; 3 European Food Safety Authority,
Parma, Italy; 4 ULSS 15 Padova, Italy; 5 Department of Oto Specialised
Surgical Sciences, University of Florence, Florence, Italy; 6 Mario Negri
Institute of Pharmacological Research, Milan, Italy; 7 Department of
Biomedical Sciences for Health, University of Milan, Milan, Italy
Background: For scientific and ethical reasons, experiments involving
animals should be appropriately designed, correctly performed and
transparently reported. Objectives: We evaluated the characteristics
of reporting, methodology and differences in the efficacy pattern
of statins in animal models (mice, rats and rabbits). We explored
where these have implications for the conduct and interpretation of
meta-analyses. Methods: We searched Medline and Embase. All
eligible articles were examined and results about total cholesterol (TC),
myocardial infarction and survival were extracted. We recorded also
design and experimental characteristics. Weighted mean difference
and odds ratios were pooled. Fixed and random effects models were
compared. Heterogeneity, prediction intervals, publication bias, and
meta-regression analyses were done. Results: We included 161
studies and more than 2500 animals. Statins lowered TC in all species
considered although with large differences in the magnitude of the
effect size: −30% in mice, −20% in rabbits and −10% in rats.
Few studies considered strains at high risk of cardiovascular diseases
and hard outcomes. Although the majority of studies reported they
were randomized (55%), many omitted essential information about
gender, age or weight of the animals undermining the opportunity
for meta-analyses. In 4% of the studies the number of animals used
was not reported. Fixed and random effects models gave different
results (ratio of effect size increased by five folds). Within animal
models heterogeneity was consistently substantial. Accounting for
co-variates had minimal impact on it. Publication bias is highly
suspected. Prediction intervals were width. Conclusions: Although
statins showed efficacy in animal models, the preclinical data were
scarce, often un-interpretable and difficult to reproduce. Meta-analyses
were inconsistent: a reliable approach to estimate the true parameter
was imperceptible. In such conditions one would ideally simply consider
improper to meta-analyse animal studies.
Attachments: Methodology of animal studies and impact on aggregating data VPecoraro.pdf
A strategy to increase partnerships between
health care professionals and Cochrane Canada:
online peer review modules for dietitians
Santesso N1 , Thirsk J2 , Vilis E3 , Arratoon C4 , Grimshaw JM5
McMaster University, Canada; 2 Dietitians of Canada, Canada; 3 Canadian
Cochrane Centre, Canada; 4 Canadian Centre on Substance Abuse, Canada;
5 Ottawa Hospital Research Institute, Canada
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Background: Cochrane Canada continues to work to create partnerships with health care professional groups to increase the awareness
and use of Cochrane Reviews. Recently, Cochrane Canada and
the Dietitians of Canada saw the opportunity to involve dietitians
more actively in the systematic review process, and in particular, to
include the unique perspective of dietitians in the peer review/referee
process. Objectives: Develop online peer review modules for dietitians
to increase their confidence, expertise and comfort in knowledge
synthesis; use the experience of practicing dietitians to ensure
Cochrane Reviews are relevant to dietitians’ needs; involve dietitians in
authoring nutrition-related Cochrane Reviews and integrating them into
practice or guidelines. Methods: Twenty-one stakeholders from 15
organizations across Canada—representing a variety of clinical, public
health, educational, research and community backgrounds—joined
the brainstorming, planning, development, revision and pilot testing
of three online peer review training modules. Managing editors from
15 Cochrane Review Groups were invited to provide nutrition-related
protocol and review examples for the modules. After pilot testing,
a one-day stakeholder planning and dissemination meeting was held
to review the pilot testing results, exchange ideas and plan module
dissemination. Results: Evaluations from dietitians completing the
modules were positive and Cochrane managing editors welcomed
the new peer reviewers. Six months following the launch of the
modules on October 1, 2012, thirty dietitians have completed the
modules with twelve deciding to become peer reviewers/referees.
Dietitians’ peer review areas of interest cover 13 Cochrane Review
Groups and one field. Conclusions: Although collaborating with
multiple stakeholders requires time, the iterative development of
the online modules harnessed the collective strengths and unique
perspectives of both researchers and clinicians. In the future, the
basic online module structure could be used and examples adapted to
other healthcare professions to solidify additional partnerships between
Cochrane researchers and other clinicians.
Local strategies for disseminating knowledge
on evidence: a Cuban project
Torres Pombert A1 , Piedra Piz M1 , Toledo Fernández AM2 , Núñez M3 ,
Torres Orúe I1 , Vázquez Niebla JC4
National Coordinating Centre of Clinical Trials, CU; 2 Ministry of Public
Health, CU; 3 INFOMED, CU; 4 National Institute of Endocrinology, CU
Background: Scientific evidence is the better knowledge to ensure
the best health decisions. This topic is undervalued in Cuba and
a change is needed. Information & communication technologies,
education and knowledge transfer constitute key pieces to get it.
Objectives: To promote evidence-based practices and the work of
the Cochrane Collaboration in Cuban health system. Methods: A
research-development project was carried out by the Coordinating
Centre of Clinical Trials (CENCEC) throughout the Ministry of Health
during three years, into the human resources formation branch.
Results: A promotional group composed of national and foreign
professionals was created. A thematic website supported in the web
2.0 was launched in 2010 through Infomed; it includes a promotion
column of Cochrane Collaboration. A chair at the Medical University
of Havana was formed. The first postgraduate course on searching,
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
retrieval and critical appraisal of the evidence was validated and it
has graduated more than 50 professionals; this includes workshops on
the Cochrane Library and systematic reviews. A motivational seminar
program is being carried out on our proposal or by request from the
health institution concerned and has had over 1320 recipients from
three levels of health-care. A joint work with Iberoamerican Cochrane
Centre to validate Cuban medical journals for hand-searching of clinical
trials was completed. The hand-searching was restarted and sending
full-text articles previously identified was made through Dropbox.
Supporting the Cuban Public Registry of Clinical Trials (RPCEC) tasks
and the development of the first national workshop about evidence
as main topic are some other results. Final considerations: Our
perspectives are related to bring education& training programs toward
virtual learning environments (ongoing on Moodle), to design a central
database on the web of published reports of Cuban clinical trials for
promoting and facilitating the development of systematic reviews and
to keep working for RPCEC.
Evaluation of a wiki-based platform to develop
clinical practice guidelines
von Dincklage JJ1 , Olver IN1 , Garrett AJ2 , Holliday LR1 , Vuletich C1
Cancer Council Australia, Australia; 2 Australia
Background: Clinical practice guidelines in cancer need to be
effectively disseminated, regularly updated as new evidence is published
and enable wide stakeholder consultation. These goals were difficult
to achieve with printed guidelines, so Cancer Council Australia has
developed a wiki-based platform to support all stages of guideline
development (GD). Objectives: To evaluate the utility of the wiki
platform at each stage of guideline production. Methods: The key
steps in guideline production had to be integrated with the wiki
capability. Clinical questions were identified by the guideline working
group and search strategies were developed to perform a systematic
review for each question. Literature searches were recorded and an
online tool was developed to screen and appraise the results as well as
extract the key data of each relevant study on the wiki. Evidence-based
recommendations were developed and evidence tables automatically
generated. Stakeholders could comment on each section of the
guidelines on the wiki and then the guidelines were disseminated
electronically. Web analytics were used to monitor usage. Results:
The wiki platform was developed in 2010. For the lung guidelines,
22 authors identified 67 clinical questions. The literature search and
screening process resulted in 2035 potentially relevant articles being
forwarded for detailed methodological evaluation with another 571
added through snowballing and other methods. To fine-tune the
initial draft content, the working party used the wiki to exchange 156
internal comments in 9 weeks. The web statistics recorded that 1055
users visited lung cancer content pages during the initial 30-day public
consultation period. There were 38 external comments which resulted
in 31 content edits by the working party. Conclusions: The wiki
platform was embraced by both guideline writers and the public. The
next phase is to test sustainability and develop and link educational
modules about the guidelines.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Social work and the Cochrane Collaboration:
qualitative interviews with Cochrane
contributors of social work background
Health Communication and Participation, La Trobe University and Cochrane
Consumers and Communication Review Group, Australia; 6 Canadian
Agency for Drugs and Technologies in Health, Canada; 7 Ottawa Hospital
Research Institute, Cochrane Effective Practice and Organisation of Care
(EPOC) Review Group , Canada; 8 Ottawa Hospital Research Institute,
Cochrane Canada, Canada
Shepard L
University of Utah College of Social Work, USA
Background: Health systems globally are interested in promoting
appropriate prescribing by health care providers and use of medicines
by consumers. Currently, interventions that improve prescribing are
underutilized and related evidence is not readily accessible. Rx for
Change is a publicly available, Cochrane-supported, online database
that provides quick access to systematic reviews regarding best practices
for prescribing and using medicines (www.rxforchange.ca). Despite an
on-line tutorial to maximize use, uptake of Rx for Change has been
suboptimal. Providing database training that includes knowledge user
(KU) input may facilitate the uptake of evidence among health care
providers, policy makers and consumers. Objectives: To describe the
development of a collaborative, international training program using
feedback from two KUs in Canada (provider-based organizations) and
two KUs in Australia (consumer-based organizations). Methods:
The training development and evaluation is guided by the CIHR
Knowledge-to-Action framework. The process consists of four stages:
(1) interviews with key informants in each organization; (2) development of training; (3) implementation and evaluation; (4) application
to future training programs. This presentation will describe results of
the first two stages.The teams in Canada and Australia will meet with
two to four volunteers within each organization. The interviews will
include short answer questions and a hypothetical exercise to observe
engagement with Rx for Change. Results and local data from each
organization will be used to develop training. Results: Results of key
informant interviews and how they were used to guide the development
of a training module for Rx for Change will be presented. Issues specific
to consumer versus provider organizations and challenges related to
working with KUs will be described. Conclusions: Engaging KUs
in shaping the content of training may improve database awareness
and uptake of evidence on interventions aimed at improving medicine
prescribing and use.
Background: The relationship between the Cochrane Collaboration
and social work has never been formally discussed in published
literature, potentially undermining the goals of both organizations.
Objectives: In commemoration of the Cochrane Collaboration’s
20th anniversary, this study explores the historical and potential
relationship of social work and the Cochrane Collaboration through
semi-structured qualitative interviews with Cochrane contributors
of social work background. Methods: Cochrane contributors of
social work background were invited through purposive and snowball
sampling to participate in a semi-structured interview that explored the
relationship of social work and the Cochrane Collaboration. Informed
consent was secured for each of seven participants. Interviews took
approximately one hour and were conducted in person or via the Web.
Participant interviews have been recorded, transcribed, and explored
using thematic content analysis. Results: Member checking pending,
a preliminary analysis of seven interviews indicates no formal link
between social work and the Cochrane Collaboration. Participants
provided multiple rationales for their participation in Cochrane, but
generally noted a shared value of evidence-based practice. Participants
identified social work as having an informal presence in Cochrane
through cross-over of relevant content, objectives, and contributors.
Furthermore, participants described social work as largely relevant to
Cochrane through a common interest in supporting evidence-based
decision-making. Participants identified some barriers to the Cochrane
and social work relationship, including conflicting research traditions,
lack of resources, and a research-to-practice disconnect. Finally, a few
participants suggested that it might be beneficial to discuss formally
organizing social work within Cochrane. Conclusions: Social work
and the Cochrane Collaboration appear to have some common goals,
values, methodologies, and contributors, indicating the significance of
formally considering the relevance and potential collaboration of the
two groups. Ultimately, it is recommended that this research inform
such directed discussions within both social work and the Cochrane
Working with knowledge users to improve
evidence-based medicine prescribing and use:
key informant interviews and the process of
developing an international training
Helis E1 , Colquhoun H1 , Mayhew A2 , Lowe D3 , Taylor M4 , Hill S5 ,
Belanger D6 , Worswick J7 , Grimshaw JM8
Ottawa Hospital Research Institute, Canada; 2 Ottawa Hospital Research
Institute, Cochrane Effective Practice and Organization of Care (EPOC)
Review Group, Canada; 3 Centre for Health Communication and
Participation, La Trobe University, Australia; 4 Australian Institute
for Primary Care & Ageing, La Trobe University, Australia; 5 Centre for
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Involving service users and clinicians to identify
research uncertainties of preterm birth: the
James Lind Alliance Priority Setting Partnership
Uhm S1 , Chivers Z2 , Crowe S3 , David AL4 , Dowling I5 , Duley L6 , Gale C7 ,
Gyte G8 , James CP4 , McNeill J9 , Turner MA10 , Shennan A11 , Oliver S12
1 Social Science Resaerch Unit, Institute of Education, University of London,
UK; 2 Bliss- the premature and special care baby charity, London, England;
James Lind Alliance, Oxford, England; 4 UCL Institute for Women’s Health,
London, England; 5 Premature Babies, Dublin, Ireland; 6 Nottingham Clinical
Trials Unit, University of Nottingham, Nottingham, England; 7 Academic
Neonatal Medicine, Imperial College London, London, England; 8 National
Childbirth Trust (NCT), London, England; 9 School of Nursing & Midwifery,
Belfast, Northern Ireland; 10 Liverpool Women’s NHS Foundation Trust,
Liverpool, England; 11 Kings College London, London, England; 12 Social
Science Research Unit, Institute of Education, University of London,
London, England
Background/Objectives: Preterm infants have immature internal
organs and often need help with breathing, feeding, and other
Cochrane Database Syst Rev Suppl 1–212 (2013)
life support. Those who survive may suffer ill health or disability in
childhood, which could potentially continue to adulthood. Even modest
improvement for these infants and their families would be important.
We aimed involving service users and clinicians to identify and prioritise
uncertainties that are of greatest importance to them. Methods: This
research adapted a mixed-method approach developed by the James
Lind Alliance to establish Priority Setting Partnerships. We recruited 44
clinical and service users’ organisations across UK and Ireland from April
2011 and formed a Steering Group. Online surveys were conducted
from March to February 2013, with paper-based survey at UK hospitals
(December 2012). Results: 1103 participants started the survey,
while 371 of them (service users: 57%, clinicians: 30% and both
12%) suggested 654 research uncertainties. We received feedback
from clinicians of various specialities (neonatologist: 28%, nurse: 25%.
obstetrician: 18%, midwife: 12% and others 10%). Most service user
respondents were white British and middle class. Service users asked
about aetiologies, interventions and outcomes for pre-pregnancy (12),
antenatal (42), perinatal (18), postnatal (58) and other (20), revealing
interests in a broad range of issues surrounding preterm birth. Priorities
of the identified uncertainties will be set by consensus development
meetings and voting. Conclusions: Preterm birth is a highly technical
and emotive topic. This study has shown service users’ and clinicians’
willingness to participate in furthering the research agenda and their
desire for greater understanding and knowledge. Responses ranged
from pre-pregnancy education to childhood interventions, highlighting
the importance of continuity and duration of care for preterm infants.
Finding ways of providing emotional and practical support to mothers
and families was also frequently expressed. Furthermore, this study
also showed need to engage service users from ethnic minorities and
disadvantaged backgrounds with setting research agendas.
Cochrane Reviews need to cope with the flood
tide of innovations
Weingart O
Medical Advisory Service of the Statutory Health Insurance Funds
North-Rhine (MDK-Nordrhein), Cologne Germany
Background: In Germany the reimbursement of new methods not
covered by German DRG, is based on a yearly request by hospitals. An
individual contract with health insurances is compulsory for covering
additional costs. Requests by ten or more hospitals indicate the vast
use in patient-centered care. To support the negotiations of health
insurances, the Medical Advisory Service prepares evidence overviews
assessing the health benefits and risks for patients. Objectives:
To assess whether Cochrane Reviews can support the needs of
reimbursement controlled health systems. Methods: For new non
pharmaceutical interventions ten or more hospitals requested in 2012
the Cochrane Library was scanned for titles, protocols and published
reviews of these interventions. The number of RCTs was retrieved from
the results of the evidence overviews prepared in 2012. Results: In
2012 more then 10 hospitals requested special reimbursement for 30
new interventions. For nine of them, at least one RCT was published,
but only four Cochrane protocols and one title addressed these topics
(see Table). There was no specific full Cochrane Review for any
topic. Conclusions: The introduction of new innovations is faster
than the generation of evidence, which may result in risks for patients
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
in reimbursement controlled health systems. It seems likley that the
publication of Cochrane Reviews is too slow to serve the preparation
of evidence overviews. On the other hand, it would be of much help if
Cochrane Reviews would be published if no RCT is included. This will be
the case often in early stages of innovation development. Addressing
the lack of evidence and allowing clinical / scientific discussion, as well
as identifying the need for further research, is of paramount importance
for patient health and safety. The annually updated evidence overviews
could even be useful for prioritizing Cochrane Reviews, since these
indicate the needs in patient-centered care.
Attachments: Table.pdf
Feasibility scans could improve prioritization and
selection of systematic review topics
Bekhuis T, Stein C
University of Pittsburgh School of Medicine, USA
Background: Public demand for comparative medical information
strains the organizations that produce reviews. Feasibility scans or
scoping reviews could reduce the strain by summarizing the volume
and nature of extant research, usually without synthesis. Objectives:
To assess the prevalence of infeasible Cochrane Reviews, as well
as evidence for feasibility scans or scoping reviews in the research
literature. Methods: We built a stratified random sample where each
stratum was a Cochrane Review Group. Specifically, we randomly
selected 10 groups and then randomly selected 10 reviews within each
group (n = 100 reviews). We recorded bibliometric information and
the number of studies included in each review. An ‘infeasible review’
was defined as having included 0 or 1 study; thus, synthesis was
not possible. To assess publication trends, we retrieved deduplicated
Medline and Embase records in Embase.com that mentioned ‘feasibility
scan’ or ‘scoping review’ using the next/1 adjacency operator; this can
improve simple string matching. Results: Published assessment dates
for Cochrane Reviews ranged from 1997 to 2013. The median number
of included studies per review was 6 (range: 0, 65); the mode was
0 (Fig. 1). The estimated prevalence of infeasible reviews was 18%
(90% CI: 14.2%, 21.8%). The term ‘feasibility scan’ did not appear in
Embase or Medline, as it may be unique to the US Agency for Healthcare
Research and Quality. ‘Scoping review’ appeared in 203 records (72
Embase, 131 Medline). Excluding year 2013 as being incomplete,
the trend for ‘scoping review’ is exponential and rapidly accelerating
(RSQ = .95, P < .001; Fig. 2). In the retrieval set, 112 conditions
were mentioned; the most frequent were obesity, chronic disease,
disability, and depression. Conclusions: Feasibility scans or simple
scoping reviews could aid in topic prioritization and selection by review
groups. Additionally, reducing the prevalence of infeasible reviews
could enhance perceived usefulness by clinicians seeking just-in-time
Attachments: Bekhuis Figure-1-FreqDist-NumStudiesIncluded v2.
pdf, Bekhuis Figure-2-FreqDist-NumRecs-ScopingRev v2.pdf
Cochrane Database Syst Rev Suppl 1–212 (2013)
Prioritisation for Evidence Aid: choosing
systematic reviews for the Evidence Aid
Allen C1 , Kayabu B2 , Clarke M3
Evidence Aid, UK; 2 Evidence Aid and Trinity College, Dublin, Ireland;
3 Evidence Aid and Queens University, Belfast, UK
Background: Evidence Aid draws on knowledge from Cochrane
Reviews and other systematic reviews which assess interventions/
actions which might have an impact on health in disaster settings.
Objectives: To identify Cochrane Reviews relevant to Evidence Aid, to
provide reliable, up-to-date and timely access to evidence for natural
disasters, healthcare emergencies or humanitarian crises. Methods:
In August 2012, The Cochrane Library contained 5168 full Cochrane
Reviews and 2236 published Protocols. Each of these 7404 records
was assessed to ascertain whether it might be relevant to Evidence Aid.
For protocols and reviews published up January 2012, this assessment
was done by three people working separately to categorise potentially
eligible records as ‘High priority’, ‘Unsure’ or ‘Not Relevant’. Three
Cochrane Review Groups were sent their selected records and provided
feedback leading to the addition of a category of ‘Low priority’. Lists
of records were then sent to all other Cochrane Review Groups for
prioritisation. A more streamlined approach was adopted for the
protocols and reviews published since the start of 2012, and the
registered titles for a small number of Cochrane Reviews were also
considered. Results: All assessors categorised 135 records as ‘high
priority’; prioritisation for 522 records was inconsistent. 91 records
contained in the Special Collections were automatically marked as high
priority and not assessed. This gives a total of 226 high priority records
for the prototype for the Evidence Aid database which have since
been assessed by the International Rescue Committee. Conclusions:
Prioritisation is important to Evidence Aid to ensure that the database
contains relevant information. Evidence Aid will partner with aid
agencies, NGOs and others to incorporate views and priorities. A
workshop in 2013 will help to identify the highest priorities, using the
approach developed and refined by the James Lind Alliance; results
from this will be presented at the Colloquium.
A framework to identifying and characterise
research gaps from systematic reviews
Robinson KA
Johns Hopkins University, USA
Background: Research gaps prevent systematic reviewers from
making conclusions and, ultimately, limit our ability to make informed
health care decisions. Methods for conducting a systematic review
are well-defined but there has been no explicit process for the
identification of research gaps from systematic reviews. Objective:
To develop and evaluate a framework for the identification and
characterisation of research gaps from systematic reviews. Methods:
We developed a framework that uses PICOS (Population, Intervention,
Comparison, Outcomes, Setting) to describe the gaps and categorizes
the reasons for the gaps as: (A) insufficient or imprecise information,
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
(B) biased information, (C) inconsistent or unknown consistency results,
and/or (D) not the right information. We evaluated the framework
by: (1) applying the framework to existing systematic reviews, and
(2) asking Evidence-based Practice Centers (EPCs) to use the framework
and provide feedback on usability and usefulness of the framework.
Results: Our application of the framework to 50 systematic reviews
identified about 600 unique research gaps. Key issues emerging from
this evaluation included the need to clarify instructions for dealing with
multiple comparisons (lumping versus splitting) and need for guidance
on use of the framework retrospectively. We received evaluation forms
from seven EPCs, applying the framework in eight projects. Challenges
identified by the EPCs led to revisions in the instructions including
guidance for teams to decide a priori whether to limit the use of
the framework to questions for which strength of evidence has been
assessed, and the level of detail needed for the characterization of the
gaps. Conclusions: Our team developed and evaluated a framework.
Future research is needed to evaluate the relative costs and benefits of
using this framework, for review authors and for users of the systematic
Validating prognosis search filters using relative
recall based on prognosis systematic reviews
Parker RM, Hayden JA, Tougas M
Dalhousie University, Canada
Background: Methods for conducting systematic reviews of prognosis
research are currently being developed and refined. The comprehensive
identification of primary studies is a crucial component of systematic
reviews; search filters have played a significant role in the effective
retrieval of relevant studies. Previous research has demonstrated that
the inconsistent use of prognosis-related language in the citations of
prognosis studies makes systematic searching difficult, and presents
challenges to the development and use of methodological filters.
Furthermore, few prognosis reviews employ search filters to assist in
citation retrieval. Validating filters based on relative recall of included
studies from systematic reviews has been effectively used in the past
to create test sets but this approach has not yet been widely applied in
prognosis research. Objectives: We will use the included studies from
prognosis reviews identified from the Prognosis Systematic Review
Database (PSRD) to validate various PubMed prognosis search filters
using relative recall. Methods: From reviews in the PSRD, we will
identify those that used an explicit prognosis search strategy; we will
include systematic reviews that meet methodological standards. Data
will be extracted about the topic, search strategy, methodological
search filter, and citation information for all included studies. Included
studies retrieved through PubMed will serve as a test set for validation
of the modified prognosis filters. Results: For the PSRD, we used a
sensitive strategy to search five high impact journals (all years) and
select prognosis systematic reviews. Relative recall using modified
prognosis filters will be compared to published precision of the Clinical
Queries prognosis filter. We will explore differences in effectiveness of
the filters for different research topics and for different types of prognosis
systematic reviews. Conclusions: Using a relative recall approach, we
will test the recall and precision of published and modified prognosis
filters to inform best practices for prognosis systematic reviews.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Using a search filter to improve literature
searching efficiency for clinical question
Amos Q1 , Chan W2 , Tom G1
Kaiser Permanente, Care Management Institute,
Permanente, NW Permanente, USA
Background: Guideline updates require comprehensive search
strategies to identify all relevant studies. The number of studies
identified initially can be quite large and requires an efficient process
to quickly identify the most relevant studies. Objectives: Describe
the methods used by a US health care delivery organization to create
comprehensive search strategies and filter results to improve efficiencies
in literature searching. Methods: A comprehensive search strategy
was constructed for a systematic review addressing a clinical question
within a cardiovascular disease guideline. Identified abstracts were
evaluated using a filter consisting of the top general medicine and
disease specific journals. If filtered abstracts met inclusion/exclusion
criteria, the systematic review was evaluated for possible updating
using key questions (e.g. do the newly identified studies change the
recommendation, confidence interval, or point estimate?). If yes, the
systematic review was updated necessitating review of all identified
abstracts. If no, the systematic review was not updated resulting in
no change to the clinical question. Results: Search strategy results
identified 396 abstracts; 98 were identified in key journals and did
not meet inclusion/exclusion criteria thereby warranting no update.
Reviewing 98 abstracts compared to 396 reduced review time by 75%.
Conclusions: Using a filter to review relevant abstracts saves time by
reviewing only those abstracts identified in top journals allowing the
updating process to proceed more rapidly.
Using social media and crowdsourcing to gather
important publications for a scoping review
about wikis and collaborative writing tools
Archambault PM1 , van de Belt T2 , Grajales F3 , Faber M4 , Kuziemsky C5 ,
Gagnon S6 , Bilodeau A7 , Rioux S6 , Fournier C6 , Nadeau C6 , Émond M6 ,
Aubin K8 , Gold I9 , Gagnon M8 , Turgeon A10 , Heldoorn M11 , Poitras J12 ,
Kremer J2 , Eysenbach G13 , Légaré F14
Department of Family Medicine and Emergency Medicine, Faculté
de médecine, Université Laval, Québec, Canada; 2 Radboud University
Nijmegen Medical Centre, Department of Obstetrics and Gynaecology,
Division of Reproductive Medicine, Nijmegen, The Netherlands; 3 IMIA
Social Media Working Group, Geneva, Switzerland; 4 Radboud University
Nijmegen Medical Centre, Radboud REshape and Innovation Center,
Nijmegen, The Netherlands; 5 Telfer School of Management, University
of Ottawa, Canada; 6 Centre de santé et de services sociaux AlphonseDesjardins (CHAU de Lévis), Lévis, Canada; 7 Institut national de santé
publique du Québec, Québec, Canada; 8 Faculté des sciences infirmières,
Université Laval, Québec, Canada; 9 Association of Faculties of Medicine of
Canada, Ottawa, Canada; 10 Division of Critical Care Medicine, Department
of Anesthesia, Faculté de médecine, Université Laval, Québec, Canada;
Federation of Patients and Consumer Organisations in the Netherlands,
The Netherlands; 12 Faculté de médecine, Université Laval, Canada;
Centre for eHealth Innovation, Université of Toronto, Canada; 14 Centre
de recherche du Centre hospitalier universitaire de Québec (CRCHUQ),
Québec, Canada
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: Social media like wikis, Google Docs and social reference
managers (e.g., Mendeley) could be used when conducting a scoping
review to crowdsource (i.e., obtaining content by soliciting contributions
from an online community) important unpublished work found in the
grey literature. Objectives: To compare the performance of email
and three crowdsourcing tools to collect and share citations to be
considered for inclusion in a scoping review. Methods: This study
is part of an ongoing scoping review. Our methodology has been
published (http://goo.gl/MbtIV). In addition to standard databases,
the grey literature sources searched for this review were: HTAi
vortal, Mednar, OpenSIGLE, Google, Bing and Yahoo. In order
to identify any missing articles or unpublished work, 40 experts
were invited by email to share relevant papers using one of three
different crowdsourcing tools: an HLWIKI page (http://goo.gl/oeL1I), a
Mendeley Group (http://goo.gl/alhpo) and a Google Docs spreadsheat
(http://goo.gl/QlyCC). We also tweeted about the study protocol. In
each of these crowdsourcing tools, we added some of the articles we
had found in order to stimulate reciprocal sharing and to give experts
an idea of the kind of papers we were looking for. Results: Figure
1 presents our flow chart. We sent emails to 40 different experts and
our protocol was tweeted 12 times (http://goo.gl/oe4jL). Direct email
generated the most responses (n = 10) which allowed us to identify
two papers that met our inclusion criteria. Mendeley and HLWIKI did
not generate any new articles. For the Google Docs spreadsheet, two
experts proposed two different links to papers, but none of them were
included in the scoping review. Conclusions: More research is needed
to identify the barriers and facilitators to the use of crowdsourcing in
academic research. This would help us understand how to improve
the use of crowdsourcing tools to support the conduct of knowledge
Attachments: Flow chart poster 1.pdf
Reporting methodological search filter
performance comparisons: a review
Harbour J1 , Fraser C2 , Lefebvre C3 , Glanville J4 , Beale S4 , Boachie C2 ,
Duffy S4 , McCool R4 , Smith L1 , Varley D1
Healthcare Improvement Scotland, UK; 2 University of Aberdeen, UK;
3 Lefebvre Associates Ltd, UK; 4 York Health Economics Consortium, UK
Background: Effective retrieval of literature is essential for
evidence-based healthcare. Methodological search filters are tools
for retrieving studies using specific research method. As the number
of filters proliferates, choice of filter is likely to be based on filter
performance data. Aim: To review measures reported and presentation
methods in comparing methodological search filter performance.
Methods: Studies were identified from the InterTasc Information
Specialists Subgroup (ISSG) Search Filter Resource website, a search
by the Cochrane UK Centre and references from a concurrent review.
Included studies compared two or more methodological search filters
for randomised controlled trials (RCTs), diagnostic test accuracy studies
(DTA), systematic reviews (SR) or economic evaluations. Results:
Eighteen papers met the review inclusion criteria comparing DTA (8),
RCT (5), SR (3), economic evaluations (1) and both RCT and SR filters (1).
The number of filters compared in a single study ranged from 2 to 38.
Seventeen studies assessed performance against a gold standard set
Cochrane Database Syst Rev Suppl 1–212 (2013)
of studies derived from hand-searching journals (10), included studies
from systematic reviews (5) or from database records (2). The most
commonly reported measures were sensitivity/recall (16) and precision
(13). Specificity was calculated for seven studies. All studies displayed
results in tables, generally listing filters in descending order by the
measure of interest. Results were given as percentages or proportions
in all studies. Two studies supplemented results tables with graphical
displays of data: bar graph of the proportion of retrieved and missed
gold standard references per filter; forest plot of the overall sensitivity
and specificity of each filter. Conclusions: The most commonly
reported measures in filter performance comparisons were sensitivity
and precision. Methods of presenting results of filter performance
comparisons were limited to tables and a small number of graphs.
Finding the largest pool of relevant citations in
MEDLINE using the Pearl Harvesting Information
Retrieval Theory
Sandieson R, Torabi N
Western University Canada
Background: Locating as many topic related research studies as
possible is critical for meta-analyses, systematic reviews and scoping
studies. However, performing a comprehensive literature search can be
complicated using current protocols, and evidence indicates difficulties
even for experienced researchers (e.g., Valentine et al., 2010). MEDLINE
is important for health sciences so developing a comprehensive, verified
system for information retrieval here is essential. Objectives: The
Pearl Harvesting Information Retrieval Theory is premised on finding
and using the largest possible set of topic related search terms (i.e.,
a synonym cluster) to locate a comprehensive set of relevant studies.
The present investigation tested this theory in MEDLINE using search
terms representing the topic of autism Methods: A synonym cluster
of search terms representing autism was produced according to the
theory. Testing was done comparing this list with terms from MeSH
searches and text searches used in 18 meta-analyses on autism in
the Cochrane library. Results: Twenty-three potential autism search
terms were found, nine of which were verified as essential. Two
terms were not used in any of the Cochrane Reviews, but they added
only a small number of relevant citations. However, many terms
used in the Cochrane Reviews produced thousands of non-relevant
citations, thereby making them unnecessary. Conclusions: Locating
the maximum number of relevant studies is critical for acquiring
knowledge leading to evidence informed decision-making. As found
here, also knowing what not to search is equally important in terms
of managing time and costs of searching. The Pearl Harvesting Theory
utilizes a unique, yet simple approach relying on a verified list of topic
related search terms. The effectiveness of this approach for the topic of
autism was indicated here in MEDLINE. Once located, synonym clusters
can be shared with all those interested in specific topics; saving time
and effort.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Searching for unpublished data for Cochrane
Reviews: cross-sectional study
Schroll JB1 , Bero L2 , Gøtzsche PC1
The Nordic Cochrane Centre, Denmark; 2 University of California, USA
Background: Failure to include unpublished data in meta-analyses
will generally lead to too positive results. New sources of unpublished
data have become available in recent years but it is unknown to
what extent such data are being used. Objectives: To describe the
experiences that Cochrane authors have with searching for, getting
access to and using unpublished data. Methods: Cross-sectional
survey of corresponding authors of Cochrane Reviews. Authors were
invited by e-mail to an online survey which contained open-ended and
closed questions. Results: We sent 5915 invitations and got 2184
replies (37% response rate). Of those, 1656 (76%) had searched for
unpublished data. In 913 cases (55%), new data were obtained, and
details about these data were provided in 794 cases. The most common
data source was trialists/investigators accounting for 74% (n = 587) of
the 794 data sources. Most of the data were used in the review (82%,
651/794) and 54% (424/794) received their data in less than a month.
Most common were summary data, which 51% (403/794) of the data
sources provided, whereas 21% (163/794) provided individual patient
data. Only 6% (50/794) reported to have obtained data from the
manufacturers and this group waited longer and used more contacts
to get the data. The data from manufacturers were less likely to be
individual patient data and less likely to be used in the review. Data
from regulatory agencies accounted for 3% (24/794) of the obtained
data. Conclusions: Most authors that searched for unpublished
data received useful data, primarily from trialists. Manufacturers and
regulatory agencies were uncommon sources of unpublished data.
Attachments: Figure1 - short.pdf
Dual monitors to increase efficiency
of conducting systematic reviews
Wang Z, Asi N, Elraiyah T, Abu Dabrh AM, Undavalli C, Murad M
Knowledge and Evaluation Research Unit, Mayo Clinic, USA
Background; Systematic reviews (SR) are the cornerstone of evidence
based medicine and guide the development of guidelines, policy
decisions and clinical decision making. However, a high-quality
SR takes significant resources and time. Methods to improve the
efficiency of conducting SRs are needed. Objectives: To evaluate
the effectiveness of using dual monitors (i.e. two screens for each
computer) on speed (measure of efficiency) and inter-rater agreement
among the two reviewers (measure of possible adverse effect of
speed). Methods: A cohort of reviewers before and after using
dual monitors was compared to a control group that did not use
dual monitors between 2009 and 2013. The outcomes of interest
were time spent for abstract screening, full-text screening and data
extraction, and inter-rater agreement measured by Cohen’s Kappa. We
adopted difference-in-differences linear regression models by adjusting
number of studies eligible for each step, number of questions for data
extraction, rate of complicated questions, and reviewer’s experience in
SRs and content expertise. Results: A total of 57 reviewers and 59 SRs
were included in the analysis. Compared to the control group, we found
Cochrane Database Syst Rev Suppl 1–212 (2013)
a significant reduction of time spent on data extraction (median time
difference = −22.23 minutes, 95% CI: −42.98, −1.48, p = 0.04).
No significant change was found in time spent on abstract screening,
full text screening, or inter-rater agreement (Table 1). Conclusions
Using dual monitors in SR reduces time spent on data extraction
without affecting inter-rater agreement.
Attachments: table.pdf
A numbers of randomized controlled trials
reported in Chinese literature are not covered
Zhang L, Wang Y, Lei JQ, Yang KH
Evidence-Based Medicine Center, School of Basic Medical Sciences,
Lanzhou University, Lanzhou, China
Background: More and more randomized controlled trials(RCTs) have
been published in Chinese journals; However, Language restriction can
be a problem for English-speaking countries collecting the relevant
research data when they conduct systematic reviews. Objectives: To
the aim of this survey is to assess the number of reporting of RCTs
in Chinese database comparing MEDLINE reporting Chinese literature
number. Methods: We conducted a comprehensive search using
the term of ‘random*’, including MEDLINE from 1983 to 2012, and
Chinese databases included Chinese BioMedical Literature (CBM) and
China National Knowledge Internet (CNKI). We counted the number
and calculated the proportion of RCTs in CBM and CNKI which are
linked to MEDLINE. Results: RCTs published in Chinese-based journal
have been incorporated in Medline since 1983. Chinese-based journals
included in MEDLINE increase annually (1% in 1983 vs. 10% in
2007), but are still a small proportion of the whole .152 237 RCTs were
indexed in CBM and CNKI form 1978 to march of 2013. Of those, 5661
were linked to MEDLINE with less than 4% of RCTs indexed in CBM and
CNKI not in MEDLINE. Percentage of Chinese language RCTs indexed
in CBM and CNKI, 99% of RCTs recorded in CBM and CNKI were
written in Chinese. We found that the maximum number is 547 RCTs
published in Chinese journals in 2007.After 2007, number of RCTs
published in Chinese-based journal but not incorporated in MEDLINE
has increased dramatically. In 2012, 7388 articles were classified as
RCTs in CBM and CNKI. Our survey revealed only 2512 articles (34%)
were true RCTs, and others were not RCTs. Conclusions: The number
of RCTs published in Chinese journal increases year by year. The
Chinese RCTs were also becoming valuable resources of systematic
reviews. The great majority of Chinese RCTs are not incorporated in
Medline. Local language literature database may not be neglected.
Proposal to establish a Cochrane Diet
and Nutrition Trials Register
Durão S1 , Volmink J2 , van Binsbergen J3
South African Cochrane Centre, South African Medical Research Council,
South Africa; 2 South African Cochrane Centre, South African Medical
Research Council and Centre for Evidence-based Health Care, Stellenbosch
University, South Africa; 3 Department of Primary and Community Care,
Radboud University Nijmegen Medical Center, Netherlands
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background and Objectives: Under- and over-nutrition negatively
affect the health and development of individuals and communities.
Evidence-based interventions addressing nutritional risk factors
contribute to ameliorating these effects. The Cochrane Diet and
Nutrition subfield of the PHC Field was formed in 2005 with the key
goal of supporting the preparation of nutrition reviews, which are
currently widely distributed across Review Groups. One of its original
aims was to establish a specialized register of nutrition trials but this
has not yet been realized. We propose establishing a Cochrane Diet
and Nutrition Trials Register with the following specific Objectives:
• Provide a comprehensive repository of randomized controlled trials
(RCTs) and controlled clinical trials (CCTs) assessing the effectiveness
of diet and nutritional interventions for systematic review authors and
other stakeholders. • Provide a resource to study the epidemiology
of nutrition trials and identify knowledge gaps for future research.
Methods: Studies will be included in the register if they meet the
eligibility criteria outlined in Table 1, regardless of publication status.
We will develop a search strategy, and conduct an initial comprehensive
search of all relevant sources, including CENTRAL, MEDLINE, EMBASE,
and other electronic databases recommended by nutrition experts. No
time or language limits will be used. We will assess eligibility through
screening of abstracts, or full-text articles if necessary. Another
investigator will conduct a quality check on a sample of the data. We
will store citations in Microsoft Access 2007, coding them as RCTs or
CCTs. Conclusions: We will collaborate with individuals and groups
within and outside of the Collaboration in the development of this
work. Immediate challenges identified include: • Development and
validation of a comprehensive search strategy with a filter for nutrition
trials. • Identify funding for developing and maintaining the register.
Attachments: Table 1 Eligibility criteria for selecting studies for the
Diet and Nutrition trials register.pdf
Evidence about colchicine for gout to be added
to 17th WHO EML
Lu J1 , Xu T1 , Li YP2 , Wu B1
Department of Pharmacy, Chinese Cochrane/EBM Centre, Evidence-Based
Pharmacy Direction, West China Hospital, Sichuan University, Chengdu,
China; 2 Chinese Cochrane/EBM Centre, West China Hospital, Sichuan
University, Chengdu, China
Background: Gout is the most common inflammatory arthritis and
Colchicine is the primary choice, which was not yet in the 17th
WHO Essential Medicines List and applied to be added. So we are
appointed to perform a review of colchicine for gout by the WHO
19th Expert Committee on Selection and Use of Essential Medicines.
Objectives: To assess the efficacy, safety, cost of colchicine for gout,
and provid evidence for WHO Expert Committee. Methods: Databases
of the Cochrane Library, PubMed, EMBASE, VIP, CNKI, Wanfang and
reference lists of relevant reports were searched. Systematic reviews,
meta-analysis, clinical guidelines and clinical studies of colchicine for
gout were included. Study inclusion, quality assessment and data
extraction were performed by two independent reviewers. We would
conduct meta-analysis if possible, or a narrative summary instead.
Results: One meta-analysis (43 patients), Five RCTs (550 patients),
and 118 case reports (118 patients) were included, and we conducted
two meta-analysis to evaluate the efficacy and dose relevant of
colchicine. Efficacy: the meta-analysis suggested that colchicine could
Cochrane Database Syst Rev Suppl 1–212 (2013)
reduce the pain or VAS score (MD: −34.00, 95% CI: −50.33, −17.67)
for gout with higher events of diarrhea (MD: 49.85, 95%CI: 15.28,
162.60), comparing with the placebo. Low dose has equal efficacy
with high dose (RR: 0.97, 95% CI: 0.75, 1.25), but lower events of
diarrhea (RR: 4.03, 95% CI: 2.81, 5.77). Safety: The major adverse
event is diarrhea, especially higher in high dose group. Other AEs
are neuromyopathy, leucopoenia, liver dysfunction. SAEs such as
rhabdomyolysis, multi-system organ failure also reported in some case
reports. Cost: The public price of colchicines is 0.2USD/1mg in China,
comparing the average cost of 0.11–0.13USD/1mg in most countries
except the USA. Conclusions: Based on current clinical evidence,
colchicine was effective for gout, ADRs are dose relevant, the cost
was acceptable. Low dose could be the priority choice. So, we
recommended colchicine be added to 17th WHO EML.
Attachments: pain relief.png, adverse event.png
International cooperation in the abstracts of the
20th Cochrane Colloquium
Yang KH1 , Sun R1 , Shi CH1 , Tian JH1 , Li L2 , Tian HL2 , Wang Q2
Evidence-Based Medicine Center, School of Basic Medical Sciences,
Lanzhou University, China 730000; 2 The First Clinical Medical College,
Lanzhou University, China 730000
Background: Cochrane Colloquium is the annual scientific and
business meeting of the Cochrane Collaboration, an international
network of more than 28 000 dedicated people from over 100
countries/regions. However, what countries/regions involved in the
Colloquium and how they worked with each other were unknown.
Objectives: To provide a visualized map of international cooperation
based on the abstracts of the 20th Cochrane Colloquium. Methods:
Two researchers (R Sun and CH Shi) extracted the information of
author’s countries/regions for each abstract of the 20th Cochrane
Colloquium. Co-occurrence matrix of author’s countries/regions was
built with the bicomb software and visualized with the UCINET software.
Results: There were 251 abstracts, including 68 oral abstracts and 183
poster abstracts, in the 20th Cochrane Colloquium, with involvement
of 44 countries/regions. The median of participant countries/regions
in one abstract was 1 (range: 1–12), and the five countries/regions
participated in most abstracts were USA (55, 21.9%), China (48,
19.1%), Canada (47, 18.7%), Australia (36, 14.3%) and UK (33,
13.1%). The visualized network (Fig. 1) showed that USA and Canada
were located near the center of the chart and had bigger node size,
which means they linked more to other nodes (European countries like
UK, Switzerland, Norway, Italy, Poland, Spain, Finland etc. as well as
Latin American Countries like Costa Rica, Argentina and Chile etc.).
Many Asian countries/regions (including China, Thailand, Singapore,
Japan, Korea, Myanmar and Taiwan) could be considered periphery
members. India, Belgium and Malaysia even had no links with other
countries/regions. Conclusions: USA and Canada participated in
the most abstracts, were located close the center of the international
network, and had closer relations with European and Latin American
countries/regions. Asian countries/regions, especially China, although
participated in many abstracts, but hardly cooperated with other
countries/regions, which need to be improved.
Attachments: Figure 1. Social network-mapping of the participating
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
The attention of reporting in journals’under
the Chinese Medical Association: research
on ‘instructions for authors’
Li XL1 , Li H1 , Yao Q2 , Bai Z3 , Yang KH3 , Ding G2
1 Evidence-Based Medicine Center, School of Public Health, Lanzhou
University, Lanzhou, China; 2 School of Public Health, Lanzhou University,
Lanzhou , China.; 3 Evidence-Based Medicine Center, School of Basic
Medical Sciences, Lanzhou University Lanzhou, China
Background: The Chinese Medical Association (CMA) is an important
social force in the development of medical science and technology in
China. The CMA publishes 126 medical journals covering all medical
fields till January 2013, and the journals’ Instructions for authors
provides recommendations for reporting to authors. However, the
information of the journals’ publication and reporting requirement of
these journals is unclear. Objectives: To know the basic information
of CMA journals and assess if they have a good reporting guide
for authors on the Instructions. Methods: We searched journals’
‘Instructions for Authors’ on journals’ websites, databases or Google
scholar, and extracted the information Instructions including journals’
publication place, publication frequency, reporting guidelines (PRISMA,
STROBE or CONSORT) mentioned or not, requirement on papers format
and so on by data extraction table predesigned. Journals included
in this research are under CMA’s and published in Chinese only.
Results: Of 96 journals included, 44 (45.83%) published in the capital
Beijing, 30 (31.25%) published in eastern region whicn excluding
Beijing city and 22 (22.92%) published in other regions. 56 (58.33%)
published monthly and 31(32.29%) bimonthly. 52 (54.17%) journals
had submission system online already and 47 (48.96%) metioned
peer-reviewed in Instructions for Authors, 11 (11.46%) published at
home and abroad. On the requirement on research format, 43 (44.79%)
mention ethics on people involved in and 1 (1.04%) mentioned ethic
on animals test, 90 (93.75%) journals had requirement in form
and 6 (6.25%) had requirement on content. 9 (9.38%) mentioned
explaination of methods choosing and 17 (17.71%) required on study
design. None mentioned authors to comply the recommendation in
the relevant reporting guidelines policy on the requirement in research
reporting. Conclusions: The reporting requirement and distribution
of CMA’s journals is unbalance in China. For the purpose of improving
reliability of medical research literatures, there is a need for CMA’s
journals to post more strict requirement and put reporting guidelines
in journals’ Instructions for Authors.
An analysis of randomized controlled trials of
tuberculosis prophylaxis and treatment in Africa
Abrams A, Kredo T
South African Cochrane Centre, South Africa
Background: Africa is severely affected by tuberculosis (TB). In 2011
sub-Saharan Africa carried the greatest proportion of new cases with
over 260 cases per 100 000 population. Completed, ongoing and
planned trial information is needed by health workers, researchers,
policy makers, consumers and other stakeholders, in order to apply
the best available strategies to treat and prevent the disease and to
Cochrane Database Syst Rev Suppl 1–212 (2013)
plan future research. Objectives: To identify and describe randomized
controlled trials (RCTs) of TB conducted in Africa. Methods: We
searched electronic databases to identify RCTs of TB in January 2013
The search strategy incorporates the highly sensitive RCT search string
developed by the Cochrane Collaboration and an African trials search
filter developed and validated at the South African Cochrane Centre.
We searched the Pan African Clinical Trials Registry (www.pactr.org)
for data on on-going trials.We analyzed the distribution of trials by
country and by decade and will further analyze trials conducted in the
past 20 years for clinical characteristics, principal investigators location
and funding patterns. Results: We obtained 4479 records describing
tuberculosis in Africa between 1966 and 2011. Of, 197 controlled
trials 51 trials focused on prevention, 135 on treatment and 33 on
vaccines. Fifty-four included children as participants. The highest
numberof trials were conducted in South Africa (67) Uganda (20),
Tanzania (17), Malawi (14), Nigeria (6) and Zimbabwe (5). Currently
there are 27 TB related trials registered in www.pactr.org Current
studies are conducted in South Africa (6), Tanzania (3), and one each
in Gabon, Zimbabwe, Zambia, Uganda, Mozambique. Conclusions:
Trial research related to TB is extensive and widespread in South Africa.
The focus on treatment, and the density of trials in the sub-Saharan
region highlight the disease burden of the region. Exploring the TB
trial landscape on the African continent can assist in directing limited
funds to appropriate endeavours.
Transferring knowledge: equity for health
professionals in Ethiopia
Hagstrom C1 , Kendall S2 , Pielechaty R2
1 Gerstein Science Information Centre, University of Toronto, Canada;
Mount Sinai Hospital, Toronto, Canada
Background: In response to the Ethiopian Government’s aim to
train 5 000 specialist MDs and PhDs and 10 000 Masters graduates
by 2018, the Toronto Addis Ababa Academic Collaboration (TAAAC)
was established to co-build capacity and sustainability in graduate
programming at Addis Ababa University (AAU). The Library Science
Project (LSP) began in 2008; librarians travelled to Addis in 2011 and
2012 to offer health literacy sessions. Objectives: A program for
clinical medical librarians will build capacity in library literacy skills,
including the accessing of up-to-date information, with foundational
knowledge of appraising the evolving literature in evidence-based
medicine and critical thinking skills to support medical faculty and
trainees. Methods: Annual train-the-trainer programs, as well as the
provision of access to the University of Toronto’s online resources by
affiliated researchers through the Ptolemy project, including clinical
decision support tools. Results: Approximately 400 learners have
attended sessions so far, including over 160 clinical residents. The
train-the-trainer aspect has resulted in a further 140 students being
instructed by in-country trainers. Conclusions: Our training sessions
reinforce and sustain medical library literacy skills for librarians through
an inter-professional exchange of in-country and distance training.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
The use of Cochrane Reviews for decision making
by a local public health department
Ward M1 , Ciliska D2
Peel Public Health, Canada; 2 McMaster University, Canada
Background: Peel Public Health, one of Canada’s largest local public
health departments, is midway through a ten year strategy focussed
on evidence-informed decision making. Central to the strategy is
a rapid review process, developed in-house, for finding, appraising
and applying the best available research evidence to program and
policy decisions. Objectives: For the first 24 rapid reviews, the
use of Cochrane Reviews in program decision making was examined.
Methods: Search results and relevance and quality assessments were
reviewed to identify which rapid reviews used Cochrane Reviews.
Topics were grouped according to domain of public health practice:
communicable disease control, environmental health, chronic disease
and injury prevention, family health, and other. Impact of the research
evidence on the program decision was evaluated using a standardized
tool for assessing applicability and transferability. Gaps were noted
for domains where there were no Cochrane Reviews. Results: A
total of 22 Cochrane Reviews were used in one third (8 of 24) of
the rapid reviews. Two reviews, both on workforce development,
accounted for more than half (12 of the 22 Cochrane Reviews). Each
public health domain used at least one Cochrane Review. However,
chronic disease and injury prevention was underrepresented in the
use of Cochrane Reviews. Research significantly influenced the final
program decision in 12 of 24 reviews. Other decisions were more
strongly influenced by politics, resources, reach or community needs.
Program decisions included stopping a program, staying the course,
developing a new approach to current programming, and starting a
new program. Conclusions: Public health decision making embraces
a range of factors, of which research evidence is only one. Cochrane
Reviews are being used regularly in our rapid review process, and are
influencing our program and policy decisions.
Do Cochrane Systematic Reviews help decision
makers from middle income countries? Update
of the Chilean experience
Pantoja T1 , Herrera C2 , Soto M3
Department of Family Medicine, Pontificia Universidad Catolica de
Chile/Cochrane EPOC Group; 2 Department of Public Health, Pontificia
Universidad Catolica de Chile; 3 Department of Family Medicine, Pontificia
Universidad Catolica de Chile
Background: Chile has been facing a health system reform since
2000, in which health services for 80 health conditions have been
prioritized. Policy-makers need the best evidence to decide on the
efficacy of interventions for these conditions. Systematic Reviews (SR)
of comparative studies represent the best quality evidence for questions
about effectiveness and the Cochrane Collaboration is committed to
making them widely available. In 2006 we reported the availability of
Cochrane SRs (CSRs) for clinical questions related to the first 56 health
conditions of our health reform. Up to 2012, 24 additional conditions
have been included. Objectives: To update to what extent CSRs
Cochrane Database Syst Rev Suppl 1–212 (2013)
respond to the needs of policy-makers in the Chilean health reform.
Methods: We retrieved the last version of clinical guidelines issued
for each of the 80 prioritised health conditions from the Ministry of
Health (MoH) website. We identified the recommendations included in
each guideline and the evidence supporting them (in footnotes and/or
lists of references) focusing on the presence of SRs. Results: We
assessed 72 clinical guidelines from the MoH website. There was no
guideline available for the other 8 conditions. They presented a median
of 19 recommendations (range 4–211). Fifty-seven of them (79%)
made reference at least to one systematic review, with a median of 5.5
reviews cited (range 1–38) by guideline. Regarding Cochrane Reviews,
39 (54%) of the guidelines cited at least one of them, with a median
of 3 (range 1–21) reviews per guideline. Conclusions: Cochrane
and non-Cochrane systematic reviews have been used by the guideline
development groups in the Chilean health system. However, there is a
wide variation in their use in the different clinical areas covered by the
High risk cancer screening in workers exposed
to asbestos. Application of evidence through
partnerships in managing injured workers
Martin C1 , Rothfels P2 , Lam S3 , Dunn C4 , Pelman G1 , Noertjojo K1
Evidence-Based Practice Group, Clinical Services, WorkSafeBC; 2 Clinical
Services, WorkSafeBC; 3 Respiratory Division, Faculty of Medicine, UBC;
Medical Services, WorkSafeBC
Background: Epidemiological studies demonstrated that patients
with asbestosis have a 6× increased risk of developing lung cancer
and people who smoke have an 11× increased risk of developing
lung cancer. However, people who are diagnosed with asbestosis and
smoke have a 59× increased risk of developing lung cancer. Several
high quality systematic reviews and recent randomized controlled trials
showed that screening these high risk individuals with low does chest
CT scanning may lead to early detection and treatment of lung cancers.
At present, WorkSafeBC has approximately 200 workers that have
been diagnosed with asbestosis and the vast majority of these workers
are smokers or ex-smokers. Objectives: - To describe evidence-based
policy development in the area of occupational medicine - to describe
the process and implementation of such policy - to describe early
outcome of this policy. Methods: Systematic review based business
proposal was developed by concerned departments at WorkSafeBC
and presented to the senior executives for funding approval. - Outside
stakeholders, including the BC Cancer Agency, were identified and
engaged in the development of the screening protocol. - Upon senior
executives’ approval, the program was implemented and outcome
monitoring is ongoing. Results: - Low dose CT lung cancer screening
program among workers exposed to asbestos started in January 1,
2013 is ongoing - Development process of this screening project, incl.
the evidence-based protocol, will be described as well as the early
outcomes. Conclusions: Among workers exposed to asbestos, low
dose CT scan screening is effective in detecting lung cancer at early
stage, provides better quality of life to workers and cost-effective to
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Utilizing a logic model framework to evaluate
patient navigation interventions on colorectal
cancer screening time to diagnostic follow-up
care: a study protocol
McIntosh B, Kazanjian A
University of British Columbia, Canada
Background: Colorectal cancer (CRC) is the second leading cause
of adult cancer death in the United States. CRC mortality rates can
be reduced through screening using a Fecal Occult Blood Test and
timely follow-up care. Following a positive CRC screening result, a
patient must undergo diagnostic follow-up. Patient navigation (PN)
uses trained individuals to guide patients through the healthcare
system to obtain care. A growing body of evidence examines whether
PN decreases the time from CRC screening to diagnostic follow-up;
however, there is a paucity of reviews examining this topic, and where
reviews exist, most underutilize logic models. Logic models can improve
systematic reviews through evaluative reasoning and methodological
transparency. Objective: Using a logic model framework, this
systematic review will assess the effects of PN interventions on times
from CRC screening to diagnostic follow-up. Methods: Utilizing
a conceptual and analytical logic model framework, the Cochrane
Colorectal Cancer Group Specialized Register, Cochrane Central
Register of Controlled Trials, MEDLINE, Cochrane Library, PsycINFO,
Dissertation Abstracts, and CINAHL will be searched without language
restrictions for studies dated from December 1995 to July 2013.
Randomized controlled trials and controlled clinical trials assessing
times from CRC screening to diagnostic follow-up will be selected.
Participants will include adults age 50 and above. One reviewer will
screen the studies for relevance and two will independently assess
the studies for inclusion. Data will be extracted by one reviewer
and assessed by two. Studies will be evaluated on the population,
intervention, comparison, outcome, setting, fidelity, and bias will be
assessed using the Cochrane Risk of Bias Tool. Results: Results will be
presented using summary tables. Discussion: This updated systematic
review will fill a gap in evidence and improve efficiency within the
healthcare system by using a logic model framework to evaluate the
effects of PN on timely CRC diagnostic follow-up.
Evidence-Informed Healthcare Renewal Portal:
the development of an online repository of
policy-relevant documents addressing
healthcare renewal in Canada
Kowalewski K1 , Moat KA2
EIHR Portal, McMaster Health Forum, McMaster University, Canada;
2 Health Systems Evidence, Program in Policy Decision-making, McMaster
Health Forum, McMaster University, Canada
Background and objective: Policymakers need timely access to
different types of evidence that can be integrated with the messages
arising from systematic reviews. The Evidence-Informed Healthcare
Renewal (EIHR) Portal makes readily available online policy-relevant
Cochrane Database Syst Rev Suppl 1–212 (2013)
documents that address healthcare renewal in Canada. It is a
collaborative effort between the McMaster Health Forum and the
EIHR Roundtable, which is comprised of various governmental and
non-governmental Canadian health organizations. Our objective
is to describe the development, content and usage of the EIHR
Portal. Methods: The EIHR Portal was developed in several stages:
(1) A taxonomy of 24 document types that address priority areas
identified by Canadian health care organizations was iteratively
developed and integrated with a pre-existing taxonomy of health
systems arrangements; (2) Roundtable members referred documents
for eligibility assessment; and (3) Two independent reviewers assessed
documents for eligibility and coded each based the taxonomies.
Descriptive statistics about the Portal’s contents and usage are collected
each month. Results: There are717 documents included in the EIHR
Portal. The top document types are situation analysis (n = 271),
health and health system data (n = 134) and jurisdictional review
(n = 71). The top national priority areas addressed in the documents
are health human resources (n = 586), quality as a performance
indicator (n = 392) and information technology (n = 312). There
are 1081, 71 and 570 systematic reviews that address these same
priority areas in HSE, and interested users are prompted to consult
them with links. There are currently 373 policymakers, stakeholders
and researchers signed up to receive EIHR Portal content updates,
and 713 of the users registered for Health Systems Evidence (HSE)
have enabled content from the Portal. Conclusions: The EIHR
Portal provides health policymakers in Canada with easy access to
the range of policy-relevant evidence focused on health systems while
promoting the use of systematic reviews through lateral linkages
to HSE.
Evidence-based guideline implementation
within primary care practices on hypertension
and diabetes
Stein AT, Sirena SA, Baldisserotto J, Kopitke L
Grupo Hospitalar Conceicao
Background: The implementation of evidence-based guidelines
(EBG) into the clinical practice of primary care teams is essential
to achieve quality assurance in this setting. There is a need
to define the framework for deciding the effectiveness to develop
and introduce clinical guidelines, as patients with diabetes and
hypertension typically obtain most of their care from primary care
providers (PCPs). Objectives: To undertake a literature review
on the effectiveness of guideline implementation on hypertension
and diabetes in a primary health care setting. Methods: The
MESh terms used in this review were: implementation, guideline,
hypertension, diabetes and primary health care. MEDLINE, Cochrane
Controlled Trial Register, EMBASE, and the specialized register of the
Cochrane Effective Practice and Organization of Care (EPOC) group
were used as data sources. Separate analyses were undertaken for
comparisons of different types of intervention. Results: There are
four types of strategies for implementing an evidence-based guideline
in hypertension and diabetes: (1) educational training, including
face-to-face training individual or grouped sections, manuals for
self-directed learning, patient management flow-charts, practice based
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
education and newsletters; (2) internal or external audit, including
feedback reports on performance and peer review; (3) Information
Communication Technology devices; (4) combination among the
different kind of interventions. Conclusion: The implementation
of EBG instruments is likely to improve the process of care in diabetes
and hypertension, rather than patient outcomes. Decision-makers need
to integrate several approaches on the management of hypertension
and diabetes.
Attachments: cochrane abstract implementation EBG.pdf
Cochrane Journal Club: meeting the expectations
of our growing membership
Urquhart B1 , Cayley W2 , Clarke M3
Wiley, Chichester, UK; 2 University of Wisconsin, Department of Family
Medicine, Augusta, USA; 3 Queens University Belfast, Belfast, UK
Background: Cochrane Journal Club (CJC) was launched in October
2009 to promote awareness of Cochrane Reviews, educate students
and others to critique and use research findings, and aid in the
translation of research into practice. By the 21st Colloquium in
Quebec, CJC will have been published monthly for almost four
years (www.CochraneJournalClub.org). Objectives: To analyse data
collected from visitors to CJC. To identify the CJC issues receiving the
highest number of unique visitors in the first 2 months of publication.
To survey users of CJC to find out how they use the CJC resources and
whether the materials presented meet their requirements. Methods:
Google Analytics has been used to collect data on visitors to the
CJC website since launch. In addition, an online survey of users was
circulated to the CJC membership list in March 2013. The survey will
be compared to an earlier CJC user survey, conducted in 2010. We
will also discuss practical experience with the CJC in one residency
program, including recommendations from that experience that have
emerged for possible improvements or added features to CJC. Results:
In April 2013, the CJC website has 7806 members and there have
been 158 000 unique users. Most visitors come from the UK (25.6%
of all visitors). The rest of the top 10 (in decreasing number of
visitors) are US, Australia, India, Canada, Italy, Spain, China, Brazil
and Japan. The user survey will be analysed during May 2013 and
presented with updated usage data at the 21st Cochrane Colloquium
in Quebec. Conclusion: Each issue of CJC is reaching a wide audience
and CJC is a valued resource. We wish to continue to develop CJC
to meet the expectations of users and provide resources that match
their needs.
Easy access to information on evidence based
mental health interventions for children in
Norway: the website ‘Ungsinn’
Martinussen M, Reedtz C, Eng H, Willy-Tore M
RKBU-Nord, University of Tromsø, Norway
Cochrane Database Syst Rev Suppl 1–212 (2013)
Background: Practitioners and decision-makers in the area of child
and adolescent mental health are in great need of information about
available evidence based interventions for treatment, prevention
and mental health promotion. The Norwegian web-site Ungsinn
(Youngmind) has been developed to facilitate easy access to information
about interventions and their knowledge base. The website was
developed upon request from the Norwegian Directorate of Health.
The purpose of this presentation is to present the aims and structure
of the Ungsinn website as well as the criteria for classification of
interventions. Communicating evidence: Each intervention on the site
is presented by a description followed by a classification of evidence
level. A review of existing research with emphasis of effect studies is
an important part both of the description and serve as a basis for the
classification. The database ‘Ungsinn’ aims both to give practitioners
new knowledge, but also to stimulate to more research. Evidence may
include a wide range of research designs and methods, not only the
RCT studies. The criteria for classification in Ungsinn are built as a
‘bottom—top model’. This means that the criteria for inclusion at the
lowest level of evidence are fairly simple and will include interventions
with potential for being effective. By conducting further research;
interventions can climb up the ladder of evidence, and receive a higher
ranking. The top level of evidence reflects the most desirable research
design to ensure intervention effectiveness. A total of 35 interventions
have so far been described and rated in ‘Ungsinn’. Conclusions:
Ungsinn seeks to reach the goal of contributing to improved services
to children and their families by simplifying access to knowledge,
stimulating to more research on interventions, and by highlighting
areas in need of more evidence.
Designing a social media strategy for a Cochrane
Thomas J1 , Mayoral J1 , Riis J1 , Owens N2 , Chapman S3 , Millward H3 ,
Welsh E4 , Irving C5
1 Cochrane IMS Team, Denmark; 2 Cochrane Web Team, Australia; 3 UK
Cochrane Centre, UK; 4 Cochrane Airways Review Group, UK; 5 Cochrane
Schizophrenia Review Group, UK
Background: Cochrane entities continue to seek effective ways
of communicating information, both within the Collaboration and
to those interested in our work, such as consumers and other
stakeholders. Social media is one of the fastest growing areas in
modern communication technology and allows users to share, create,
discuss and modify content and information quickly and effectively. Any
communication plan should consider the importance of incorporating a
social media strategy to promote news about the entity’s work, attract
larger audiences and offer opportunities for engagement. Objectives:
Design and share an effective Cochrane social media strategy which
could be adapted by any Cochrane entity. Any plan should allow entities
to share news and resources with a wider audience, and promote more
effective communication, engagement and participation. Methods:
This work will be developed in collaboration with several Cochrane
entities who are at different stages in their use of social media. In
developing a social media strategy, we will identify benefits in terms of
participation and engagement on topics with other Cochrane entities;
recognise improvements in understanding by users of our services;
and evaluate increased interactions with stakeholders. As part of the
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
strategy we will also consider the value of a social media policy and
how developing a social media strategy fits in to the broader context
of an entity communication plan.
Consumer participation on a Cochrane Review
Gunderson J1 , Brachaniec M1 , Rader T1 , Busch A2
Cochrane Musculoskeletal Group; 2 Author Cochrane Musculoskeltal
Background: In 2011, two consumer volunteers were invited to join
the writing team on a series of reviews on exercise for fibromyalgia. The
role of consumers on the writing team was established. Methods: The
review team meets once a month via SKPYE or Blackboard Collaborate.
Materials circulated electronically prior to meetings include agendas
and instructions regarding preparation as needed. The two consumers
take part in team meetings and are prepared to comment in all
discussions. Consumers help evaluate outcome measures, provide
reflections on summaries of included studies, and help identify research
gaps and priorities for future reviews. In the area of knowledge
translation, consumers review manuscripts, provide feedback about
the suitability for lay audiences, assist in developing plain language
summaries, and help to develop a knowledge translation plan to share
results with lay audiences. Challenges- Consumers needed to learn
various technical and scientific terms along with becoming familiar with
software such as DropBox and Review Manager. Although there was a
definite learning curve, all consumer members were able to meet these
challenges. Results: All team members including the two consumers
adjusted to the new technologies allowing full participation from across
Canada including a rural area. The traditional role of a consumer with
a Cochrane Review has grown considerably with this writing team.
Conclusion: This approach demonstrates ways to include consumers
throughout the entire review process, from planning to manuscript
preparation. Consumers felt included and valued by the team, while
scientific members appreciated the insights and opinions offered by the
consumer collaborators.
Café Scientifique—public outreach
Tarbett L
Canadian Cochrane Centre, Canada
Background: The ‘Café Scientifique’ funding program is an innovative
initiative funded by the Canadian Institutes of Health Research (CIHR).
The goal of a Café Scientific is to bring together researchers with
members of the public to spark a discussion about some of the most
interesting research currently underway in Canada. Objectives: The
Canadian Cochrane Centre (CCC) applied to the Canadian Institutes
of Health Research’s (CIHR) Café Scientifique funding program to
hold a public discussion titled, ‘Health information in the age of the
internet. Why Google your health questions when you can Cochrane
them’? The goal of this particular Café Scientifique was to inform
the local public about a valuable online resource in which they could
research reliable health treatment evidence: The Cochrane Library.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Given that one in three adults search health information online, it is
crucial that they understand which sites are reputable and have the
best evidence on which to base their health decisions. Results: The
CCC’s application was successful and ranked sixth out of 82 approved
applications (94 submissions). The Café was a tremendous success.
There were 73 attendees and all feedback received was positive. The
Café was held just after working hours in a pub which provided an
ideal time of day and atmosphere. Many participants inquired as to
when we would be holding our next event. Conclusions: The Café
Scientifique program provided a relaxed atmosphere in which the public
could feel comfortable engaging with scientists/researchers/physicians
to whom they often do not have the opportunity to speak. Café
Scientifiques are a great way to engage the public in learning about
The Cochrane Collaboration, The Cochrane Library and Cochrane
Review evidence. Given that many of today’s interactions take place
online, this face-to-face event was a unique opportunity to bring the
public and researchers together.
Attachments: CafeScientifiquePoster.pdf
The young doctor’s opinion on Evidence-Based
Health Care (EBHC) in Stellenbosch University’s
medical curriculum
Rohwer A1 , Young T2
1 Centre for Evidence-based Health Care, Faculty of Medicine and Health
Sciences, Stellenbosch University, South Africa; 2 South African Cochrane
Centre, South African Medical Research Council
Background: Stellenbosch University (SU) has obtained funding
for the Stellenbosch University Rural Medical Educational Partnership
Initiative (SURMEPI), aiming to enhance the skills of doctors in HIV/AIDS
and TB care, as well as increasing the research capacity in this field.
Strengthening Evidence Based Health Care (EBHC) knowledge and
skills at an undergraduate level is particularly important within this
context.This survey is part of a situational analysis of undergraduate
EBHC teaching at SU. Objectives: To gather perspectives of recently
qualified doctors regarding the appropriateness of undergraduate EBHC
teaching. Methods: We invited doctors to participate in an electronic
survey by sending bi-weekly emails. We analysed quantitative data
using SPSS statistical software. Qualitative data was managed and
coded with the help of Atlas.ti software. We grouped codes into
emerging themes for each question. Ethics approval was obtained.
Results: We obtained 375 (38%) responses. Most respondents agreed
that it was important to learn EBHC at undergraduate level and that
EBHC teaching at SU was adequate. However, in contrast to rating
EBHC teaching as adequate in the quantitative part of the survey,
qualitative responses showed that newly qualified doctors found that
they lacked EBHC skills. They felt that EBHC teaching should be
integrated into clinical rotations by making use of relevant examples.
They recommended that interactive teaching methods, as well as
online learning platforms and social media could be used. Access
to information in the clinical field emerged as the most important
challenge when practicing EBHC. Time constraints, work-overload,
lack of self-motivation and the work environment were also listed
as barriers. Conclusion: Although there is some EBHC teaching at
undergraduate level, graduates feel that they are not well equipped to
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
practice EBHC. EBHC teaching should be integrated into a variety of
disciplines. SU should consider granting their alumni access to their
online library.
Knowledge translation: the number, coverage,
and application of Cochrane Reviews in China
Mao X1 , Jia P1 , Du L2 , Zhang M1
Chinese Cochrane Center, West China Hospital, Sichuan University, China;
Journal of Evidence-Based Medicine, China
Background: It was reported that Chinese authors were the third
largest contributor in the Cochrane Collaboration. However, little
is known about the coverage and application of Cochrane Reviews
in China. Objectives: To investigate the number, coverage and
application of Cochrane Systematic Reviews (CSRs) in China. Methods:
We searched Archie from 2006 to 2011 for the information of reviews
published by at least one Chinese author and the distribution of
Chinese authors in CRG. We searched the Chinese Science Citation
Database (CSCD) using the term ‘Cochrane’ from 1989 to Deccember
2012 to know the application of CSRs. Microsoft Excel 2007
was used to perform data extraction and analysis. Results: The
number of publication for full Reviews by at least one Chinese
author was increasing from the year 2009 to 2011, with 143, 177
and 217 respectively. The distributions of Chinese authors in top
ten groups were: Hepato-Biliary (192), Renal (173), Stroke (106),
Heart (99), Ear, Nose and Throat Disorders (90), Oral Health (85),
Gynaecological Cancer (83), Acute Respiratory Infections (77), Epilepsy
(68), Hypertension (68). There were 3468 CSRs cited by the Chinese
medical Journals, which of 2998 CSRs were cited once. A total of 450
CSRs were cited more than twice. The Chinese articles citing CSRs
increased dramatically from 2 articles in the year of 2000 to 560 articles
in 2011. In the 600 Chinese medical journals included by CSCD only
158 journals cited CSRs counting for 26%. The top five Chinese medical
journals cited CSRs were: Chinese Journal of Evidence-Based Medicine
(656), Chinese Journal of Tissue Engineering Research (240), World
Journal of Gastroenterology (176), The Journal of Evidence-Based
Medicine (173), Chinese Journal of Practical Gynecology and Obstetrics
(123). Conclusions: The application of Cochrane Reviews in China is
still limited and need to be improved.
Usefulness of Cochrane Systematic Reviews
in health technology assessments in Argentina
Ciapponi A, Pichón-Riviere A, Garcı́a Martı́ S, Glujovsky D, Bardach A,
Alcaraz A, Augustovski F
Argentine Cochrane Centre - Institute for Clinical Effectiveness and Health
Policy (IECS)
Background: Health Technology Assessment (HTA) has been increasingly considered for decisions in health care policy in many countries
but this trend is just beginning in Latin America. The Institute
for Clinical Effectiveness and Health Policy (IECS) is a leader HTA
agency that provides its reports to public and private institutions
Cochrane Database Syst Rev Suppl 1–212 (2013)
in Argentina. Objectives: To describe the usefulness of Cochrane
Systematic Reviews (SR) in the production of HTA documents by a
weighty HTA agency in Argentina and to establish differences over
time. Methods: All HTA documents (rapid response documents, brief
technical documents, and complete HTA) produced since 2000 will be
assessed and will be classified as: (a) evaluating drugs; (b) therapeutic
procedures; and (c) diagnostic procedures. Documents can be accessed
through internet (www.iecs.org.ar). Pairs of independent researchers
will evaluate the number of HTAs using SR, how much coincidence
you found between the question of the HTA and the question of the
SR that was used (very/enough/poor/not related), the contribution of
the SR to answer the HTA’s question (entirely/enough/marginally/null),
problems of the SR to answer de HTA’s question (non-updated SR, bad
quality, applicability, none). Discrepancies will be solved by consensus.
We will analyse separately Cochrane SR (CSR), and non-Cochrane SR
(NCSR) and the NCSR/CSR ratio stratified by the previously mentioned
classification. This analysis will be compared with a random sample of
100 HTAs published in the Centre for Reviews and Dissemination (CRD)
database during the year 2012. Results: 315 HTA documents were
published by IECS since the year 2000. The results will be presented at
the Colloquium.
CRISP: online summaries of Cochrane Reviews
for policy
Turner T, Brennan S, Cossens L, McDonald S
Australasian Cochrane Centre, Monash University, Australia
Background: Systematic reviews are a key source of research to
guide health policy, however, relevant reviews can be difficult for
policy-makers to identify and are often challenging to apply in
practice. CRISP (Cochrane Reviews Identified and Summarised for
Policy) provides web-based summaries of Cochrane Reviews that are
relevant to health policy. Objectives: To support the use of research
to inform health policy by providing policy makers with access to
reliable and relevant research in an accessible format. Methods:
Each issue of The Cochrane Library is scanned to identify new and
updated reviews relevant to health policy. Reviews are appraised using
AMSTAR, and the location of the included studies and the authors of
the review are indicated on a map. The key messages derived from
the review are displayed on the front page of the summary along
with the essential characteristics of the review (PICO, study settings
and study quality). Users of the site can click through for more
details about the review (‘What the authors looked for’ and ‘What
they found’) plus a summary of the main results. There are also links
to the review in The Cochrane Library and to related reviews within
the CRISP site and within the Library. Results: The CRISP website
(www.policymakers.evidencemap.net) currently contains more than
150 summaries of Cochrane Reviews. To enable browsing, reviews
are grouped into six broad categories (e.g. population health; health
systems) and then by sub-groups within each category (e.g. injury
prevention; financing). Individual reviews are then linked to narrow
questions, such as ‘What works to prevent occupational injuries’. The
site also supports free-text searching. Conclusions: Cochrane Reviews
are a valuable source of evidence to inform health policy decisions but
can be difficult to use. CRISP summaries present the key information
and findings of policy-relevant reviews through an easily accessible site.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Reporting of interim analyses, stopping rules,
and data safety and monitoring boards
in protocols and publications of discontinued
randomized trials
Stegert M1 , Kasenda B1 , von Elm E2 , Briel M1
1 Basel Institute for Clinical Epidemiology and Biostatistics, University
Hospital Basel, Switzerland; 2 Cochrane Switzerland, Health Care Evaluation
Unit/IUMSP, CHUV and University of Lausanne, Switzerland
Background: Pre-planned interim analyses, stopping rules, and
the presence of an independent Data Safety and Monitoring Board
(DSMB) are means to increase transparency and credibility of the
decision-making process in case of randomized controlled trials (RCTs)
discontinuation. Objectives: To determine: (1) the prevalence
of planned interim analyses, stopping rules and DSMBs in RCTs;
(2) the purpose of interim analyses (safety, efficacy, futility, other);
(3) the proportion of discontinued trials which report DSMBs; (4) the
proportion of discontinued trials with a matching stopping rule;
(5) discrepant reporting between protocols and publications; and
(6) trial characteristics associated with reporting of planned interim
analyses, stopping rules, and DSMBs. Methods: A multi-centre
cohort of RCTs was established including protocols approved by six
research ethics committees (RECs) in Switzerland, Germany and Canada
between 2000 and 2003. Data on trial characteristics were extracted
from protocols and corresponding publications. The completion and
publication status of RCTs was assessed using information from
REC files, literature searches, and by investigators survey. Results:
We included 949 RCT protocols. Of these, 302 (31.8%) reported
interim analyses, 160 (16.9%) stopping rules, and 263 (27.7%)
the presence of DSMBs. The main reported purposes of interim
analyses were: efficacy (26.2%), safety (19.2%), and both combined
(21.9%). Of a total of 250 (26.3%) discontinued trials (due to any
reason), 63 (25.2%) mentioned a DSMB in protocol. We found some
evidence for an association between pre-specification of a stopping
rule and trial discontinuation (odds ratio 1.56, 95% CI 0.98–2.49,
p 0.06). However, only 10/250 discontinued RCTs pre-specified
a matching stopping rule in the protocol [benefit (N = 3), harm
(N = 6), futility (N = 1)]. Full results regarding all outlined
objectives will be presented at the Colloquium. Conclusions:
Trial discontinuation appears to happen mostly ad-hoc. Systematic
reviewers should bear this in mind when assessing the risk of bias of
discontinued RCTs.
Systematic reviews on nutrition interventions
relevant to low and middle income countries:
descriptive assessment of methodological
Salam R1 , Welch V2 , Das J1 , Bhutta Z1
Aga Khan University, Karachi, Pakistan; 2 Bruyere Research Institute,
University of Ottawa, Canada
Background: Less than a quarter of developing countries are
on-track for achieving the Millennium Development goal of halving
Cochrane Database Syst Rev Suppl 1–212 (2013)
under-nutrition. Rigorous and transparent systematic reviews are
recognized internationally as a credible source for evidence of effects.
However, in the nutrition field, there are a number of conflicting
systematic reviews which has reduced their credibility. Objective:
We aimed to assess the reasons for conflicting findings of systematic
reviews in four purposefully selected areas of nutrition. Methods: We
identified a purposive sample of systematic reviews in four areas of
nutrition. We assessed the following possible reasons for differences
in conclusions and Results: (1) methodological quality; (2) risk of bias
assessment of included studies; (3) inclusion and exclusion criteria;
(4) methods used (e.g. subgroup analyses, applicability assessment);
and (5) external factors. Results: We included 90 systematic reviews
across nine content areas. We found that the definition of the
question influenced the results of reviews. The generalizability was
dependent upon which components of an intervention were included,
whether the population was undernourished or healthy, whether
outcomes were defined by clinical diagnosis or self-reported symptoms,
and whether the control group received an active intervention or
placebo. Methods used to conduct the systematic reviews also
varied substantially across the 90 systematic reviews. There were
variations in study designs, eligibility criteria and methods for assessing
mediating effects. Conclusion: There is a need for improved
justification of methodological choices in systematic reviews on
nutrition. We propose the need to follow standards for conducting
and reporting systematic reviews, such as the Cochrane Handbook
and PRISMA reporting guidelines. We propose there is a need to
develop nutrition-specific guidance and centralized editorial review for
nutrition-related reviews. The Cochrane and Campbell Collaborations
are ideally positioned to carry this initiative forward due to their
international reputation for rigour, transparency and freedom from
conflicted funding.
Is adequate reporting on health equity
in systematic review equivalent to an equitable
recommendation? A case report
Shi CH, Tian JH, Wang Q, Yang KH
Evidence Based Medicine Centre of Lanzhou University, China; School of
Basic Medical Sciences, Lanzhou University, China
Background: Transparently reporting of equity-focused systematic
review (SR) is recognized as a contribution to improving the evidence
base for evidence-informed, equity-oriented recommendation.
Objectives: Aim to discuss whether adequate reporting on health
equity in SR is equivalent to a evidence-based, equitable recommendation. Methods: We conducted a case report, basing on a WHO
‘Guideline: vitamin A supplementation in pregnancy for reducing
the risk of mother-to-child transmission of HIV’ [1]. The reporting
characteristics on health equity of all systematic reviews which
are used in guideline are investigated by PRISMA-E 2012 [2].
Then we investigated which factors are considered to formulate
recommendations and discussed the relationship between reporting
on equity and equitable recommendation in further. Results: Only
one Cochrane Review [3] is used by the guideline, which assessed the
effects of vitamin A targeted at HIV-positive women. Sexual (sexual
health status), place of residence (low- and middle- income coutries)
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
and age (i.e. HIV-positive pregnant women, different children’s
age groups) factors are considered in this review. 7 items (i.e.
Items 2B, 3A, 6, 6A, 16, 26 and 26A in PRISMA-E 2012 checklist)
are not adequately described, especially items on extent and limits
of applicability to HIV-positive women, the logic model/analytical
framework, a pre-specified subgroup analysis to investigate the
differences across age and place of residence factors, etc. According
to PROGRESS-Plus framework, only sexual (sexual health status) factor
is incorporated to formulate the only recommendation. However, they
are lack of recommendations on different age groups and countries,
although relevant evidences of synthesizing findings are adequately
reported in results section. The main reason maybe no significant
effects on the primary outcomes. Conclusions: Although they are
summaried and reported in SR, relevant evidences on equity in this
case are not used to develop corresponding recommendations, which
limit their usage in policy making of health equity where relevant.
La généralisation des résultats de méta-analyses
dans les recommandations formulées par les
organisations internationales
Druetz T, Ridde V, Haddad S
Université de Montréal, Centre de Recherche du CHUM, Canada
Background: Les méta-analyses sont généralement considérées
comme des études fournissant des preuves scientifiques d’excellente
qualité, et elles influencent les recommandations sanitaires des
organisations internationales. Afin d’augmenter la validité interne
des résultats de méta-analyses, des outils d’évaluation de biais ont été
développés, notamment par Cochrane. Toutefois, les méta-analyses
peuvent aussi présenter des problèmes de validité externe. Objectives:
Notre objectif est de mesurer le décalage qui peut s’opérer entre la
généralisabilité des résultats de méta-analyses et la portée effective
de leurs conclusions à travers les recommandations internationales.
Incidemment, notre mission est d’attirer l’attention sur la nécessité
de développer des outils d’évaluation de la validité externe des
méta-analyses. Methods: Nous avons réalisé une étude de cas autour
du thème de la prise en charge de la pneumonie infantile par des
agents de santé communautaires [CCMp]. Cette étude a consisté
à: (i) recenser et apprécier la validité externe des méta-analyses
ayant évalué les impacts de la CCMp et; (ii) examiner la portée
des recommandations internationales. Results: Trois méta-analyses
ont démontré l’efficacité de la CCMp pour réduire la mortalité et
la morbidité attribuables à la pneumonie. Hormis une, toutes les
études incluses dans ces méta-analyses ont été conduites sur le
continent asiatique. Les organisations internationales, s’appuyant sur
ces preuves, recommandent désormais l’implantation de la CCMp
dans les pays prioritaires du Compte à rebours pour l’atteinte des
Objectifs du Millénaire pour le Développement, dont la plupart
sont situés en dehors du continent asiatique. Conclusions: Cette
étude montre que la validité externe des méta-analyses peut être
limitée et insuffisamment prise en compte dans l’élaboration des
recommandations internationales.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Cochrane’s impact on child health guidance
in three Western countries
Thomson D, Sommerville M, Hartling L
Child Health Field, Canada
Background: The Cochrane Collaboration was founded on the
premise that the preparation of systematic reviews is a foundation for
better health care outcomes. However, the real impact of evidence
synthesis comes from use. We measured the potential use of Cochrane
evidence in child health by assessing the degree to which Cochrane
Reviews are cited in pediatric policy statements and clinical practice
guidelines in three Western countries. Objectives: To evaluate the
use of Cochrane evidence in child health guidance in Canada, the US
and the UK. Methods: We identified the practice guidelines and policy
position statements of the Canadian Paediatric Society (CPS) and the
American Academy of Pediatrics (AAP), as well as the child-relevant
clinical guidelines of the National Institute for Clinical Evidence (NICE) in
the UK. We extracted the number of references to Cochrane systematic
reviews. Results: AAP Practice Guidelines (n = 18): 44% reference
CDSR; no trend by year, no CDSR references before 2001. AAP Policy
Statements and Statements of Endorsement (n = 594): 4% reference
CDSR, 5.5% from 2000 onwards; no trend by year, no CDSR references
before 2000. CPS Position Statements (n = 194): 24% reference
CDSR; no trend by year, no CDSR references before 2001. NICE
Clinical Guidelines: 100% of Children and Youth guidelines (n = 19),
94% of all guidelines that mention children (Children and Youth +
Children and Adults, n = 48)), and 90% of the guidelines tagged as
Child Health (n = 10) reference CDSR. Further analysis by clinical area
is ongoing. Conclusions: There is considerable variability between
Canada, the US and the UK in the degree to which Cochrane evidence
is used in child health guidance. More detailed research would help
establish if there are areas where guideline authors require evidence
but Cochrane Reviews are not available. This could serve to identify
and prioritize topics for future Cochrane Reviews.
Structural recommendations assessment of eight
clinical practice guidelines developed
in Colombia
Flórez ID, Pérez AV, Prieto LC, Cañón LA
Health Technology Assessment Institute- IETS, Colombia
Background: There is not enough information to guide editorial
wording of recommendations within CPG (Clinical Practice Guidelines)
development. The AGREE-II instrument suggests the inclusion of
population, intervention and outcome (P-I-O) components within
recommendations. Objectives: To evaluate P-I-O component in CPG
recommendations and to analyze its relationship with the AGREE-II
evaluation. Methods: Eight recently developed in Colombia CPG were
chosen and assessed by four methodological experts; the presence
of P-I-O component in each recommendation was established, and
compared with an external evaluation score of the 15th item of
AGREE-II instrument. Results: Eight guidelines with a total of
691 recommendations were evaluated, all of them were appraised by
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
external international review with the Spanish AGREE-II instrument and
its use were recommended. An average of 9.9% of recommendations
met P-I-O structure; the absence of each component was 31.2%
for population, 6% for intervention and 85.2% had no outcome.
The item 15 of AGREE-II instrument reported results between 4
and 7, scores of good quality. Conclusions: Recommendations
in CPG seem to be clear, but most of them don’t contain the
evaluated criteria for their report. External evaluation emphasizes
in clarity of recommendation, and there is no agreement with the
percentages obtained according to P-I-O structure, which enhance
its understanding. It is advisable to standardize methodology for
recommendations to include all components that reflect the answer to
the research question.
Critical appraisal of clinical practice guidelines
for treatment of pancreatic cancer based on the
global disease burden
Li CC1 , Li XL1 , Li YP1 , Chen Y2 , Wang L1 , Tan J1
1 Chinese Evidence-Based Medicine Center, China; 2 West China School of
Clinical Medicine, China
Background: Pancreatic cancer is the eighth most common reason for
cancer-related death worldwide. Many countries either lack appropriate
clinical practice guidelines for the treatment or the quality of their
guidelines has never been evaluated. Objectives: The main objective
of our work was to identify published pancreatic cancer guidelines and
evaluate the burden and treatment guidelines of pancreatic cancer.
Methods: Literatures concerning pancreatic cancer guidelines were
identified through PUBMED, National Guidelines Clearinghouse and the
Guidelines International Network. Appraisal of Guidelines for Research
and Evaluation (AGREE) were applied to assess the methodological
quality of the guidelines. Results: A total of 14 relevant guidelines
published from 2001 to 2012 were identified, involving four continents
(Asia, Europe, North America, Oceania), six counties, four international
organizations. According to the AGREE instrument, two guidelines
can be strongly recommended, 11 with provisos and alterations while
one guidelines cannot be recommended for adaptation due to poor
methodological quality. There were only two domains, ‘Scope and
Purpose’ and ‘Clarity of Presentations’, getting high average scores
(more than 60%) among all guidelines. Their subjects of 14 guidelines
covered six treatment categories: Chemotherapy, surgery, radiotherapy,
support therapy, radiotherapy and interventional therapy. Guidelines
recommended the most Categories in Asian. Conclusions: The overall
methodological quality of pancreatic cancer treatment guidelines is
suboptimal in different countries or regions. The guidelines mainly
focused on the treatment of Chemotherapy, surgery, radiotherapy
and support therapy. Interventional and Traditional Chinese Medicine
therapy were the most recommended agents in china guidelines
unresectable pancreatic cancer.
Attachments: cuicui li 1.pdf
Cochrane Database Syst Rev Suppl 1–212 (2013)
The Endocrine Society Guidelines: when the
confidence cart goes before the evidence horse?
Brito JP1 , Domecq JP1 , Murad MH2 , Guyatt GH3 , Montori VM1
Division of Endocrinology, Diabetes, Metabolism, Nutrition, Mayo Clinic,
Rochester, MN; 2 Division of Preventive, Occupational and Aerospace
Medicine, Mayo Clinic, MN; 3 Department of Medicine, McMaster
University, Hamilton, Ontario L8N 3Z5, Canada
Background: In 2005, the Endocrine Society (TES) adopted the
GRADE system of developing clinical practice guidelines. This system
rates the panel’s confidence in the estimates of effect of the available
options (from high to very low confidence) and in the value of following
a recommendation (strong or conditional recommendation). GRADE
working group guidance suggests that strong recommendations based
on low or very low (l/vl) confidence may often be inappropriate.
Objectives: We sought to characterize TES strong recommendations
based on l/vl confidence evidence. Methods: We identified all
strong recommendations based on l/vl confidence evidence published
in TES guidelines between 2005 (when TES started using GRADE)
and 2011. We applied a taxonomy of paradigmatic situations in
which strong recommendation based on l/vl confidence estimates may
be appropriate. Independently and in duplicate, reviewers extracted,
for each recommendation, whether a strong recommendation was
appropriate and if so which paradigmatic situation applied. Results:
206 (58%) of the 357 TES recommendations issued were strong; of
these, 121 (59%) were based on l/vl confidence evidence. Of these
121, we classified 43 (36%) as ‘best practice’ recommendations for
which sensible alternatives do not exist and do not require grading . In
5 (4%), we concluded that moderate or high confidence in estimates
was warranted and in another 5 (4%) that the recommendations
were for ‘additional research’. Of the remaining 67, 33 (27% of the
original 121) were judged inappropriate. Of the 35 appropriate ones,
the most common situation (13, 37%) was low confidence evidence
for benefit and high confidence evidence for harm thus warranting
a strong recommendation against the intervention. Conclusions:
Guideline panels should beware of formulating inappropriately strong
recommendations when confidence in estimates is low. Our taxonomy
of paradigmatic situations when such recommendations are appropriate
may be helpful.
Publication and appraisal of methodological
guidelines: the development of systematic
reviews (SR) and meta-analyses of randomized
clinical trials by the Department of Science and
Technology of the Brazilian Ministry of Health
Koury C1 , Vieira N1 , Elias F1 , Gadelha C1 , Calvalcanti A2 , Buehler A2 ,
Figueiró M2 , Berwanger O2
1 Brazilian Ministry of Health, Brazil; 2 HCor
Background: Since 2004, DECIT supports the production of SRs by
teaching and research institutions in Brazil. However, these studies
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
were guided by international recommendations causing some variability
in the execution and presentation of results. In order to standardize
and equalize the elaboration quality of SRs throughout Brazil, DECIT
requested to research institute Hospital do Coração draft this guideline.
Objectives: To describe the publication and review guideline’ process.
Methods: Descriptive analysis based on Ministry of Health’s data.
Results: The guideline was based on two international guidelines
used in clinical research: The Cochrane Reviewer’s Handbook and a
guideline prepared by the The Australian National Health and Medical
Research Council and the first draft was finalized in 2011. After
that, many meetings were realized to evaluate its recommendations,
as well as presentation in scientific events to get some feedbacks.
After almost 1 year under appreciation, the guidelines were published
in 2012, which suffered some changes and adjustments from the
first draft. There are 11 recommendations aiming to standardize and
to get robustness to SR and Meta-Analyses of RCT. Conclusions:
Methodological guidelines for SR and Meta-Analyses of RCT have
spread out around the world. In 2012, the Brazilian MoH published its
own guideline, which was elaborated taking into account the feedback
of many important actors involved direct and indirectly with SR and
Meta-Analyses of RCT, such as governmental institutions, universities,
researchers and health managers. Nowadays, all SR fostered by MoH
must follow the guidelines’ recommendation. As this field is constantly
in development, the guidelines will be revised until 2014.
Attachments: appraisal methodological guide.pdf
Brain metastasis management: difficulties with
integrating Cochrane Review evidence into
Grant R, Quinn G, Jess C
Cochrane Neuro-Oncology Group, UK
Background: Treatment options for brain metastasis include surgery,
stereotactic radiosurgery (SRS) or whole brain radiation therapy (WBRT).
Multiple randomised controlled trials (RCTs) have been performed
comparing various combinations of these therapies. Objectives:
To determine if advances in RCT evidence is being synthesised into
Cochrane Reviews and if this in turn is being used to appropriately
formulate evidence based national guidelines. Methods: National
guidelines were identified by searching the websites of the major
worldwide neuro-oncology associations. Cochrane Reviews and
randomised controlled trials were identified through searching
CENTRAL (issue 3, 2013). Only RCTs comparing wither surgery,
SRS or WBRT (either alone or in combination) were included) and
categorised into four specific treatment questions (surgery for single
metastasis; surgery versus SRS; WBRT +/− SRS; SRS +/− WBRT).
Chemotherapy, molecular targeted therapy, radiation sensitisers and
different radiation regimes were not eligible for inclusion. Results: A
total of 13 RCTs, 4 Cochrane Reviews and 3 national guidelines were
identified. The Cochrane Reviews had some overlap but in total covered
3 of the 4 main treatment questions and 77% of eligible RCTs. National
guidelines included 69% of the RCTs in total (range 53–92%) but did
not cite any Cochrane Reviews. Conclusions: The major limitation to
evidence based management of brain metastasis appears to be a lack of
integration of Cochrane Reviews into national guidelines. Advances in
Cochrane Database Syst Rev Suppl 1–212 (2013)
Cochrane methodology, for example multiple-treatment comparisons,
minimising review overlap and keeping reviews contemporary may help
to make Cochrane Review evidence more relevant. Recent formation of
the Cochrane neuro-oncology group and a higher profile at international
neuro-oncology meetings may help to increase awareness of Cochrane
Reviews in the neuro-oncology community.
Is replication research informing the results
of systematic reviews in knowledge translation
Curran J1 , Vachon B2 , Grimshaw JM3 , Research R4
1 Dalhousie University, Canada; 2 Universite de Montreal, Canada; 3 Ottawa
Hospital Research Institute, Canada; 4 Team, Canada
Background: Replication is necessary to advance science as reliable
evidence depends on the empirical demonstration of its reproducibility,
validity, and generalizability. Replication of prior research is rare in
many research fields. In knowledge translation (KT) research, it has
been argued that choice of KT strategy proceeds on the basis of
intuition or anecdotal stories of success and complex interventions are
generally insufficiently described to be replicated. Objectives: To
document the extent and type of replication present in the field of KT
research for one specific intervention, audit and feedback. Methods:
We examined 140 randomized control trials included in a recent audit
and feedback review for evidence of replication. Our data abstraction
form was based on a replication framework developed through a
concept analysis of the literature. Findings were analyzed to determine
the number of studies reflecting different types of replication and their
characteristics. Results: Explicit reference to replication was found in
a minority of studies included in the review. A small number (n = 24)
of authors questioned the reliability of findings from previous studies
in the background to their work. Fewer authors describe testing an
intervention (n = 5) or the research design (n = 2) of a previous
study when recording their methods. The most prevalent reference to
replication was found in the discussion of study findings. A number
of factors influencing generalizability, reliability and validity of study
findings were identified as limitations by 62 authors and many authors
(n = 54) shared recommendations for future research. Conclusions:
While opportunities for different types of replication can be found
in individual studies, there is little evidence of intentional replication
of a previous study. The lack of replication in this review restricts
our confidence in the validity, reliability and generalizability of the
effectiveness of audit and feedback interventions and thus limits the
impact of the review.
Tools to evaluate the methodological quality of
physical therapy trials. What items should we
use from these tools? A factor analysis
Armijo-Olivo S, Cummings G, Fuentes J, Saltaji H, Ha C, Chisholm A, Rowe
B, Hartling L, Rogers T
University of Alberta, Canada
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: Numerous tools and items have been proposed to
judge methodological quality of randomized controlled trials (RCT) in
various health research areas. The frequency of use of these items
varies according to health area, which suggests a lack of agreement
regarding their relevance to trial quality. Recently, researchers have
called for more in-depth analysis of the items through psychometric
testing [i.e. factor analysis]; especially in the physical therapy (PT)
field. Objectives: To identify the underlying component structure
of items and determine relevant items from tools used to evaluate
quality/Risk of Bias (RofB) of PT trials. Methods: RCTs used for
this study were randomly selected from the Cochrane Database of
Systematic Reviews. All studies were evaluated by 2 reviewers using 7
tools and their items for a combined set of 45 items. An exploratory
factor analysis using Principal Axis Factoring (PAF) method followed
by Varimax rotation was conducted. Results: 214 trials were
selected. PAF identified 34 items that loaded on 9 common factors
as follows: 1) Selection bias; 2) Performance and detection bias;
3) Eligibility, interventions details, and outcomes measures description;
4) Psychometric properties; 5) Contamination and compliance bias;
6) Attrition bias; 7) Data analysis; 8) Sample size; and 9) Control and
placebo adequacy. One item (i.e. intention to treat-ITT- performed)
did not load in any of the factors mentioned; however, it was added
to this set of items based on its relevance to RofB. Conclusions: To
our knowledge, this is the first study in PT to explore the underlying
component items used to evaluate methodological quality/risk of bias
of trials using factor analysis. The items and/or factors represent a
starting point for evaluating the methodological quality/risk of bias in
PT trials. Empirical evidence of the association between these items
with treatment effects (meta-epidemiological approach) is required to
validate these items before widespread use.
Network meta-analysis in Health Technology
Assessments: how frequently used and how
necessary are they?
Ciapponi A, Garcı́a Martı́ S, Glujovsky D, Bardach A, Alcaraz A,
Pichón-Riviere A, Augustovski F
Argentine Cochrane Centre - Institute for Clinical Effectiveness and Health
Policy (IECS)
Background: Network meta-analysis (NMA), in the context of a
systematic review, is a meta-analysis in which multiple treatments (that
is, three or more) are being compared using both direct comparisons
of interventions within randomized controlled trials and indirect
comparisons across trials based on a common comparator. NMA
holds promise to provide evidence on comparative effectiveness that
is valuable for decision-making, in the context of Health Technology
Assessments (HTAs), because it allows comparisons of interventions
that may not have been directly compared in head-to-head trials.
Moreover, in many cases the probability of future head-to-head
trials is very low because costs or futility reasons considered by
research sponsors. Objectives: To describe the proportion of HTAs
comparing interventions without head-to-head trials, and from them
how many searched, identified relevant NMA, and eventually if they
were considered in HTAs’ conclusion. Methods: We analysed all
HTAs comparing interventions, published in the Centre for Reviews and
Cochrane Database Syst Rev Suppl 1–212 (2013)
Dissemination (CRD) database during the year 2012. Out of this sample
we will evaluate the proportion of HTAs without head-to-head trials for
its main question, the proportion of HTA searching and including NMA.
We will search in Pubmed, Embase, and CENTRAL the existence of
NMA for each relevant topic. From HTAs using NMA we will evaluate
the match of their conclusions about the comparisons (Fig. 1). Results:
951 HTAs were published in 2012 in CRD. The results will be presented
at the Colloquium.
Attachments: Figure 1 NMA in HTAs.jpg
The growing trend of network meta-analyses
topic appearance in medical literature
Ciapponi A, Glujovsky D, Garcı́a Martı́ S, Bardach A, Comandé D
Argentine Cochrane Centre - Institute for Clinical Effectiveness and Health
Policy (IECS)
Background: Frequently, interventions for a given health problem
have never been compared in head-to-head randomized controlled
trials. In this context, adjusted indirect comparisons based on network
meta-analyses (NMAs) could answer the question posed by most
healthcare professionals: what is the best intervention among the
existing interventions for a specific condition? Objectives: To evaluate
the trend in NMAs publication topic in medical electronic databases
and in the top five impact factor journals in the ‘Medicine, General
and Internal’ category. Methods: A search strategy was performed
in Medline (PubMed), EMBASE, and CENTRAL, since inception (Fig. 1).
We analysed the general yearly trend all together and separately by
database and by journal. Results: During the analysed period, the
reporting of studies mentioning NMA has increased since the beginning
of the XXI century and markedly since 2009. EMBASE was the database
with the highest cumulative number of references bout NMA and the
most manifest increasing trend, while CENTRAL showed a more steady
increasing trend (Fig. 1). The most important sources of NMA topic
reports are presented in Table 1. The Lancet was the only one among
the top-five impact-factor journal in ‘Medicine, General and Internal’
category (1) that ranked in the first 10 sources that published about
NMA. The other four top-five impact-factor journals published a lower
number of articles: NEJM, Annals of Internal Medicine, JAMA, and
Plos Medicine. Conclusions: Although the relevance of our search
strategy was not validated, this study showed a growing report of
NMA topics in medical literature, probably reflecting the absence
of head-to-head comparisons to identify the best interventions for
specific conditions. This trend was not observed among the top-five
journals. 1. The Cochrane Library Impact Factor Data Pack—July 2011
org/files/uploads/Impact factor report 2010.pdf Accessed 25/3.2013
Figure 1. Yearly trend in NMA publication topic in
medical electronic databases.jpg, Table 1. Ranking of sources publishing NMA topic.jpg
Priority setting distinguishing methodological
quality from report quality: assessment
example of systematic reviews about
non-pharmacological intervention for
depression with PRISMA and AMSTAR
Wang J1 , Zhai J2 , Zhang S1 , Shang H3
1 Evidence-Based Medicine Center, Tianjin University of Traditional Chinese
Medicine; 2 Tianjin Institution of Clinical Evaluation, Tianjin University of
Traditional Chinese Medicine; 3 Tianjin Institution of Clinical Evaluation/
EBM center, Tianjin University of Traditional Chinese Medicine
Background: Methodology quality of systematic reviews (SRs) is very
important to figure out the reliability of the results and evidence.
Sometimes, during assessment it is hard to distinguish methodological
quality from report quality or identify whether the trail was carried out
according to the method written in the article. Objections: Taking
assessment of SRs and meta-analysis regarding non-pharmacological
intervention for depression as an example to check whether priority
setting including registration and protocol can improve methodology
quality and identify it partly free from report quality. Method: We
conducted comprehensive search of the EMBASE, PubMed, MEDLINE,
PsycINFO, [email protected] databases, and the Cochrane Database of
Systematic Reviews to identify possible systematic reviews before
November 1, 2012. The studies of non-pharmacological intervention
for depression were included under prior design standards. Data
was extracted and assessed the report and methodology quality
independently by PRISMA and AMSTAR checklists. The correlation
between methodological quality and report quality are examined by
spearman correlation analysis and the methodological qualities of SRs
with and without priority setting were compared. Results: 58 studies
were included and 17 of them were with priority setting while 43 were
not. The priority setting mainly included registration and protocols. The
statistical significance (P < 0.05) was found between methodological
quality assessment and method part of report quality. The priority
settings assist methodological assessment of four articles and check
the report rate of outcomes and adverse effect of SRs. Both the report
and methodology quality of the SRs with priority setting were better
than ones without it according to the AMSTAR and PRISMA scales.
Conclusions: Methodological quality closely relates to report quality
so the poor report quality brings the difficulty for the methodological
assessment. Priority settings including registration and protocol can
provide the extra information. The methodological qualities of SRs
with priority setting are better than ones without it because they are
well designed and monitored in the beginning. Thus, priority settings
are recommended to be applied in future to identify and improve the
methodological quality of SR.
Development of a topic nomination and selection
process with US Medicaid policy makers
Kriz H, Thielke A, Betteridge S, King N, King V
Oregon Health & Science University, USA
Background: Medicaid is a US federal-state partnership providing
healthcare benefits for low income children and adults. States
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Cochrane Database Syst Rev Suppl 1–212 (2013)
began collaborating as the Medicaid Evidence-based Decisions (MED)
Project to commission evidence reviews for informing policy decisions.
Developing a topic nomination and selection process that is responsive
to policy makers and results in focused relevant evidence reviews was
crucial. Objectives: To describe a topic nomination and selection
process and discuss best practices in refining and selecting evidence
review topics to inform policy decisions. Methods: Development of a
topic nomination, refinement and selection process by researchers that
is timely and sets the research priorities for the MED project. Results:
Topic selection includes three key phases: (1) nomination, (2) scanning
and refinement, and (3) ranking and selection. States use a nomination
form to describe the topic policy context, intended use of the report,
and timeline requirements. MED uses an iterative process to refine
the topic nomination with the nominating policy maker. A scan of
five clinical evidence sources including the Cochrane Library, and three
health policy organizations informs the development of the research
protocol and key questions. The nominator and subsequently, the
collaborative, must approve the research protocol and key questions
before ranking the topics. Each participant ranks every topic on a scale
of 1–10 and the top ranked topics are selected for an evidence review.
The most common topic areas selected have been health services
delivery, mental health and behavioral conditions, oral health, and
imaging. MED selects 10–12 evidence review topics during each six
month selection cycle. Conclusions: Policy makers have successfully
collaborated with researchers to develop an effective topic nomination
and selection process. Topic refinement is an iterative process and is
the most critical phase for developing a policy relevant evidence review.
Final 2013.pdf
Topic nomination and selection process Cochrane
An approach to deal with the absence of cohort
studies in prognosis systematic reviews:
a meta-analysis of cross-sectional studies
El Dib R1 , Branco A2 , Kapoor A3
Botucatu Medical School, Unesp - Univ Estadual Paulista, Brazil and
McMaster Institute of Urology, McMaster University, Hamilton, Canada;
Botucatu Medical School, Unesp - Univ Estadual Paulista, Brazil;
3 McMaster Institute of Urology, McMaster University, Hamilton, Canada
Background: Systematic reviews aim to provide an exhaustive
summary of literature relevant to a certain topic through the organization of similar primary studies and, when possible, summarize
them in a meta-analysis. This means that systematic reviews should
offer clinicians, health professionals and policy makers with level 1
of evidence for health care decision making. However, it does not
often happen as we frequently note an absence of high-quality
primary studies in the health field. There are a large number
of studies with lower level of evidence in the literature provided
by non-randomized studies and/or single case studies that could
be used to provide an alternative interpretation of the available
evidence in the literature while waiting for the results from high
level of evidence. Objectives: To describe a statistical analysis of
evaluating cross-sectional studies in prognosis health care reviews
when there is absence of cohort studies. Methods: We provided
illustrations from recent experience related to the clinical question ‘Is
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
the immunoexpression of p53 a surrogate marker for laryngeal cancer
lesions’? and, discussed the impact of the level of evidence in the
clinical practice. Studies were included if the participants of interesting
have received a diagnosis of cancer laryngeal lesion at baseline. The
control group was patients who have received a diagnosis of benign
laryngeal lesions (i.e., polyps, nodules, cysts) or normal mucosae.
This review example planned to include cohort studies as they have an
observational and prospective design features with the aim to verify the
immunoexpression of p53 as a surrogate marker in recidivism laryngeal
cancer lesions compared to the p53 positive rates in laryngeal benign
lesions. We also considered to include all available cross-sectional
studies as an anticipation of not finding many cohort studies in this
area. For the cross-sectional studies the occurrence of positive p53
immunohistochemical expression rates were treated as dichotomous
variable with their respectively 95% confidential intervals (CIs) and, the
statistically significant difference between both interventions studied
was defined if their combined 95% CIs did not overlap. The software
used to plot the cross-sectional studies into a meta-analysis was
StatsDirect. Results: 35 studies met the methodological requirements
proposed in this review: only two cohort studies with insufficient data
to plot in a conventional meta-analysis and, 33 cross-sectional studies.
As only two studies from level I of evidence for prognosis purposes
met the inclusion criteria of this systematic review, we decided to
provide a different overview through a proportional meta-analysis
of cross-sectional studies. Figures 1 and 2 show a proportional
meta-analysis of cross-sectional studies regarding the occurrence of
positive p53 immunohistochemical expression in benign and cancer
laryngeal lesions. There was a statistically significant difference
favoring cancer laryngeal lesions compared to benign laryngeal lesions
on positive p53 immunohistochemical expression rates (31%, 9% vs.
62%) as their CIs did not overlap. Conclusions: We described a
statistical analysis to evaluate cross-sectional studies in health care
prognosis reviews. In our example, there is currently some evidence
suggesting a correlation between positive p53 immunohistochemical
expression and the occurrence of cancer laryngeal lesions higher than
in benign laryngeal lesions. This method is extended to be used in the
absence of cohort studies. The use of this method leads to substantial
gains in the scientific community as it provides health professionals with
the available information for their clinical practice until higher-quality
primary studies are conducted, although we cannot ruled out the
possibility of clinical heterogeneity and methodological failures due to
the lower-quality level of evidence from these studies.
Systematic review and methodological
exploration of synthesis methods in public health
evaluations of interventions
Achana F1 , Hubbard S1 , Sutton AJ1 , Kendrick D2 , Cooper N1
University of Leicester, UK; 2 University of Nottingham, UK
Background: Systematic reviews have been accepted as providing
a transparent and consistent way of obtaining research evidence
on effectiveness of interventions in a way that minimizes bias.
Meta-analysis, which combines quantitative information from multiple
studies, is considered the gold standard in the hierarchy of evidence
for intervention effectiveness. However, widespread application of
Cochrane Database Syst Rev Suppl 1–212 (2013)
quantitative synthesis methods to public health is hampered by a
number of well documented methodological challenges. Objectives:
To review the methods currently used to synthesise evidence in
public health evaluations and to demonstrate the availability of more
sophisticated approaches. Methods: A systematic review of NICE
public health appraisals published between 2006 and 2012 was
performed to assess the methods used for the synthesis of effectiveness
evidence. The ability of new developments in evidence synthesis
methodology to address the challenges and opportunities present in
a public health context is demonstrated. Results: Only 7 (18%)
of the 39 NICE appraisals included in the review performed pairwise
meta-analyses as part of the effectiveness review with one of these
also including a network meta-analysis. Of the remainder, 31 (79.5%)
consisted of narrative summaries of the evidence only, and 1 (2.5%) had
no review of evidence. Heterogeneity of outcomes and interventions
were the main reasons given for not pooling the data. Exploration
of quantitative syntheses methods shows that pairwise meta-analyses
can be extended to incorporate individual participant data (where
it is available), extend the number of interventions being compared
by using a network meta-analysis, and adjust for subject-level and
summary covariates. All these can contribute to ensuring the analysis
answers directly the policy relevant questions. Conclusions: More
sophisticated methods in evidence synthesis should be considered to
make evaluations in public health more vigorous.
Validation of a quality assessment checklist for
case series studies
Guo B1 , Moga C1 , Schopflocher D2 , Harstall C1
Institute of Health Economics, Canada; 2 University of Alberta, Canada
Background: Very few validated quality appraisal tools exit for case
series studies (CSs). Objectives: To evaluate the construct validity
of a 20-criterion checklist that has been developed using a modified
Delphi approach. Methods: Two health technology assessment (HTA)
researchers randomly selected 105 CSs of various topics from a broad
literature search. Six HTA researchers from Canada, Australia, and Spain
used the checklist to assess these studies; each researcher assessed
35 studies, and two researchers in pair assessed the same seven
studies. An experienced biostatistician conducted a factor analysis to
examine the factor structure and to inform potential refinements of
the item pool of the checklist. Results: Preliminary results of the
factor analysis revealed a trend of a separation of 20 items into two
components: (1) Ten items on the presence of the traditional features
of the execution of a statistical hypothesis-testing paradigm; (2) Seven
items on the descriptions of the subjects’ characteristics that might
feature in the experimental design, particularly in judgments about
the likelihood of confounding. The other 3 items (i.e. multi-center
study, consecutive recruitment, and reporting of competing interest
and sources of support) do not correlate very highly with either of
the two components. The analysis provided no basis for any cutoff
scores by which study quality might be distinguished. Conclusions:
The checklist should be tailored to meet the need of different projects,
taking into account the relevant importance of hypothesis-testing versus
description of subject/intervention characteristics. The set of items for
hypothesis testing may be more critical for some conditions (e.g., type
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
1 diabetes) where causal relationship between the intervention (e.g.,
islet transplantation) and efficacy/effectiveness outcomes (e.g., insulin
independence) can be established from a before-after case series study.
The set of items describing study/intervention characteristics may be
more important when assessing clinical outcomes such as long-term
adverse effects.
Assessment of methodological quality
of systematic reviews of China health policy
He S1 , Zhao J1 , Zhang F1 , Tian JH2
Evidence-Based Medicine Center, School of Basic Medical Sciences
of Lanzhou University, China; 2 School of Public Health of Lanzhou
University, China
Background: Health policy is very important for policy makers to
make right decision and promote population health. The number of
systematic reviews (SRs) about China health policy has increased, and
there is a need to assess the methodological quality presented in
SRs and MAs. Objective: To analyze the methodological quality of
all SRs of China health policy by AMSTAR. Methods: An electronic
literature search of all SRs of China healthy policy from inception to
December 2012 was conducted using the following text and keywords
in combination both MeSH terms and text words, the search strategy
was (meta analysis OR meta analyses OR systematic review* OR
overreview) AND (health or policy) in five Chinese databases. The
methodological quality was assessed independently by two reviewers
by AMSTAR. Results: Fifty SRs were included. The methodological
quality was poor. The CSCD or non-CSCD articles, the fund support,
and the published year seem to have little impact on the quality of the
SRs, nearly all the items showed no significant difference. The number
of the authors may influence the methodological quality, because in
the comparison of this group, four items showed significant difference,
the item number of which is more than other groups. The details were
described in Table 1. Conclusions: The methodological quality of SRs
of China healthy policy was poor, and the use of AMSTAR guideline is
recommended to improve quality of SRs in China health policy.
Attachments: Figure 1 Reporting of methodological quality of SRs
according to different strata.png, Table 1-AMSTAR checklist of methodological characteristics.PDF
A QQAQ assessment of the methodological
quality of systematic reviews of China health
Zhao J1 , He S1 , Zhang F1 , Tian JH2
1 School of Public Health of Lanzhou University, China; 2 Evidence-Based
Medicine Center, School of Basic Medical Sciences of Lanzhou University,
Background: More and more systematic reviews(SR) of China health
policy have been published in Chinese and English journals recent years,
which is very import for the health policy makers to make the right
decision. Objectives: To evaluate the methodological quality of SRs of
China health policy by QQAQ. Methods: An electronic literature search
of all SRs of China healthy policy from inception to December 2012
Cochrane Database Syst Rev Suppl 1–212 (2013)
was conducted using the following text and keywords in combination
both MeSH terms and text words, the search strategy was (meta
analysis OR meta analyses OR systematic review* OR overreview) AND
(health or policy) in five databases. The methodological quality was
assessed independently by two reviewers using the QQAQ. Results: A
total of 50 SRs were identified finally. Most reviews were compliant
with the following items: findings of studies combined appropriately
(100%), conclusions made by authors supported by analysis; almost
none reviews were compliant with the following items: criteria used
for assessing validity of included studies reported, Methods used to
combine the findings of studies reported. The details were showed
in Table 1.Whether the paper is CSCD or non-CSCD, funding or
non-funding, published before 2007 or after 2008, written by less
than two authors or more than three authors, seems to have little
impact on the quality of the SRs. The reporting quality was poor. The
details were described in Figure 1. Conclusions: There is a growing
increasing number of SRs of China health policy published in Chinese
and English journals, however the methodological quality need to be
further improved.
Attachments: Figure 1 Reporting of methodological quality of SRs
according to different strata.png, Table 1.PDF
Methodological quality assessment of
systematic reviews or meta-analysis
of interventions on diabetic nephropathy
Ge L1 , Ma JC1 , Zeng QL2 , Zhang F3 , Liang L1 , Shi XT1 , Liu YC1 , Tian JH3
The First Clinical College of Lanzhou University, China; 2 The Second
Clinical College of Lanzhou University, China; 3 Evidence-Based
Medicine Center, School of Basic Medical Sciences, Lanzhou University,
Background: High-quality systematic reviews (SRs) or Meta-analyses
(MAs) of RCTs are the sources of the best evidence for diabetic
nephropathy (DN). Currently, there is an increasing number of SRs/MAs
of DN. This study provides the first examination of methodological
quality of those SRs/MAs with AMSTAR. Objectives: To examine
methodological quality of SRs/MAs of interventions on DN. Methods:
Two independent reviewers systematically searched the eight databases, The searches were implemented in September 2012. According
to the inclusion and exclusion standard, included SRs /MAs of
interventions on DN, and independently extracted data by two
reviewers. The AMSTAR was applied to assess methodological quality.
Analyses were performed by Excel, SPSS17.0 and Meta Analyst soft.
Results: 891 records were identified and a total of 64 SRs/MAs were
included.The first SR was published in 1996. 68.8% (44 studies)
were published for 2009 and beyond. More than half (57.8%, 37
studies) were written by clinicians and most of studies (84.4%, 54
studies) were reported in CSCD or SCI journals. Funding sources
were reported for 23.4% (15 studies). According to the AMSTAR
checklist, the score range of the quality was 1.5–9, the average score
was 6.16 ± 1.68 (Table 1). Figure 1 showed that there didn’t have
been any improvement in total score after the AMSTAR publishing.
The quality of CSCD theses, SCI theses and 3 authors were better
than Non-CSCD, Non-SCI and 1–2 authors. But the difference in
total score to those stratified factors were not statistically significant
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
(P > 0.05). Conclusions: The methodological quality of SRs or MAs
of interventions on DN had some problems and needs to be improved.
We sincerely hope that analysts will take this as a warning and produce
high-quality SRs or MAs in future.
Attachments: Figure 1 Stratified analysis of methodological quality
of included studies.pdf, Table 1 The results of methodological quality
for included SRs or MAs.pdf
A PRISMA assessment of the reporting quality
of systematic reviews or meta-analysis of
interventions on diabetic nephropathy
An N1 , Ge L1 , Liu YC1 , Xu JF1 , Liang L1 , Ma JC1 , Wang J2 , Shi XT1 ,
Tian JH2
The First Clinical College of Lanzhou University, China; 2 Evidence-Based
Medicine Center, School of Basic Medical Sciences, Lanzhou University,
Background: Diabetes prevalence has increased worldwide. Diabetic
nephropathy (DN) is a common complication in diabetes and a crucial
issue of public health. More and more Systematic Reviews (SRs) and
Meta-analyses(MAs) on DN with different angles and opinions are
emerging published these years. Even though SRs have become an
increasingly popular source of up-to-date knowledge but the current
report quality situation is not clearly. Objectives: To critically assess
the report quality of SRs/MAs of interventions on DN by PRISMA.
Methods: A SRs/MAs literature search of eight database was used
to identify interventions on DN published up September 8, 2012 by
two independent reviewers. According to the inclusion and exclusion
criteria, two reviewers extracted the data independently. The quality
of the SRs/MAs were assessed by the PRISMA.All related data was
analyses by SPSS19.0, Meta Analyst and Excel. Results: 891 studies
were found in eight database, 64 were selected for analysis, most
(57, 89.1%) of which used the terms SR (33, 51.6%) , followed by
MA (23, 36.0%) and both SR and MA (2, 3.1%) in the title. The
PRISMA checklist score (Table 1) range from 9 to 25, the average
score was 18.24 ± 3.22.The report quality of included literatures has
problems in different levels. A score in 21–27(14, 21.875%) indicated
provide complete information, relatively; 15–21 (44, 68.75%), little
information deficiency; below 15 (16, 9.375%), severe information
deficiency. From Figure 1 show the significance between the impact
factors, the report quality of SCI, university and author’s 3 were better
than non-SCI, hospital and single author (P < 0.05). Conclusions:
PRISMA reporting guidelines on diabetic nephropathy is low for many
included literatures and different literatures have problems in various
levels. As a key data source of information for clinicians and researchers,
focusing on improving the report quality is more necessary rather than
continuing to publish them in large quantity, which requires to widen
our future focus on.
Attachments: Fig 1 The significance among the impact factors.pdf,
Tab 1 The results of reporting quality assessment (n = 64).pdf
Cochrane Database Syst Rev Suppl 1–212 (2013)
Assessment of the quality of reporting in
randomized controlled trials of acupuncture
in the Korean literature using the CONSORT
and STRICTA statements
Kim KH1 , Kang JW2 , Choi J3 , Lee JD2
1 Department of Acupuncture & Moxibustion Medicine, Korean Medicine
Hospital, Pusan National University, South Korea; 2 Department of
Acupuncture & Moxibustion, College of Korean Medicine, Kyung Hee
University, Republic of Korea; 3 Department of Internal Medicine, Korean
Medicine Hospital, Pusan National University, South Korea
Background: Adequate reporting quality of randomized controlled
trials (RCTs) is a prerequisite for comprehensive understanding and
optimal utilization of research results. However, the current status
is not necessarily satisfactory. Objectives: This study aimed to
assess the reporting quality of RCTs of acupuncture in the Korean
literature. Methods: Twelve Korean databases and seven Korean
journals were searched to identify eligible RCTs published after 2005.
The Consolidated Standards of Reporting Trials (CONSORT) checklist
for parallel RCTs was used to assess the quality of reporting in
Korean RCTs. The revised STandards for Reporting Interventions in
Clinical Trials of Acupuncture (STRICTA) was used to investigate the
quality of reporting for intervention-related items. Results: In total,
103 eligible RCTs were identified. Reporting quality was poor in
62% (28 out of 45) of items that comprise CONSORT. Items related
to the risk of bias, including randomization reporting, allocation
concealment and outcome assessor blinding, showed poorer quality
of reporting (range 5.8–20.4%) (Table 1). Although some items
of STRICTA for acupuncture rationale (range 47.6–97.1%), needling
details (range 8.1–97.3%) and treatment regimen (range 77.7–88.3%)
were relatively well reported, items related to treatment context
(range 13.6–44.7%) and practitioner background (21.4%) were poorly
reported (Table 2). Conclusions: The reporting quality of Korean RCTs
of acupuncture was suboptimal with regard to the CONSORT and the
revised STRICTA statements. Inclusion of the CONSORT and revised
STRICTA statements in author instructions and attempts to utilize those
statements in writing and to review the overall process are necessary
to achieve better quality of reporting in Korean RCTs of acupuncture.
Attachments: Table 1 CONSORT adherence.pdf, Table 2 STRICTA
A systematic assessment of the quality of
systematic reviews/meta-analyses on
radiofrequency ablation versus hepatic resection
for small hepatocellular carcinoma
Wang Y1 , Luo Q2 , Li YP1 , Deng S3 , Li XL1 , Wei S4 , Yu J1
The Chinese Cochrane Centre, China; 2 National Chengdu Center for Safety
Evaluation of Drugs, West China Hospital, Sichuan University, China; 3 West
China Hospital, Sichuan University, China; 4 West China Medical School,
Sichuan University, China
Background: The systematic reviews (SRs) of radiofrequency ablation
(RFA) versus hepatic resection (HR) for early hepatocellular carcinoma
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
(HCC) are increasing, however, qualities of them varies. Objectives:
This study was supported by Ministry of Science and Technology
of China to evaluate the quality and their impacts on outcomes.
Methods: We searched six databases and five official websites, and
the Overview Quality Assessment Questionnaire (OQAQ), the Cochrane
Collaboration’s tool, and modified MINORS score were applied to
assess their quality for SRs, randomized (RCTs) and non-randomized
controlled trials (NRCTs), respectively. Pooled odds ratio (OR) and
95% confidence intervals (CI) were integrated by Stata 10.0 software.
Results: Nineteen SRs were included. The overall quality was
poor, with a mean OQAQ score of 3.3(95% CI, 2.6–4.1). Only five
(26.3%) SRs were assessed as good quality. Six (31.6%) misused
statistical models, and three of them changed outcome direction
after modification. The authors of five SRs included retrospective
studies as RCT. A total of 39 primary studies referenced by SRs were
included. Three RCTs were leveled grade B, and 35 NRCTs were
of moderate quality, with an estimated mean MINORS score of 15.0
(95% CI, 14.6–15.4). Certain studies (17/39, 43.6%) did not meet
inclusion criteria for the SRs; and nine were mixed with other effective
interventions in both groups. Four studies included patients with
non-primary HCC. Conclusions: The overall quality of SRs comparing
the effects between RFA and HR for early HCC is poor. There is high
heterogeneity and low evidence level. Physicians should take caution
when applying the results of these studies to their clinical practice.
Systematic review of clinical practice guidelines
on the diagnosis and management of thyroid
nodule and cancer
Tam K1 , Wu C2 , Huang T3 , Wu M2
1 Taipei Medical University, Taiwan; 2 Taipei Medical University - Shuang
Ho Hospital, Taiwan; 3 HungKuang University, Taiwan
Background: Usually, physicians base their practice on clinical
practice guidelines (CGPs), but recommendations on the same topic
may vary across guidelines. Given the uncertainties regarding thyroid
nodule assessment and management, physicians should be able to
identify systematically and transparently developed recommendations.
Objectives: The aim of this systematic review was to assess the quality
and consistency of recommendations of international CGPs on the
diagnosis and management of thyroid nodule and cancer, and to assist
physicians in their choice of recommendations. Methods: CGPs on the
management of thyroid nodule and cancer published before March 1,
2013 were retrieved using MEDLINE, EMBASE, CINAHL, the National
Guideline Clearinghouse, and the G-I-N International Guideline Library.
All guidelines in English were included. Four reviewers independently
assessed rigor of guideline development using the Appraisal of
Guidelines Research and Evaluation-II (AGREE-II) instrument, and
their reported evidence base was evaluated. Results: Ten guidelines
were deemed eligible: nine had been developed by professional
organizations, and the other one had regional independent body
endorsements. Three guidelines performed satisfactorily, achieving a
score of greater than 50% in all six AGREE-II domains. The overall
quality ranged from 2.5 to 6.25 out of 7 on the AGREE-II tool. The
highest scores were for ‘scope and purpose’ (> 61.1% for 8 CGPs)
and the lowest were for ‘applicability’ (< 38.5% for 5 CGPs). Most
of the CPGs’ recommendations on the management of thyroid cancer
Cochrane Database Syst Rev Suppl 1–212 (2013)
were quite consistent. Guidelines varied in the indication of fine
needle aspiration for thyroid nodule, and the suggestion of radioiodine
ablation postoperatively. Cervical lymph node dissection was unnoticed
by 3/10 CPGs. Conclusions: Our analysis shows that the current CPGs
varied in methodological quality, more efforts are need to improve the
quality of recommendations on the diagnosis and management of
thyroid nodule and cancer.
Low carbohydrate diets and cardiovascular
health: an example of a rapid response with
high quality reviews to inform public health
Naude CE1 , Schoonees A1 , Young T1 , Senekal M2 , Volmink J1 , Garner P3
Centre for Evidence-Based Health Care, Faculty of Medicine and Health
Sciences, Stellenbosch University, South Africa; 2 Division of Human
Nutrition, Department of Human Biology, Faculty of Health Sciences,
University of Cape Town, South Africa; 3 Effective Health Care Research
Consortium, International Health Group, Liverpool School of Tropical
Medicine, Liverpool, United Kingdom
Background: Low carbohydrate diets for weight management and
cardiovascular-related benefits have generated controversy between
advocates, the media and the health profession in South Africa over
the last two years. The Heart and Stroke Foundation of South
Africa approached the Centre for Evidence-based Health Care to
provide evidence to inform their response to the ongoing debates.
Objectives: (1) To provide a reliable summary of the effects of
low carbohydrate diets on cardiovascular health for a public health
client; (2) To road-test a feasible, robust and timely approach for
completing a systematic review in response to a public health concern.
Methods: We established a review team that wrote the protocol and
a multidisciplinary technical group that provided advice. We firstly
conducted an overview of systematic reviews. When clear answers
were not identified, we carried out a rapid systematic review of
randomised controlled trials using Cochrane methods, addressing the
gaps identified in the overview. Results: The overview revealed 38
existing systematic reviews of mostly low and moderate quality from
AMSTAR scores. All had a variety of problems relating to inclusion
criteria and comparisons that made interpretation and generalisability
difficult. This phase helped us design a protocol that more closely
aligned the advocated diets to the various trials, with clear delineation
of inclusion criteria and comparisons. We carried out a rigorous review
of 19 RCTs against the protocol approved by the technical group, which
is potentially rapidly adaptable as a Cochrane Review. Conclusions:
We completed a review against an approved protocol on a complex
topic that fed straight into public health promotion in less than a year.
This illustrates the power of listening to stakeholders, the value of
timely information, and the ability to deliver a rigorous review rapidly.
Cochrane Groups should have the capacity to complete such reviews
rapidly with active, capable teams.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Reporting guidelines for reporting searches
of network meta-analysis are needed
Yang KH, Li L, Tian HL, Tian JH, Sun R
Evidence-Based Medicine Center, School of Basic Medical Sciences,
Lanzhou University
Background: The search in network meta-analysis is very critical,
as network meta-analysis aims to rank the benefits (and harms)
of interventions based on all available randomized controlled trials
(RCTs). Objectives: So it is necessary to assess the search status in
network meta-analyses. Methods: Published network meta-analyses
were retrieved by searching databases (Pubmed, the Cochrane library,
Embase, and ISI Web of Knowledge) and hand-searching other sources
(Google engine, HTA websites, references lists). Two independent
reviewers conducted search, select studies, abstracted data. Statistical
analyses were conducted using SPSS version 15.0 for Windows.
Results: 104 network meta-analyses were included. The searches
in network meta-analysis were not comprehensive, although 92.6%
searched databases and hand-searched one or more other resources.
The median number of databases was 3 (IQR 2–4). Medline, Embase,
and CENTRAL are the most common used databases. However,
7.4% used the included studies in specific systematic reviews and
hand-searching other resources and unpublished data were not well
conducted. Although most network meta-analyses (70.4%) stated
search terms, their reporting for search was poor and inadequate, as
search strategy was reported in 24.1% network meta-analyses using
simple format and the restrictions and details for search were not well
stated. Conclusions: The searches in network meta-analysis were not
comprehensive, and the reporting for search was poor and inadequate.
The best way for retrieving studies for network meta analysis should be
using of two or more databases, cross-checking the reference lists of
previous systematic reviews and hand searching of other resources by
two independent searcher and/or information professionals. And the
reporting guidelines for the searches of network meta-analysis should
be developed, and at least include items related to search resources,
search terms, search restrictions, search date and the searchers.
Underreporting of conflicts of interest in clinical
practice guidelines: cross sectional study
Bindslev JBB, Schroll JB, Gøtzsche PC, Lundh A
The Nordic Cochrane Centre, Denmark
Background: Conflicts of interest may affect recommendations
in clinical guidelines and disclosure of such conflicts is important.
However, not all conflicts of interest are disclosed. Objective: To
determine the prevalence and underreporting of conflicts of interest
among authors of clinical guidelines on drug treatments. Methods:
We included up to five guidelines published from July 2010 to March
2012 from each Danish clinical specialty society. Using the disclosure
list of the Danish Health and Medicines Authority, we identified
author conflicts of interest and compared them with the disclosures
in the guidelines. For each guideline we extracted information on
guideline development. Results: We included 45 guidelines from
14 specialty societies. Of 254 authors, 135 (53%) had conflicts of
interest, corresponding to 43 of the 45 guidelines (96%) having one
Cochrane Database Syst Rev Suppl 1–212 (2013)
or more authors with a conflict of interest. Only 1 of the 45 guidelines
(2%) disclosed author conflicts of interest. The most common type
of conflict of interest (83 of the 135) was being a consultant, an
advisory board member or a company employee. Only 10 guidelines
(22%) described the methods used for guideline development, 27
(60%) used references in the text and 11 (24%) graded the types of
evidence behind specific recommendations. Conclusions: Conflicts
of interest were very common, but disclosures were very rare. Most
guidelines did not describe how they were developed and many did
not describe the evidence behind specific recommendations. Publicly
available disclosure lists may assist guideline issuing bodies in ensuring
that all conflicts are disclosed.
The use of collaborative writing applications
in healthcare education - a scoping review
van de Belt T1 , Grajales F2 , Faber M1 , Kuziemsky C3 , Gagnon S4 , Bilodeau
A5 , Rioux S6 , Fournier C6 , Émond M6 , Nadeau C4 , Lalonde TM4 , Aubin
K6 , Gold I7 , Gagnon M8 , Turgeon A1 , Heldoorn M9 , Poitras J4 , Eysenbach
G10 , Kremer J1 , Légaré F10 , Archambault PM4
Radboud University Nijmegen Medical Centre, The Netherlands; 2 Advisor
on Health Information and Communication Technology to the Surgeon
General of the Republic of Slovenia; 3 Telfer School of Management,
University of Ottawa, Canada; 4 Centre de santé et de services sociaux
Alphonse-Desjardins (CHAU de Lévis), Lévis, Canada; 5 Institut national
de santé publique du Québec, Québec, Canada; 6 Faculté de médecine,
Université Laval, Québec, Canada; 7 Association of Faculties of Medicine
of Canada, Ottawa, Canada; 8 Faculté des sciences infirmières, Université
Laval, Québec, Canada; 9 Federation of Patients and Consumer
Organisations in the Netherlands; 10 Centre de recherche du Centre
hospitalier universitaire de Québec (CRCHUQ), Québec, Canada
Background: Collaborative writing applications (CWAs) (e.g., wikis,
Google Docs) offer interesting possibilities for healthcare education.
There is a need to systematically synthesize the growing evidence
concerning their impact on healthcare education. Objectives: To
assess the depth and breadth of the literature studying the impact
of CWAs in healthcare education. We aimed to discover the type of
CWAs studied, the educational setting of their use and the educational
impact on the learner. Methods: This review is part of a larger scoping
review exploring the use of CWA in healthcare that systematically
searched the literature in medical and education databases (PubMed,
Embase, Cochrane, CINAHL, PsychInfo, Eric and ProQuest Dissertations
& Theses) from 2001 to 2011 with the following search terms:
‘wiki’, ‘wikis’, ‘web 2.0’, ‘social media’, ‘Google Knol’, ‘Google Docs’
and ‘collaborative writing applications’. CWAs were defined as any
technology enabling joint and simultaneous editing of online documents
by many end users. We included papers presenting qualitative or
quantitative empirical evidence concerning CWA use in healthcare
education. Articles were excluded if they only discussed blogs, forums
or learning communities. Two reviewers independently reviewed
citations, selected studies and extracted data using a standardized
form. Results: Figure 1 presents our flow chart. Out of 110
articles whose full text was reviewed, we found 2 experimental and 2
quasi-experimental studies. Characteristics of these studies are detailed
in Table 1. One experimental study yielded positive results about using
Google Docs to teach scientific writing. The other experimental study
demonstrated that a wiki-facilitated problem-based learning course
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
improved student communication skills and satisfaction, but decreased
diagnostic skills. Conclusions: A formal systematic review is further
needed to critically appraise the quality of these papers and synthesize
their results. This will help inform the design of future trials exploring
the use of CWAs for teaching in the healthcare field.
Attachments: Flow chart word medical education.pdf, Table 1
Education Final.pdf
Wikis and collaborative writing applications
in healthcare: results of a scoping review
Archambault PM1 , van de Belt T2 , Grajales F3 , Faber M4 , Kuziemsky C5 ,
Gagnon S6 , Bilodeau A7 , Rioux S6 , Fournier C6 , Nadeau C6 , Émond M6 ,
Aubin K8 , Gold I9 , Gagnon M8 , Turgeon A10 , Heldoorn M11 , Poitras J12 ,
Kremer J2 , Eysenbach G13 , Légaré F14
Department of Family Medicine and Emergency Medicine, Faculté de
médecine, Université Laval, Canada; 2 Radboud University Nijmegen
Medical Centre, Department of Obstetrics and Gynaecology, Division
of Reproductive Medicine, Nijmegen, The Netherlands; 3 IMIA Social Media
Working Group, Geneva, Switzerland; 4 Radboud University Nijmegen
Medical Centre, Radboud REshape and Innovation Center, Nijmegen, The
Netherlands; 5 Telfer School of Management, University of Ottawa, Canada;
Centre de santé et de services sociaux Alphonse-Desjardins (CHAU de
Lévis), Lévis, Canada; 7 Institut national de santé publique du Québec,
Québec, Canada; 8 Faculté des sciences infirmières, Université Laval,
Québec, Canada; 9 Association of Faculties of Medicine of Canada, Ottawa,
Canada; 10 Division of Critical Care Medicine, Department of Anesthesia,
Faculté de médecine, Université Laval, Québec, Canada; 11 Federation of
Patients and Consumer Organisations in the Netherlands, The Netherlands;
Faculté de médecine, Université Laval, Canada; 13 Centre for eHealth
Innovation, Université of Toronto, Canada; 14 Centre de recherche du
Centre hospitalier universitaire de Québec (CRCHUQ), Québec, Canada
Background: The rapid rise in the use of collaborative writing
applications (CWAs) (eg, wikis, Google Documents, and Google Knol)
has created the need for a systematic synthesis of the evidence of
their impact as knowledge translation tools in healthcare. Objectives:
To explore the depth and breadth of evidence for the use of CWAs
in healthcare, and to identify areas that require further systematic
reviewing and where more primary research is needed. Methods:
We performed a scoping review searching PubMed, EMBASE, CINAHL,
PsycINFO, ERIC, EPOC, ProQuest Dissertations and Theses, HTAi vortal,
Mednar, OpenSIGLE, Google, Bing and Yahoo without any language
restrictions, but limited to articles published after 2001. Keywords
used were: ‘wiki’, ‘wikis’, ‘Web 2.0, ’ ‘social media, ’ ‘Google Knol,’
‘Google Docs,’ and ‘collaborative writing applications’. CWAs were
defined as any technology enabling joint and simultaneous editing of
online documents by many end users. Two reviewers independently
reviewed citations, selected eligible studies and extracted data using
a standardized form built into EPPI-reviewer 4. Papers presenting
qualitative or quantitative empirical evidence concerning healthcare
and CWAs were included. Results: Figure 1 presents our flow chart.
Among the 111 included papers, we found 4 experimental studies, 3
quasi-experimental studies, 5 observational studies, 54 case studies,
23 surveys about wiki use and 22 descriptive studies about the quality
of information in wikis. Table 1 presents the experimental studies
and their results related to the use of CWAs: (1) increased physical
activity and improved blood pressure control; (2) better scientific writing
Cochrane Database Syst Rev Suppl 1–212 (2013)
skills among health science students; (3) improved medical student
self-confidence and communication skills, however worse diagnostic
skills; and (4) better nursing leadership skills. Conclusions: Although
there are many studies about CWAs in healthcare, a formal systematic
review still needs to be conducted to further assess their impact on
healthcare delivery and inform future clinical trials.
Attachments: Flow chart poster 1.pdf, Table1forCochraneabstract.
Calculating confidence intervals for the absolute
risk reduction taking uncertainties of relative
risk and baseline risk estimates into account
Bender R1 , Newcombe R2
Institute for Quality and Efficiency in Health Care (IQWiG), Germany;
Cardiff University, UK
Background: In Cochrane Reviews as well as in the GRADE system
absolute estimates of treatment effect are frequently calculated by using
relative risk (RR) estimates based on a meta-analysis in combination
with an independent baseline risk (BR) estimate. Spencer et al. (BMJ
2012;345:e7401) pointed out that GRADE and all other systems for
rating confidence in absolute treatment effect estimates do not fully
address uncertainties in BR estimates. Calculations of confidence
intervals for the absolute risk reduction (ARR) currently performed
under the GRADE framework take into account the imprecision of the
RR estimate, but not that of the BR estimate. Objectives: The aims of
this paper are firstly, to show that a method for interval estimation of
ARR is available that takes the uncertainties of RR and BR estimates
into account and secondly, to discuss the impact of accounting for
both uncertainties on the confidence in absolute estimates of the
treatment effect. Methods: If BR and RR are estimated from different
independent sources, confidence limits for ARR can be calculated from
those for BR and RR by a procedure called method of variance estimates
recovery (MOVER-R). This method is explained and applied to examples.
The resulting confidence intervals are compared to those obtained by
the method currently used by GRADE, and to those obtained by the
naive method of directly combining the confidence limits for RR and
BR. Results: Neglecting the uncertainty of BR estimates leads to
confidence intervals which are too narrow whereas the naive method
of directly combining the confidence limits for RR and BR results in
confidence intervals which are unnecessarily too wide. Conclusions:
A simple and effective method is available to calculate confidence
intervals for ARR from independent interval estimates of BR and RR.
This method should be applied in practice.
Translation and validation of the Cochrane
Collaboration’s tool for assessing risk of bias
into German
Buchberger B, Katzer C, Huppertz H, Wasem J
University of Duisburg-Essen, Institute for Health Care Management and
Research, Germany
Background: Working inter alia with the Cochrane Risk of Bias
(RoB)-tool for Health Technology Assessments, systematic reviews and
other evidence syntheses, the idea of a translated version came up being
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
helpful for teachers and lecturers in evidence-based medicine (EbM).
They would be able to communicate topics much more quickly and
easily. Furthermore, a translation into the mother tongue could help
medical professionals, developers of guidelines, patient advocacy-, and
patient self-help groups and single patients to gain a better knowledge
and a deeper understanding of the principles of EbM. Objectives: Our
work will contribute to the further dissemination of EbM-principles as
well as to the academization of paramedical professions. Methods:
According to the methods described by Beaton et al. 2000 and in
close cooperation with the German Cochrane Centre, a translation
and validation of the RoB-tool and its information will be undertaken.
Beaton et al. describe the process of translation in six stages: In
stage one and two, an informed and an uninformed translator will
work out a translation each into the target language and synthesize
the results. In stage three at least two native speakers without
medical background and unaware of the original version will create
back-translations. To achieve a prefinal version, a committee will be
established at stage four, consisting of all translators, methodologists,
language professionals and possibly health professionals. In stage
five a pretest with about 40 subjects will be conducted followed
by stage six, an audit wherein the developers of the tool or the
committee will appraise the adaptation process. Further validity-tests
should be desirable. The editors of the Cochrane Handbook are being
requested. Conclusions: The ease of use and transparency of the
RoB-tool as well as its simply understandable graphical representation
of assessment-results are the most persuasive reasons to increase the
degree of the instruments’ prominence.
The Norwegian electronic health library - helping
Norwegian health professionals in accessing
English language resources
Rosenbaum S, Tjensvoll K, Eggen R
Norwegian Knowledge Centre for the Health Services
Background: A large part of the world’s accumulated knowledge
about health care is published in the English language, including many
of the highest quality resources. But people who are not native English
speakers can have difficulty finding and reading documents in English,
even if they are relatively fluent. For this reason, the Norwegian
electronic health library identified language translation as one of the
primary areas to promote access and use of high quality research
and clinical support resources. Objectives: We wanted to make
it possible for library users to enter search queries in Norwegian or
English and retrieve search results for documents in both languages.
We also wanted to promote international resources of high quality in
search interface, without sacrificing easy access to important resources
in Norwegian language. Methods and Results: • We developed
an enterprise search solution that includes a translation dictionary
function. This allows a person to search in Norwegian and also
receive results from English language resources. • Search results from
both Norwegian and English resources are compiled together on one
page. • We developed several ‘spotlight’ functions for presenting
prioritized search results on the top of the search page, so that the
highest quality and most preferred sources are easier to find quickly.
• We manually translated over 200 patient leaflets (from BMJ Best
Practice) from English to Norwegian for use in Norwegian health care
context, and made them ‘findable’ through the spotlight function.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Conclusions and future developments: Translation is very timeconsuming. Resources in English can also be made more accessible
to users by improving the search functionality. The library is currently
leading a project to translate MeSH to Norwegian, which will open new
doors to transforming search queries into relevant results for our users.
Chronically sick to chronically well: a realistic
and concrete way to do things differently with
evidence in the Canadian system!
Laframboise F, Mireault J
Context: With only 5% of the population consuming 80% of the
canadian health care, who are those persons at risk in the community
& what are the evidence and effective actions to create a chronically
well population? An international comparative study has looked
at the Canadian health care system with seven countries. It shows a
strong and frequent emergency use amongst the population, especially
in Québec and Ontario. These difficulties reflect a weak primary
care organization in the community. Objective: Two regional Québec
initiatives will be presented to demonstrate how to renew community
care with a chronically sick population and high consumers of care while
reducing preventable emergency visits and hospitalisations. Method:
Simple actions working with the 5% of the population who’s consuming
80% of the care will be discussed and revisited: • Organisational portrait
and origine of the greatest consumptions of care in the system know the
difference between system induced consumptions and complex case
management in the community • Significant evidence for an integrated
and proactive approach with the chronically sick • Simple actions
with great impact (ex : computarized nominative stratification, NHS
complex case management, empowerment of families/patients, . . .)
• Caracteristics of the chronically sick and the myths surrounding
them • Relevent Performance indicators and documentiation on Return
on investments. Results: Results indicate very significant decrease in
preventable ER visits and hospitalisations, an increase in timely and
quality community follow ups. With the SF- 12, an increased well-being
was observed amongst the most vulnerable. Conclusion: Simple &
high impact systemic multi-level strategies for creating a chronically
well population exist. Let’s share learned lessons to build a stronger
primary care system for all PS either french or english. Thanks.
Health Systems Evidence: the development of
a ‘one-stop-shop’ of health systems research
evidence to support policymaking
Moat KA1 , Wilson MG2 , Lavis JN3 , Hammill A4 , Boyko J5 , Grimshaw JM6 ,
Flottorp S7
1 Lead, Health Systems Evidence, Program in Policy Decision-Making,
McMaster Health Forum, McMaster University, Canada; 2 McMaster Health
Forum, McMaster University, Canada; 3 McMaster Health Forum, McMaster
University, Canada; 4 Program in Policy Decision-making, McMaster
University, Canada; 5 McMaster University, Canada; 6 University of Ottawa,
Canada; 7 Norwegian Knowledge Centre for the Health Services, Norway
Background and Objective: Systematic reviews about health
systems aren’t always available when policymakers and stakeholders
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
need them, or in formats they can use. One strategy that has been
promoted to support the use of systematic reviews in policymaking
is the development of online ‘one-stop-shops’ that facilitate timely
access to relevant reviews. Researchers at the Program in Policy
Decision-making and McMaster Health Forum, with partners in a
number of high-, middle- and low-income countries developed Health
Systems Evidence (HSE)—a ‘one-stop-shop’ of the best available
research evidence about health systems. Our objective is to describe
the development, content and usage of HSE. Methods: HSE was
developed in several stages: (1) A taxonomy of health system
arrangements and implementation strategies, and document types
was developed; (2) Searches of online databases were conducted
alongside hand searches, continuous scanning of journals, listservs
and websites (3) Two independent assessors reviewed content and
coded those meeting inclusion criteria based on the taxonomies; (4) An
approach to ensure HSE is continuously updated with new content, and
to provide ‘added value’ to existing content was developed. Descriptive
statistics about HSE content and registered users’ usage are collected
each month. Results: The HSE taxonomy is organized by governance,
financial and delivery arrangements in health systems as well as
implementation strategies that can support these arrangements. There
are 6601 documents (2487 of which are systematic reviews) that are
searchable based on their relevance to the taxonomy. Currently 4855
users are registered, including 1222 policymakers, 1203 health care
professionals and 623 managers. Over 15 000 searches have been
conducted to date, and the majority of users are from Canada,
the U.S., the U.K. and Australia. Conclusions: The ongoing
development and evaluation of HSE and similar efforts should be
prioritized as a way to ensure these approaches are optimally designed
and implemented.
Comparison of two experiences of development
of healthcare quality indicators
Roqué M1 , Osorio D2 , Rigau D1 , Pardo H1 , Solà I1 , Bellmunt S2 , Escudero
JR2 , Bonfill X1
Iberoamerican Cochrane Centre, Spain; 2 Hospital de la Santa Creu i Sant
Pau, Spain
Background: Healthcare quality indicators are direct measures of
the appropriateness of care provided in a particular health condition.
Evidence-based indicators are built from clinical recommendations (CR)
supported by robust evidence. The complexity of building healthcare
indicators depends on the characteristics of the condition studied, as
well as on the existing evidence on management of the condition.
Objectives: To compare the process and results of developing
evidence-based healthcare quality indicators in two different clinical
specialties, obstetrics & delivery (OBD) and peripheral vascular disease
(PAD). Methods: The OBD and PAD projects followed a similar
methodology, described elsewhere. Systematic reviews (SR) were
identified through bibliographic searches, and their risk of bias was
assessed. Clinical recommendations were built from low risk of bias
SR, and their quality of evidence was assessed. Only those CR
supported by high quality evidence were used to define indicators.
The proposed indicators were assessed to discard those measuring
controversial interventions (e.g. unclear benefit-harm balance) or of
limited clinical relevance. Results: There was less available evidence
Cochrane Database Syst Rev Suppl 1–212 (2013)
for OBD than for PAD, but such evidence was of higher quality and
led to more clinical recommendations (see Table 1). In the end, 20
quality indicators were built for OBD and 6 for PAD. Reasons for
discarding CR were a controversial intervention (1 case in OBD), and
limited clinical relevance (1 in OBD, 2 in PAD). While indicators could
be defined for every main intervention in obstetrics, we could not
define indicators for important surgical and diagnostic techniques in
PAD (e.g. endovascular techniques). Conclusions: The development
of evidence-based indicators is more difficult for some specialties.
Challenges arise when the available research has low methodological
quality, interventions used in clinical practice are in rapid turnover,
there is no sound evidence to support the available interventions, the
health condition is infrequent or its management is individualized.
Attachments: table 1.pdf
Advancing quality in health policy
decision-making in the face of uncertainty: an
integrated review to characterize and address
Brouwers M1 , Driedger M2 , Makarski J1 , Craigie S1 , Annable G2
1 Department of Oncology, McMaster University, Canada; 2 Department of
Community Health Sciences, University of Manitoba, Canada
Background: Evidence-based decision-making has become a cornerstone of effective health care in both clinical and policy contexts.
Specific to the health policy setting, decision-makers must make
decisions within the context of uncertainty, a phenomenon that has
been poorly understood. Specifically, while research in this area has
focused on key themes, a better articulation of the specific types
of uncertainty, their impacts, and strategies available to navigate
or mitigate them are warranted. Objectives: Our aim was to
identify and characterize the unique uncertainties experienced by
health policy decision-makers and to identify strategies for how
to deal with them. A systematic review of the literature was
undertaken to identify: (1) types and sources of uncertainty that
decision-makers experience; (2) the impacts of these sources of
uncertainty on decision-making; and (3) strategies to measure,
navigate, and mitigate uncertainty. Methods: Scopus and Ovid
Medline databases (1995–2011) were searched for English language
articles relating to health policy and uncertainty, complemented by
a targeted book review and search of the grey literature. Results:
A total of 292 articles met inclusion. Three domains comprising
12 factors were identified: scientific (clinical, methods, evidence,
statistics, models, generalizability), structural (adoption, practical,
affordability), and contextual (acceptance, political, values). Impacts of
uncertainty included delayed action, avoidance, suboptimal decisions
and non-recommendation. Over 30 formal strategies to deal with
uncertainty were identified, ranging from statistical methodologies, to
formal methods used in policy contexts, to broader principles (e.g.,
Precautionary Principle). Conclusions: We successfully characterized
uncertainty in the health policy context and created a working
framework. These findings will be taken forward to develop a
tool to assist health policy decision-makers to navigate uncertainty.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
The publishing characteristics of Cochrane
Reviews for nursing research
Zhang F1 , Zhou Z2 , Li XL1 , Zhang J3 , Yang KH1
Evidence-Based Medicine Center, School of Basic Medical Sciences,
Lanzhou University, Lanzhou 730000, China; 2 Postgraduate School,
Lanzhou University, Lanzhou 730000, China; 3 Gansu province people’s
hospital, Lanzhou 730000, China
Background: Accompanied booming of the Nursing science and
Evidence-Based Medicine, Concepts and methods of evidence-based
nursing were given great attention by clinical practitioners and
managers. However, due to the scientific and artistic characters
of nursing discipline, they are facing challenges. Objectives: To
describe the publishing Characteristics of the Cochrane Reviews of
Nursing Research. Methods: We searched the Cochrane library by
the topic on ‘Nursing’, and retrieved the Advanced Search by term
of nursing as a supplement in March 2013. The EndNote X5 and
Excel were used for data description and analysis. Results: We
included 201 Cochrane Reviews of nursing researches out of the 226
identified, 32 of them published in 1998–2005, 169 published in
2006–2013. There were 9 (4.48%) Protocols, 38 (18.91%) New
Searches, 13 (6.47%) Conclusions Changed, 7 (3.48%) Withdrawn,
3 (1.49%) Methodology, 1 and 3 Comment and overview of the
inclusion respectively; Among which, 16 Reviews included 0 studies,
101 included 1–10, 37 included 10–20, 33 included more than 20.
130 (67.71%) only included randomised controlled trials (RCTs) or
quasi-RCTs, 40 (20.83%) included some of RCT or CCT or controlled
before and after studies or interrupted time series. 54 researches are
focused on Community or home care, 18 and 13 pay close attention
to Obstetric and pediatric nursing respectively, 60 to other patient
care at the hospital, 19 are associated with Care system, only 2 are
related to nursing education. Conclusions: Although more and more
Cochrane Reviews about nursing is published, the quantity of the
evidence should be improved; At the same time, we should pay more
attention to Nursing education and systematic review of observational
studies and qualitative research.
RCT databases - reducing research wastage from
the systematic review process
Nankervis H, Williams H, Thomas K, Delamere F
University of Nottingham, UK
Background: When a systematic review is conducted, the effort in
finding and extracting data from studies is usually only used for that one
review. The same process is then repeated by other researchers when
creating a systematic review on the same condition. As information
and communication technology has developed sharing of research
data is now easier than ever. The Global Resource of EczemA Trials
(GREAT) database allows researchers to quickly and easily find and
appraise randomised controlled trials (RCTs) of eczema treatments
gathered in the process of creating a systematic review. Objective:
To describe how information and communication technology can be
Cochrane Database Syst Rev Suppl 1–212 (2013)
used to extend and enhance the life of trial data gathered whilst
conducting a systematic review. Methods: The GREAT database has
two levels of data. The publicly accessible data provides enough detail
for trials to be identified and screened for inclusion in further reviews
or studies. This includes details about trial design, outcome measures
and participant inclusion criteria. The second level of data in the
GREAT database can be used in collaboration and includes extracted
results data for clinically relevant outcomes. Results: The GREAT
database (www.greatdatabase.org.uk) contains entries for over 500
RCTs and links to published systematic reviews of eczema treatments.
The database can be searched and filtered using keywords or browsed
using categories such as treatment, year, author or journal. The
database provides links to PubMed and full citations for all trials.
Conclusions: The GREAT database will facilitate future research on
eczema treatments by greatly speeding up the identification of relevant
trials. The creation of similar databases for other diseases could
replicate this. This will avoid duplication of effort by researchers around
the world searching for evidence to produce systematic reviews that
will be used to inform guidelines.
Technological solutions for enhancing efficiency
and sustainability of data abstraction in
systematic reviews
Li T1 , Vedula S2 , Hadar N3 , Parkin C3 , Lau J3 , Dickersin K4
Cochrane Eyes and Vision Group US Project & US Cochrane Center,
USA; 2 Johns Hopkins University, USA; 3 Brown University Evidence-based
Practice Center, USA; 4 US Cochrane Center & Cochrane Eyes and Vision
Group US Project, USA
Background: The Systematic Review Data Repository (SRDR) is an
example of an open-access, state-of-the-art, web-based data system
that allows online form building, data entry by multiple users, and data
management and sharing. Objectives: To describe our experience
using SRDR for data abstraction. Methods: The project leader creates
the project and abstraction forms in SRDR following user-friendly
wizard. S/he then adds users to the project and assigns roles. Users
extract and enter data directly from study reports into SRDR online
for seamless data saving and procession. The Data Comparison Tool
within SRDR allows identification and adjudication of discrepancies.
SRDR can be used to keep track of progress with data collection and
workflow. The data can be exported out of SRDR into an analyzable
format or a report. SRDR allows different alternatives for archiving
and publishing the data. Results: The Box summarizes steps for
developing abstraction forms in SRDR. We successfully used SRDR to
collect data from about 400 trials involving 15 data abstractors (800
records in SRDR due to double data abstraction). Our form contains
125 questions and 550 data items. It takes on average an hour for
one data abstractor to collect data from one article and another hour
for adjudication of discrepancies. Because the data can be directly
exported in an analysis-ready format, we have used SAS c for data
management and analysis. Because SRDR codes and stores data in
distinct data fields, evidence tables and risk of bias tables can be easily
generated. Conclusions: SRDR has facilitated efficient data collection
and preparation of a dataset from a large number of studies. To enable
authors of Cochrane systematic reviews to use this freely available tool
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
for data collection, future efforts must focus on developing tools to link
SRDR to RevMan.
Attachments: Box Steps for setting up forms in SRDR.pdf
Dealing with publication bias
Salmond S, Jadotte Y
Dealing with Publication Bias Publication bias has been defined as the
tendency on the part of investigators to submit, or journal editors, to
accept manuscripts based on the significance of findings. Publication
bias iimplies that positive study results have a better chance of being
published, are published earlier, and are published in journals with
higher impact factors. Conclusions exclusively based on published
studies, therefore, can be misleading, and yet, most systematic reviews
rely on published studies. A number of reasons have been cited for
publication bias, including: negative findings; failure of authors to
submit manuscripts; rejection of manuscripts by journal editors. This
poster presents ways in which to find and access those studies that have
not been published, yet are important to determining best practice.
Risk of bias assessment in cross-sectional genetic
research: the impact of genetic polymorphisms
on methadone response
Dennis B1 , Bawor M2 , Sohani Z3 , Thabane L4 , Guyatt GH5 , Samaan Z6
1 Department of Clinical Epidemiology and Biostatistics - McMaster
University, Population Genomics Program - McMaster University, Canada;
2 McMaster Integrative Neuroscience Discovery & Study (MiNDS) Program McMaster University, Population Genomics Program - McMaster University,
Canada; 3 Department of Clinical Epidemiology and Biostatistics - McMaster
University, Population Genomics Program - McMaster University,
Population Health Research Institute - Hamilton Health Sciences, Canada;
Department of Clinical Epidemiology and Biostatistics - McMaster
University, Departments of Paediatrics and Anesthesia - McMaster
University, Centre for Evaluation of Medicine, Biostatistics Unit, Father Sean
O’Sullivan Research Centre - St. Joseph’s Health Care Hamilton, Population
Health Research Institute - Hamilton Health Sciences, Canada; 5 Department
of Clinical Epidemiology and Biostatistics - McMaster University, Canada;
Department of Psychiatry and Behavioral Neurosciences - McMaster
University, Population Genomics Program - McMaster University,
Department of Clinical Epidemiology and Biostatistics - McMaster
University, Population Health Research Institute - Hamilton Health Sciences,
Background: The prevalence of genetic association studies in the
literature has increased exponentially over the past decade. Most are
cross-sectional studies that present unique methodological challenges
and risks of bias; they should be appraised accordingly when included
in systematic reviews and meta-analyses. Objectives: To develop
a method for assessing risk of bias in genetic association studies
and demonstrate its use in a review of the association between
a genetic polymorphism (CYP2B6*6) and metabolism of a drug
(methadone plasma concentration). Methods: We searched Medline,
Cochrane Database Syst Rev Suppl 1–212 (2013)
EMBASE, CINAHL, PsycINFO, and Web of Science databases. Two
independent reviewers included studies that reported methadone
plasma concentration and the CYP2B6*6 polymorphism. Results:
We modified the Newcastle-Ottawa Scale to assess the risk of bias in
studies of the effect of genetic polymorphisms on drug metabolism. We
removed several categories highlighting the comparability of cohort
or case/control selection and the importance of adequate follow-up
between study groups, while also introducing categories that emphasize
explicit outcome and genetic assessment. We identified seven studies
assessing the association between methadone plasma concentration
and the CYP2B6*6 polymorphism. Five were cross-sectional; two
were case-control. Trough (R) methadone plasma concentration was
higher in CYP2B6*6 homozygous carriers compared to non-carriers
(SMD = 0.53; 95% CI 0.05–1.00; p = 0.03; I2 = 0%). Trough
(S) methadone plasma concentration was higher in *6 haplotype
homozygotes than in non-carriers, (SMD = 1.44; 95% CI 0.27–2.61;
p = 0.04; I2 = 69%). Conclusions: Participants homozygous for the
CYP2B6*6 genotype have higher trough (R) and (S) methadone plasma
concentrations compared to non-carriers, suggesting that methadone
metabolism is significantly slower in *6 homozygous carriers. We
developed an instrument to appraise risk of bias in genetic association
studies; it rates the evidence in this review to be of moderate quality
and cautions our confidence in the estimates of association. This
presentation will focus on that instrument and its application.
Does the modified intention-to-treat reporting
affect the estimate of the treatment effect in
meta-analyses? A meta-epidemiological study
Abraha I1 , Montedori A1 , Cozzolino F1 , Orso M1 , Luchetta L2 , De Florio
R3 , Schünemann HJ4 , Germani A5
1 Regional Health Authority of Umbria, Perugia, Italy; 2 Local Health Unit 2,
Foligno, Italy; 3 Local Health Unit 1, Perugia, Italy; 4 McMaster University,
Canada; 5 Azienda Ospedaliera di Perugia, Perugia, Italy
Background: The intention to treat (ITT) principle helps to preserve
the balance of prognostic factors among allocated groups generated
by randomized trials (RCTs). The prevalence of trials using modified
intention to treat (mITT) may influence estimates of treatment effects.
Objectives: To investigate for any association between estimates of
treatment effects among trials with respect to the approach used for
analysis (ITT versus mITT). Methods: We performed a computerized
search of Medline and selected a random sample of systematic reviews
published between 2006 and 2011 with the following inclusion criteria:
(1) dichotomous data, and (2) presence of meta-analysis of at least
two randomised trials with at least one reporting mITT. Within each
systematic review, trials were classified according to the type of
intention-to-treat analyses used as follows: (1) ITT, trials reporting
the use of standard ITT analyses; (2) mITT, trials reporting the use
of ‘modified intention-to-treat’ analyses; or (3) ‘no ITT’ trials not
reporting the use of any intention-to-treat analyses. Risk of bias
criteria [sequence generation, allocation concealment and blinding,
the type of the center (single vs. multicenter trial), the presence of
post-randomization exclusions] and funding source were evaluated for
each trial. A meta meta-analysis was performed and ratio of odds ratios
(ROR) were calculated comparing ‘mITT trials’ against ‘ITT trials’ (or
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
‘no ITT trials’). A ROR less than one implying that trials reporting mITT
exaggerate intervention effect estimates. Results: After screening
2268 abstracts, 377 full-text publications were analyzed and 201
meta-analyses remained for inclusion. Of these 56 had at least one RCT
with a mITT reporting and overall included 804 trials. Conclusions:
Previous work reported that the proportion of statistical significance
within RCTs reporting mITT was high. This study determines whether
mITT represents a source of bias. Final results will be presented at the
Evidence of design-related bias among
studies validating clinical prediction rule:
a meta-epidemiological study
Ban J
University of Oxford, UK and Providence Health and Services, USA
Background: Proper validation is needed for the performance of
clinical prediction rule to be trusted. Validating clinical prediction
rule using inadequate methodology may result in biased estimation of
predictive performance. Objectives: This study aims to examine the
association between design deficiencies in validation studies of clinical
prediction rule and estimates of predictive performance. Methods:
MEDLINE, EMBASE, the Cochrane library and the Medion Database
were searched for systematic reviews of clinical prediction rule studies
published between 2006 and 2010. Data were extracted from all
validation studies included in the systematic reviews that allowed for
the construction of a diagnostic 2 by 2 table. A meta-analytic approach
was used to evaluate the influence of design deficiencies. First,
meta-regressions were conducted in each meta-analysis for selected
design features. Then, the natural logarithms of relative diagnostic odds
ratios (RDOR) from meta-regressions were meta-analyzed to estimate
the summary RDOR. Results: A total of 287 validation studies of
clinical prediction rule were collected from 15 systematic reviews
and 31 meta-analyses. Validation studies using case-control design
produced the largest summary relative diagnostic odds ratio (RDOR)
of 2.2 (95% confidence interval: 1.2–4.3) in multivariable analysis
under random-effects assumption between meta-analyses (Fig. 1). The
summary RDOR of studies using differential verification was 2.0 (95%
confidence interval: 1.2–3.1) and the summary RDOR of studies using
inadequate sample size was 1.9 (95% confidence interval: 1.2–3.1).
Narrow validation, validation studies conducted in similar settings or
with similar patients to derivation, produced the summary RDOR of
1.8 but the 95% confidence interval was 0.8–4.4. Conclusions:
Case-control design, differential verification and inadequate sample
size are associated with the overestimation of predictive performance
in validation studies. The results of validation studies should be
interpreted with caution if design deficiency is detected.
Attachments: Figure 1.pdf
Cochrane Database Syst Rev Suppl 1–212 (2013)
Randomised clinical trials with negative results:
Is there an increase in their reporting?
Martı́nez-Zapata MJ1 , Rigau D1 , Roqué M1 , Solà I1 , Vernooij R1 , Pardo H1 ,
Simon C2 , Gich I3 , Urrútia G1
Iberoamerican Cochrane Centre, IIB Sant Pau, Barcelona, Spain; 2 Servicio
de Farmacologı́a Clı́nica, Hospital de Bellvitge, Barcelona, Spain; 3 Servicio
de Epidemiologı́s Clı́nica y Salud Pública, Hospital de la Santa Creu i Sant
Pau, IIB Sant Pau, Barcelona, Spain
Background: One of the main aspects of publication bias is
underreporting of randomised clinical trials with negative results
(RCT-NR). Due to an increased awareness of the importance of
publication bias, researchers and entities are now more prone to
promote registration of protocols of clinical trials and publication of
their results. Objectives: Primary: TTo assess changes across time
in the prevalence of published RCT-NRs. Secondary: To describe the
main characteristics of published RCT-NR (e.g. sample size, medical
specialty, journal of publication). To describe the concordance between
results and conclusions for the main outcome in abstracts of published
RCT-NRs. Methods: We planned a retrospective, cross-sectional,
comparative study of a random sample of RCTs from PubMed database,
published in two different periods of time the years: 1998 (first period)
and 2009 (second period). We excluded references with no abstract
available and studies with designs other than RCT. The main outcome
was the difference in percentage of RCT-NRs in the two periods. A
total sample size of 964 RCTs, 482 from each period would have a
minimum of 80% power to detect a difference greater than or equal
to 10% in the main outcome, assuming a 20% of RCT-NRs in the first
period, a 5% type I error and allowing for 40% attrition. Two authors
will independently extract data. The chi-squared test will be used to
compare the data of the main outcome. We will contrast the trial
result associated with the main outcome with the authors’ conclusions.
Results: In April 2013, we obtained 49 363 references of possible
RCTs after the application of a validated RCT filter. We identified 623
references from the first period and 2000 from the second period. We
randomly selected 482 references from each period. Conclusions:
We plan to present the results and conclusions of this study during the
2013 Cochrane Colloquium.
Obtaining confidential protocols to increase the
completeness and accuracy of risk of bias
assessments for RCTs: an example from
recombinant human bone-morphogenetic
protein-2 (rhBMP-2) for spinal fusion
Rodgers M1 , Brown J1 , Heirs M1 , Higgins J1 , Mannion R2 , Simmonds M1 ,
Stewart L1
1 Centre for Reviews and Dissemination, University of York, UK;
Addenbrookes Hospital, Cambridge, UK
Background: Risk of bias assessment is an integral part of a systematic
review. The Cochrane risk of bias tool covers selection, performance,
detection, attrition, and reporting biases. Trials are classed as ‘high’,
‘low’, or ‘unclear’ risk of bias. The ability to assess a trial confidently
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
as ‘high’ or ‘low’ risk of bias is often hindered by poor reporting
of methodology in publications. Objectives: To explore whether
access to trial protocols provides more definitive assessments of risk
of bias than use of publications and conference abstracts. Methods:
As part of a systematic review and meta-analysis investigating the
effectiveness of rhBMP-2 in spinal fusion we conducted risk of bias
assessments for 12 published RCTs. We compared judgements about
selection bias, performance bias, and detection bias for each trial
based on information from trial publications and abstracts, from
publicly available summary protocols and from detailed confidential
trial protocols. Original detailed (in this case confidential) trial protocols
were made available to us by the manufacturer of the product
or through contacting study authors. Results: Eleven RCTs were
conducted by the manufacturer of rhBMP-2, and one was conducted
independently. When confidential trial protocols were used, 45 of
48 risk of bias judgements were definitive (‘low’ or ‘high’). Risk
of bias assessment based on publications and abstracts resulted in
just 28 of 48 definitive judgements. This was due to non-reporting
of randomisation and allocation concealment details in the publicly
available sources. Publicly available protocols from trial registers
produced no definitive judgments; the risk of bias was judged to be
‘unclear’ for all trials across all domains. Conclusions: Reviewers can
reduce uncertainty in risk of bias judgements by obtaining detailed trial
protocols either from journals or directly from investigators or sponsors.
Protocols exclusively from trial registers are unlikely to be adequate
for this purpose.
Judging the impact of missing participant
continuous data on risk of bias in systematic
reviews of randomized trials
Ebrahim S1 , Johnston B2 , Akl EA3 , Mustafa RA4 , Sun X5 , Walter SD1 ,
Heels-Ansdell D1 , Alonso-Coello P6 , Guyatt GH1
Department of Clinical Epidemiology & Biostatistics, McMaster University,
Canada; 2 Department of Anesthesia and Pain Medicine, The Hospital For
Sick Children, Canada; 3 Department of Internal Medicine, American
University of Beirut, Lebanon; 4 Department of Medicine, University
of Missouri-Kansas City, USA; 5 Center for Clinical Epidemiology and
Evidence-Based Medicine, Xinqiao Hospital, China; 6 Iberoamerican
Cochrane Centre, CIBERESP-IIB Sant Pau, Spain
Background: We developed an approach to address missing
participant data for continuous outcomes in meta-analyses.
Objectives: To assist systematic review authors and guideline panels in
judging the impact of missing participant data on risk of bias. Methods:
Our approach involves a complete case analysis complemented by
sensitivity analyses applying four increasingly stringent imputation
strategies (Table 1). When the minimally important difference (MID) is
available, we calculate the proportion of patients who benefit from the
treatment. Systematic review authors should test a range of thresholds
that guideline panels might choose as an important effect. A guideline
panel should choose the threshold for recommending treatment. If the
entire confidence interval for the proportion is above the threshold for
all plausible imputation strategies, a panel should not rate down for
risk of bias. If the confidence interval includes the threshold, confidence
in the importance of the treatment effect decreases. We applied our
Cochrane Database Syst Rev Suppl 1–212 (2013)
approach to a systematic review of respiratory rehabilitation for chronic
obstructive pulmonary disease. Results: In the complete case analysis,
the proportion of patients who achieved an improvement effect greater
than the MID was 29% (95% CI of 21–37%) (Fig. 1). Strategies 1–3
resulted in point estimates ranging from 24% to 18%, with lower
confidence limits from 17% to 11% (Fig. 1). Strategy 4 was not
considered a plausible scenario. In the complete case analysis, the
lower confidence limit suggests that at least 21% will achieve an
important improvement. The conclusion would be similar for strategy
1 and 2. For strategy 3, if 11% benefiting would be insufficient to
recommend treatment, a panel would rate down the quality of evidence
for risk of bias. Conclusions: We provide a useful approach on judging
the impact of missing participant data for continuous outcomes on
confidence in estimates of treatment effects.
Attachments: Table 1.pdf, Figure 1.pdf
Reporting bias in industry-sponsored spinal
fusion studies of recombinant human Bone
Morphogenetic Protein-2 (rhBMP-2)
Selph S, Fu R, McDonagh M, Peterson K, Tiwari A, Chou R, Helfand M
Oregon Evidence-based Practice Center, USA
Background: The use of rhBMP-2 in spinal fusion increased 25-fold
from 2002 to 2006, with much of that increase due to off-label
use. In the midst of concerns over the safety of rhBMP-2 and
questions regarding the accurate reporting of adverse events in early
industry-sponsored trials, we were afforded access to individual patient
data (IPD), study protocols, and manufacturer’s reports which we
used to assess benefits, harms, and reporting bias. Objectives:
To assess reporting bias in publications of industry-sponsored trials
of rhBMP-2 in spinal fusion. Methods: We searched MEDLINE,
EMBASE, the Cochrane Central Register of Controlled Trials and other
databases through August 2012 for published studies of rhBMP-2.
For each industry-sponsored trial we identified a primary publication
and associated companion publications. Using a previously published
protocol, we identified and classified examples of reporting bias by
comparing journal publications with corresponding study protocols,
internal manufacturer reports, and IPD provided by the manufacturer.
Results: Nine of 16 included studies were published in medical journals
as individual trials; two were partly described in articles that analyzed
multiple studies together; five were unpublished. When we compared
published articles to manufacturer reports submitted to the United
States Food and Drug Administration, study protocols, and IPD, we
identified selective reporting, reporting of inappropriately pooled data,
and underreporting of outcome measures. While published studies of
rhBMP-2 indicated no increase in adverse events due to rhBMP-2 along
with the same or better fusion rates compared with bone graft, our
analysis of individual patient data indicated no increase in fusion rates
with possible increased cancer risk. Conclusions: Compared with
individual patient data and internal manufacturer reports, the journal
publications exaggerated the benefits and minimized the potential
harms of rhBMP-2 for both on-label and off label use.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Assessing publication bias in systematic reviews
and meta-analyses in the context of small n trials:
application of a capture-recapture method
Coronado-Montoya S1 , Kwakkenbos L2 , Thombs B2
Lady Davis Institute for Medical Research, Jewish General Hospital,
Canada; 2 McGill University, Canada
Background: Systematic reviews and meta-analyses should include
published and non-published evidence. Evidence used to support
recommendations for relatively new, easily-delivered, psychosocial
interventions, such as mindfulness-based therapy (MBT), often comes
primarily from small trials. Methods like funnel plots and other
statistical methods that are used to assess the likelihood of publication
bias, however, depend on having a sufficient number of large studies
to anchor the analysis. When there is insufficient data to support
statistical methods, an alternative method is needed. Capture-recapture
is a method that has been used to estimate missing information
and which has been used to estimate the number of articles that
may have been missed by different search methods, for instance.
Capture-recapture could also be used to compare completed trials
identified via traditional database searches and clinical trial registries.
Objectives: To investigate (1) whether evidence syntheses of MBT
effectiveness include non-published trial evidence and (2) whether risk
of potential bias is adequately evaluated in MBT evidence reviews,
and (3) to estimate the proportion of completed MBT trials that
are not published. Methods: PubMed, PsycInfo, CINAHL, Embase,
ISI, SCOPUS, Cochrane were searched through 2012 for systematic
reviews and meta-analyses on MBT. The same databases and clinical
trial registries (ClinicalTrials.gov; Standard Randomized Controlled
Trial Number Register; region-specific registries accessed through
the World Health Organization registry search portal) were searched
for trials of MBT targeting medical symptoms, including psychiatric
symptoms. Preliminary Results: Of > 20 published systematic reviews
and meta-analyses, few assessed possible publication bias, though
all who did concluded, using statistically-driven methods, that there
was no publication bias. There are, however, a large number of
unpublished trials, and we will estimate the number of these using
the capture-recapture method. Conclusions: The capture-recapture
method may be a useful method to estimate possible publication bias
in the context of relatively small trials.
Evidence from clinical trials is needed: what are
Cuban medical journals doing about it?
Torres Pombert A, Piedra Piz M, Fors López MM
National Coordinating Centre of Clinical Trials, CU
Background: To translate clinical trials into knowledge depends
on the right primary information about them but its publishing is a
scientific and ethical dilemma. Some initiatives trying to standardize
the process aren’t always accomplished in all contexts. Objectives: To
review the editorial policy in Cuban medical journals related to Uniform
Requirements of the International Committee of Medical Journals
Editors To estimate the endorsement of reports to the CONSORT
statement To assess the prospective registration of Cuban trials.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Methods: The instructions to authors of 39 journals previously
identified with the Iberoamerican Cochrane were revised for identifying
explicit parameters related to clinical trials. Some studies were
evaluated using the CONSORT checklist. Cuban registries from the
International Clinical Trials Registry Platform (ICTRP) and the Cuban
Registry of Clinical Trials (RPCEC) were checked. Results: Most of
journals refer to the ICMJE requirements but they only use it for citing.
Journals are published by pharmaceutical industry and the Medical
Sciences Press; only one refers explicitly to the CONSORT and the
prospective registration of clinical trials. 174 Cuban clinical trials
were identified through the ICTRP since the first one in 2004 in the
Australasian registry. RPCEC exists since 2007 and shows 151 trials,
54 of them after the condition of primary registry. More than 90%
of the registries have been retrospective and just a few of them have
been published in journals. The assessed reports don’t fulfill at least
the most elementary Consort items. Topics like the random sequence
generation, allocation concealment, the intention to treat analysis are
ignored. Conclusions: Editorial policy in Cuban medical journals
is not aligned to the main international standards for clinical trials
publication. As a consequence the quality of reports is not optimal.
A joint project with the Medical Sciences Press for assessing and
improving the quality of reports was signed.
Disturbing evidence
Fonfa A
Annie Appleseed Project, USA
Background: As a Patient Advocate who practices no type of medicine,
conducts no direct research, and is a full-time volunteer, I find myself
more and more concerned with the quality of evidence. Objectives:
As a Cochrane Consumer, I get the chance to evaluate evidence. As
a member of the Adverse Effects Methods Group, I am very aware
of the failure to collect evidence/information. Testifying at Food &
Drug Administration—FDA (USA) meetings, I see how evidence can be
manipulated. As a reader of many journals, newsletters and magazines,
I follow what happens when ‘evidence-based’ studies bring drugs or
devices into the community settings and fail to replicate. Methods:
At the two prior colloquiums I have attended, I was struck by posters
showing how badly evidence is collected and reported. These are
some poster titles that caught my attention at Madrid Colloquium (the
last one attended): P1A15 The sensitivity and precision of adverse
effects search filters in MEDLINE, EMBASE and Science Citation Index
P1416 The usefulness of different information sources for retrieving
adverse effects data for a systematic A603 An investigation into the
assessment and reporting of harms in clinical studies A604 What is
a rapid review? B203 Primary outcomes reported in abstracts and
ClinicalTrials.gov—do they agree? C304 Do Cochrane systematic
reviews report patient-important outcomes? P1S34 Where and how
to find data on safety: What do systematic reviews of complementary
therapies tell us? P1A48 Geographical and language distribution of
trials in Cochrane Systematic Reviews related to acupuncture P2A190
Systematic reviews of adverse events. Is screening by title and abstract
enough? Results: Clearly use of this evidence must be examined.
Let’s do it. Conclusions: Cochrane Consumers and researchers must
discuss this at Colloquium to impact change.
Attachments: Outcome research bias.JPG, Critical outcomes.JPG,
Cochrane Consumers.JPG
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Development of user-friendly summaries for
published systematic reviews and meta-analyses
in agri-food public health
Kerr A1 , Young I1 , Waddell L1 , Keay S1 , McEwen SA2 , Rajic A3
Public Health Agency of Canada, Canada; 2 University of Guelph, Canada;
3 Food and Agriculture Organization, Italy
Background: The application of systematic reviews (SRs) is increasing
to address agri-food public health topics (e.g. food safety). In order to
increase the uptake of SR evidence to inform decision-making in this
sector, there is a need to develop user-friendly formats for disseminating
this information that are more relevant to end-users. Objectives: We
developed a framework for summarizing SR evidence into user-friendly
one- and three-page summaries and applied the framework on two SR
examples that investigated two different interventions (vaccination and
feed and water additives) to reduce Salmonella spp. colonization
in broiler chickens on farms. The summaries included the SR
evidence about intervention efficacy, as well as supporting contextual
information from additional sources. Methods: We pre-selected
five relevant categories of contextual information (efficacy, cost,
availability, practicality, and public sensitivities/concerns), and data
for each category was obtained using an environmental scan approach
consisting of the following steps: (1) targeted grey literature searches;
(2) scientific literature searches; and, (3) interviews with 12 topic
experts. Results: For the vaccination intervention, 8/26 (30.8) and
4/76 (5.3%) relevant articles identified in the grey and peer-reviewed
literature searches, respectively, were used to develop the three-page
summary. In the feed and water additives summary, 14/30 (46.7%) and
3/20 (15%) relevant articles were used from the grey and peer-reviewed
literature sources, respectively. On average, approximately 6–8 hours,
4–5 hours and 1–1.5 hours were needed to obtain relevant information
from grey literature, peer-reviewed literature and topic experts,
respectively, per contextual category. Conclusions: The overall
utility of the literature searches and expert interviews depended on
the specific intervention topic and contextual category. In general,
interviews with industry experts were the most useful and rapid
method; however, the literature searches were also useful to highlight
key knowledge gaps to be investigated further by the topic experts.
Does a Cochrane contributor facilitate the
implementation of evidence-informed
recommendations in practice
Nabhan A
Ain Shams University, Egypt
Objective: to measure the rate of implementing evidence-informed
recommendations by health care providers supervised by a clinical
supervisor who is a contributor to the Cochrane collaboration as
compared to a matched clinical supervisor who is not a contributor
to the Cochrane collaboration. Methods: this observational study
included 145 healthcare providers. All participants received formal
training in evidence based practice prior to this study. Participants
worked in two groups, one group lead by a clinical supervisor who is
Cochrane Database Syst Rev Suppl 1–212 (2013)
a Cochrane contributor and the other group lead by a matched clinical
supervisor who is not a Cochrane contributor. The primary outcome was
the rate of implementing evidence-informed recommendations (of the
WHO guideline that was based on a Cochrane Review) as measured by
the rate of prescribing Intermittent iron and folic acid supplementation
to non-anemic pregnant women in contrast to the routine daily
supplements. The prescribing pattern was determined by checking
outpatient prescriptions over 9 weeks in 2013. Results: A statistically
significant difference in prescribing intermittent supplements between
the two groups was observed. Cochrane Leadership increased
the uptake of evidence informed recommendations and lead to
a significant change in the prescribing pattern (Odds ratio 5.96
95% CI 2.70–13.14, P < 0.0001). Providers who are currently
involved in the Collaboration significantly changed their prescribing
pattern as compared to non-contributors (Odds ratio 2.72 95% CI
1.30–5.68, P < 0.01). A combined Cochrane supervisor and a
Cochrane provider significantly increased the change in prescribing
pattern [Odds ratio was 7.61 (95% CI 3.12–18.56, P < 0.0001)].
Conclusion: Cochrane contributors working in clinical practice are
more likely to implement evidence-informed recommendations. A
Cochrane contributor leadership improves the uptake and application
of knowledge.
Putting the issues on the table: summarising
outcomes from reviews of reviews to inform
health policy
Brunton G1 , Thomas J1 , Paraskeva N2 , Caird J1 , Rumsey N2
1 EPPI Centre, Social Science Research Unit, Institute of Education, University
of London; 2 Centre for Appearance Research, University of the West of
England, Bristol
Background: Systematic reviews are increasingly used to inform
health policy. These often employ rapid evidence assessment methods,
involving reviews of reviews. Together, these result in particular
challenges, since policy questions can be broad, and the time available
more suitable for reviews with a more limited scope. Navigating these
issues thoughtfully both precedes and supports a more downstream
need: for knowledge translation to represent evidence in a way
that is appropriate for policy use. Configurative reviews involving
a qualitative comparison of consistency across reviews have been
recommended, but few methods to undertake such comparisons have
been reported. Objectives: To demonstrate a novel method of
representing evidence from a systematic rapid evidence assessment
(SREA). Methods: We undertook a SREA of cosmetic interventions
which asked a broad research question under tight timelines. As
a review of reviews supplemented by primary studies where review
evidence was thin, statistical synthesis was not appropriate. Instead,
we mapped in tabular format the effects (positive/no change/negative)
for each outcome against each type of cosmetic intervention. We then
compared overall effects by each cosmetic procedure and each outcome,
to derive a narrative synthesis of effectiveness. Results: The tabular
format (Table 1) illustrated the impact of cosmetic interventions on each
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
outcome (e.g. satisfaction, self-esteem, anxiety etc.). It also allowed
visualisation of the overall impact (i.e. all outcomes) of any one cosmetic
intervention. These produced very different Results: for example,
self-esteem improves across cosmetic interventions, but findings across
abdominoplasty studies suggest small or no improvements across
outcomes. Conclusions: This type of cross-tabulation adds depth to
the SREA process since evidence on narrower (i.e. procedure-specific)
interventions can be summarised visually to address broader policy
questions of effectiveness while showing overall effectiveness. The
use of systematic reviews enabled us to conduct a rigorous evidence
synthesis within the limited policy timescale.
Attachments: SUBMITTED Putting the evidence on the table Abstract
Table 1.pdf
Critically Appraised Topic (CAT) one-day
workshop—‘CAT in a day’
Jordan J, Stevenson K, van der Windt D, Dziedzic K
Arthritis Research UK Primary Care Centre, Keele University, UK
Background: Critically Appraised Topics (CATs) are brief reviews
of the best evidence that aim to generate a clinical bottom line for
implementation in clinical practice. Potential topics are brought by
clinicians to the CAT group, questions are defined and CAT teams
(clinicians and researchers) are established. Structured literature
searches are conducted and evidence is appraised and synthesized.
CATs are disseminated locally to healthcare practitioners, managers
and commissioners to inform decision-making. It can take months
to produce a CAT as these activities fit around clinical workloads.
Objectives: We wanted to see if it was feasible to develop CATs in
a one-day workshop. Our aims were to speed up CAT development,
highlight work of the group and engage new local clinicians by
teaching new skills. Methods: Topics were chosen before the
workshop based on interests of attendees and availability of evidence.
Four specific CAT questions were discussed and refined within each
group. Participants had opportunity to learn searching and critical
appraisal skills. Facilitators from the CAT group helped to interpret
research results and generate the clinical bottom line. We gave advice
on how to disseminate and implement CATs when back in clinical
practice. Structured searches were conducted after the workshop to
evaluate the one-day CATs. Results: In the workshop, we found
and appraised at least one research paper, often a systematic review,
relating to each CAT. There was insufficient good quality evidence
to instigate a change in clinical practice and gaps were highlighted
in the evidence, particularly for early mobilisation after total knee
replacement and steroid injections for plantar fasciitis. Conclusions:
It seems feasible to develop a CAT in a one-day workshop for simple
intervention questions. We will discuss the validity and limitations of
this approach and how it can be used to support training clinicians and
implementation of EBM.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Developing a conceptual framework for going
from evidence to coverage decisions
Davoli M1 , Amato L2 , Parmelli E3 , Pregno S4
1 Drugs and Alcohol Group Dept Epidemiology Rome, Italy; 2 Cochrane Drugs
and Alcohol Group, Department of Epidemiology Lazio Regional Helath
System, Italy; 3 Italian Cochrane Centre, Department of Epidemiology Lazio
Regional Health System, Italy; 4 Italian Cochrane Network, Local Health
Unit Modena, Italy
Background: DECIDE, a 5-year project funded by the European
Commission’s FP7, aims at improving the dissemination of
evidence-based recommendations by building on the work of the
GRADE Working Group to develop and evaluate methods that address
the targeted dissemination of guidelines. Within this project we
are developing tools to assist policymakers, managers and their
staff to systematically and transparently consider factors that should
influence decisions about whether to pay for the introduction of an
intervention/option in a specifichealthcare setting (coverage decision).
Objectives: To inform the development of a conceptual framework
for going from evidence to coverage decision, using input collected
through a structured consultation of our target audience. Methods:
We developed a conceptual framework considering the following
criteria: severity of the condition, benefits and harms of the proposed
interventions, quality of evidence available, patients’ values, feasibility,
equity and resource use. We consulted, through a structured feedback
form, a convenient sample of 77 individuals from six Countries,
collecting their opinions on the proposed framework. Results: To date,
49/77 (63%) people responded: 82% of them found the framework
adequate for the intended purpose, gave positive judgments about
its simplicity (83%) and usefulness (71%) and found it applicable
to different types of coverage decisions (61%). However, these
preliminary results show that only 43% of the respondent considered
the framework comprehensive: more detailed information are required
for cost effectiveness, feasibility, production capacity, and contextual
factors that impact on the decision-making process, such as ability to
implement the procedure. Conclusions: The preliminary results show
that the majority of the respondents found the framework adequate for
the intended purpose, although not always applicable to different types
of coverage decisions. Potential improvements for comprehensiveness
have been suggested. On the basis of the full results of this consultation,
the conceptual framework will be refined and then re-tested for its
Readability of Cochrane Breast Cancer Group
plain language summaries
Luis C1 , Jeffery G2 , Hickey B3
University of New South Wales, Australia. Mater Centre Radiation
Oncology Service, Australia; 2 Christchurch Hospital, New Zealand; 3 Mater
Centre Radiation Oncology Service, Australia
Background: Readability is an objective measure of the reading
skill required to understand a written text. Guidelines suggest that
information be written at an education level not greater than grade
six. The Cochrane Collaboration provides free online, plain language
summaries of Cochrane systemic reviews for healthcare consumers.
The readability of these plain language summaries is unknown.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Objectives: To assess if plain language summaries written by the
Cochrane Breast Cancer Group (CBCG) meet recommended readability
scores. A secondary aim was to improve plain language summary
readability using: simpler language, shorter sentences and active voice.
Methods: Two reviewers independently evaluated the readability
of all reviews published by CBCG. The same reviewers individually
re-wrote all plain language summaries using simpler language, shorter
sentences and active voice to improve readability. Reviews published
as ‘withdrawn’ were excluded. Readability was assessed using Flesch
Reading Ease and Flesch-Kincaid Grade Levels in Microsoft Word
2010. Flesch Reading Ease generates a readability score from 0
(unreadable) to 100 (very easy). Flesch-Kincaid Grade Levels provide a
readability score indicating the academic grade level required to read the
text. Final average scores were calculated where a difference in scoring
existed between reviewers. Results: Mean Flesch Reading Ease and
Flesch-Kincaid Grade Levels were 26.8 (SD = 11.3, range = 3.0–52.0)
and 15.0 (SD = 2.3, range = 10.9–20.0) respectively. No individual
plain language summary met the recommended readability level. Most
articles (83.3%) were written at college level. Our writing techniques
significantly improved readability (p < 0.001), mean Flesch Reading
Ease was 52.5 (SD = 9.0, range = 34.1–72.5) and Flesch-Kincaid
Grade Level 8.9 (SD = 1.3, range = 6.4–11.0). Conclusions: CBCG
plain language summaries did not meet recommended readability
levels for healthcare consumers. Writing using simple language, short
sentences and active voice are useful tools the Cochrane Collaboration
could recommend to authors to improve readability. This may improve
healthcare consumer access to the high quality information in Cochrane
systematic reviews.
Awareness and use of the Cochrane Library
in internal medicine
Letelier LM1 , Rivera S1 , Dı́az A2 , Ewolt S2 , Acuña MP2
Evidence Based Health Care Centre, P. Universidad Católica de Chile, Chile;
Internal Medicine Department, P. Universidad Católica de Chile, Chile
Background: Systematic Reviews (SR) are a fundamental tool for
practicing Evidence Based Medicine. Since 1993 the Cochrane
Collaboration’s mission is to produce SRs. However, awareness
and use of Cochrane SR, varies in different countries and specialties.
Objectives: To describe the level of awareness and use of Cochrane
RS among internists. Methods: Among participants to the XXXI
World Conference of Internal Medicine (WCIM) held in Santiago, Chile
on November 2012, we recruit volunteers to reply an online survey
consisting of 12 questions regarding awareness, access and uses of
Cochrane SRs. Results: 413 attendants to WCIM volunteered to
participate on our survey; 202 (48,9%) replied. Responders were
from 27 countries, 117 (57%) were chileans, 71 (34%) from other
latinoamerican countries and 16 (8%) were non latinoamericans.
(North America, Europe and Oceania). 103 (51%) were Internists or
internal medicine subespecialists, 53 (26, 2%) were residents, 33 (16,
3%) undergraduate students and 13 (6, 4%) other specialties. Most of
them worked in hospitals (78%) and one third worked in an academic
setting. 94% of responders report using SRs for decision making, of
these 98, 5% use Cochrane SRs and 98, 8% considered them useful
or very useful for healthcare decision. Frequency of Cochrane SRs use
was once a week in 21%, at least once a month in 54%, 5% and
16% twice a year. The most common reasons to use Cochrane SRs
Cochrane Database Syst Rev Suppl 1–212 (2013)
were: clinical decision making (67.6%), keeping up to date (64.2%),
teaching purposes (32%) and research (27%). Access to Cochrane SR
was through Institutional affiliation in 44,9%, 38,1% use free access
through Cochrane Library Plus, only 2, 8% pays for personal access.
Conclusions: Our survey shows that most internists use CL SRs very
frequently, mostly for clinical decision making or updating purposes
and considered them useful or very useful. Regarding access options,
the most frequent was institutional affiliation.
Dissemination of effective physiotherapy
treatments - analysing the relevance and
usefulness of a large database of evidence
Claes E1 , Jans C1 , Meesen R2 , Deschutter F3 , Van de Velde S4
Provinciale Hogeschool Limburg, Belgium; 2 Phd. PT. Provinciale
Hogeschool Limburg, Belgium; 3 Wetenschappelijke Vereniging voor
Kinesitherapie, EBMpracticeNet, Belgium; 4 EBMpracticeNet, Belgium
Background: Matching care to strong evidence is essential for
high-quality physiotherapy. However, many barriers hamper the
implementation of evidence based physiotherapy. To promote
evidence-based decision-making a Belgian national electronic
point-of-care information service was initiated in September 2011.
This database is free for Belgian healthcare providers and includes the
comprehensive Duodecim database with clinical guidelines and concise
evidence summaries of systematic reviews - often Cochrane Reviews.
While this database is developed for general practitioners, information
about physiotherapy interventions is included to inform physician
referral decisions. Therefore physiotherapists might also benefit from
these summaries when deciding on treatments and their parameters.
Objectives: To determine the relevance and usefulness of the available
evidence summaries for physiotherapists dealing with musculoskeletal
pathology. Methods: Evidence summaries related to musculoskeletal
physiotherapy were selected by systematic screening of the summaries
against the predetermined criteria. Relevant evidence summaries were
evaluated for usefulness using four parameters: therapy modality,
intensity, duration and frequency. Provided that a summary was not
useful, the accompanying systematic reviews were further screened
for details on these parameters. Results: Out of a total of 4 128
278 evidence summaries were relevant to musculoskeletal pathology
and 106 were relevant to physiotherapy. Six evidence summaries
contained sufficient information to be useful for physiotherapists.
Usefulness of systematic reviews is still being analyzed. These results
are expected by the end of May 2013. Conclusions: While the
evidence summaries contain relevant information for musculoskeletal
physiotherapy, essential therapy-parameters for physiotherapists are
missing in most evidence-summaries. However, the first results of
the evaluation of the full systematic reviews show that additional
parameters from these reviews might be used to increase their
usefulness towards physiotherapists.
What is the most appropriate knowledge
synthesis method to conduct a review? A scoping
Tricco A, Kastner M, Soobiah C, Antony J, Cogo E, MacDonald H, Lillie E,
Perrier L, Welch V, Horsley T, Straus S
Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Canada
Background: Though systematic reviews are often utilized to
synthesize complex interventions, additional synthesis methods may
be required in order to explore how and why interventions work
in different settings. Objectives: To conduct a scoping review of
non-traditional/novel knowledge synthesis methods across
multi-disciplinary fields, compare and contrast the different knowledge
synthesis methods, and develop an algorithm to match the most
appropriate method to a research question. Methods: Systematic
searches of electronic databases (e.g., MEDLINE, Philosopher’s Index,
PsycInfo) and targeted Internet searches (e.g., Google) were conducted.
Reports describing the development/use/comparison of non-traditional/
novel methods for synthesizing qualitative or quantitative evidence
on complex interventions within health (as per the World Health
Organization definition) or philosophy were included. The screening
criteria and data abstraction forms were tested a priori. Citations and
full-text articles were screened, and data abstraction was conducted
independently, by two reviewers. The evidence was synthesized
according to the three objectives above. Results: We screened 17
996 titles and abstracts and 1045 full-text studies reporting on over
30 different knowledge synthesis methods. The five most common
methods were: meta-ethnography, meta-synthesis, thematic analysis,
realist review, and meta-study. Key methods articles were identified
and specific steps were synthesized. Strengths identified across some
methods included the ability to (1) combine qualitative and quantitative
data, (2) move beyond aggregation to interpretation, (3) contextualize
the knowledge synthesis results, and (4) make sense out of conflicting
evidence. Based on these results, we developed a preliminary algorithm,
which can be used to match a knowledge synthesis question to a specific
knowledge synthesis method. Conclusions: Our results will allow
funders, publishers, policy-makers, researchers, teachers, and students
to identify the most suitable knowledge synthesis method for their
knowledge synthesis questions. Future work will involve consulting
with leaders in each of the methods areas to generate agreement on
the typology and priorities for research.
Attachments: Cochrane abstract KS methods 27MAR2013.pdf
Assessing generalizability of findings
in systematic reviews of public health
interventions: methods of the US Community
Preventive Services Task Force
Thota A, Elder R, Hopkins D, Mercer S
Background: Since 1996, the Community Preventive Services Task
Force (Task Force) has developed over 220 recommendations about
public health interventions across a broad range of topics, based on
systematic reviews, and compiled in The Community Guide. Integral
to this process is assessing the generalizability of Task Force findings
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Cochrane Database Syst Rev Suppl 1–212 (2013)
to a range of settings and populations encountered in public health,
and options in implementing interventions, often despite incomplete
empirical information. Objective: To refine Community Guide
methods to more systematically assess generalizability. Methods
Development: For each review, the Task Force considers three
categories of potential effect modifiers (setting, population characteristics, and intervention characteristics), and identifies specific factors
within these categories (e.g., ‘rural/urban/suburban’ under ‘setting’;
‘race/ethnicity’ under ‘population characteristics’; ‘tailoring’ under
‘implementation characteristics’) that are relevant to the intervention
being reviewed. The Task Force draws conclusions on each potential
effect modifier by considering: (1) an a priori hypothesis about the
likely direction and magnitude of effect, developed by subject matter
experts based on theoretical and experiential considerations for the
intervention being studied (e.g., ‘likely effect modifier,’ ‘unlikely to
be a substantial source of variability’); (2) the quality, quantity, and
consistency of empirical evidence related to the factor of interest; and
(3) the degree of concordance between the hypothesized relationships
and the available evidence. The strength or tentativeness of Task
Force conclusions regarding the generalizability of overall findings
across settings, populations, and intervention characteristics vary
based on these considerations. The two primary sources of evidence
considered for assessing effect modification are between-study and
within-study stratified analyses. Although the latter evidence has
stronger internal validity (e.g., no collinearity problems), the former is
much more commonly available in the public health literature, and is an
important source of evidence on these vital issues. Conclusion: These
methods might assist others considering generalizability of findings
from systematic reviews.
The reporting characteristic of qualitative study:
a review
Shi CH1 , Ren D2 , Wei H3 , Tian JH1 , Yang KH1
Evidence Based Medicine Centre of Lanzhou University, China; 2 School of
Basic Medical Sciences, Lanzhou University, China; 3 The Second School of
Clinical Medicine, Lanzhou University, China
Background: Although some searching strategies or filters have been
reported and assessed, identifying appropriate qualitative research
remains frustrating and difficult. Objectives: To review to what extent
terms on qualitative study were correctly used. Methods: On the first
part, by electronic search with broad-based strategy (Shaw RL 2004)
on qualitative study in PubMed, we collected eligible studies focusing
on developing or assessing a search strategy or filter. Then terms of
these strategies were retrieved to develop a list of terms on qualitative
study (contrast terms). On the second part, using a search filter
(Booth A 2006), qualitative reviews were collected from PubMed. Then
after screening titles and abstracts, eligible full texts were included
with randomly selected block sizes. The reporting characteristics were
extracted and investigated by comparing with the contrast terms.
Results: On the first part, 9 strategies were included from 11 studies.
A list including 29 terms on qualitative studies was developed to be
a contrast. On the second part, 308 relevant studies were retrieved
from 582 citations. Finally, 68 full-texts were randomly selected. Only
34 (50%) studies were true qualitative reviews, among which 19
(56%) clearly reported the inclusion of primary qualitative researches.
And qualitative study, experience, meta synthesis, interpretation,
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
theme, qualitative review, qualitative synthesis, meta ethnography,
expectation and grounded theory were included in our contrast term
list, except that interpretation, view, attitude and belief. Another 19
(28%) reported a synonyms on qualitative review which was included
in our contrast in titles, and 15 (22%) reported these in abstracts. But
they were not true qualitative reviews. Conclusions: Qualitative study
can be retrieved from PubMed with the existing searching strategies.
But with a lack of reporting guidance on qualitative study, terms on
qualitative review are misused.
How rare are adverse drug effects? Assessing
the frequency of harm effects of drug treatments
for the management of sciatica in primary care
Junqueira DRG1 , Ferreira ML2 , Pinto RZ2 , Cândido RCF3 , Ferreira PH4
Centro de Estudos do Medicamento, Universidade Federal de Minas
Gerais, Brazil; Faculty of Health Science, The University of Sydney, Australia;
George Institute for Global Health, University of Sydney, Australia; 3 Centro
de Estudos do Medicamento, Universidade Federal de Minas Gerais, Brazil;
4 Discipline of Physiotherapy, Faculty of Health Sciences, University of
Sydney, Australia
Background: Adverse drug reactions (ADRs) are among leading
causes of death in many countries and yet are often regarded as rare
events. This misconception is usually a consequence of optimistic
interpretations regarding their frequency. Moreover, even mild ADRs
may be responsible for poor treatment adherence, the use of additional
medication to control existing ADRs, can result in new ADRs and
self-medication behaviours. Objectives: We aimed to investigate and
classify the frequency of ADRs of drugs suggested to manage sciatica
in accordance to standard categories by the World Health Organization
- Uppsala Monitoring Centre (WHO-UMC) system. Methods: We
assessed trials that detailed ADRs in a systematic review investigating
the efficacy of drugs administered in primary care for the management of
sciatica. The frequency of ADRs was classified according to WHO-UMC
categories: very common when frequency > 10%, common when
> 1% and < 10%, uncommon when > 0.1% and < 1%, rare when
> 0.01% and < 0.1%. ADRs were grouped according to MedDRA
terminology and we present data on a subset of ADRs usually labelled
of mild or moderate severity. Results: Nine studies provided data on
the frequency of 34 unique ADRs. Frequencies of ADRs ranged from
7.1 to 71.4% (constipation), 1.1 to 22.2% (nausea), 0.6 to 13.3%
(dyspepsia), 0.9 to 35.7% (dry mouth), 0.9 to 14.3% (headache),
0.9 to 25% (drowsiness), 4.7 to 20% (epigastric pain), and 0.6 to
7.1% (dizziness). Conclusions: In accordance to WHO-UMC system,
ADRs associated to drugs administered to manage sciatica are common
or very common effects. Therefore, the assumption that ADRs are rare
events in the management of sciatica is underestimated. Reporting
often influence our judgment regarding adverse outcomes with the
intervention appearing more favourable than it should and systematic
reviews need to improve methods to address safety parameters with
more precision and accuracy.
Pinto RZ, et al. BMJ 2012; 344: e497.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Collating the knowledge base for the COMET
(Core Outcome Measures in Effectiveness Trials)
initiative - a systematic review
Gargon E, Gurung B, Paula W
University of Liverpool, UK
Background: The COMET Initiative is developing an online resource
to collate the knowledge base for core outcome set (COS) development
and implementation. This will be used by trial funders and researchers
to see what work has been done in their area of interest and by
research funders wishing to fund new work in this area who want
to avoid unnecessary duplication of effort. It will also help authors
present their findings clearly and succinctly in Cochrane Reviews, such
as within the Summary of Findings table. This requires the development
and application of a search strategy to identify work related to the
development of COS. Objectives: To identify studies that had the aim
of determining which outcomes/domains to measure in all clinical trials
in a specific condition. To identify and describe the methodological
techniques used. Methods: We developed a multi-faceted search
strategy to search electronic databases (MEDLINE, SCOPUS, Cochrane
Methodology Register). We contacted Cochrane Review Groups across
all areas of health care to request information on COS that they are
aware of. We also completed a range of hand searching activities.
Results: Databases were searched August 2012 for studies of the
selection of outcomes for use in clinical trials. The search identified 24
804 potentially relevant abstracts. Screening is ongoing to identify the
final set of included studies; it is expected this work will be completed
in August 2013. Preliminary results will be presented. Conclusions:
This systematic review has identified clinical areas where work has
been undertaken, providing the knowledge base for COS development.
This review also highlights clinical areas where gaps exist, providing
opportunities for future COS development. This is the first step in
establishing a database of COS. Ensuring that the database is as
comprehensive as possible and keeping it up to date are key to its
value for users.
Development of a question-driven framework
for evidence rating in the area of communicable
diseases—a project of the European Centre for
Disease Prevention and Control (ECDC)
de Carvalho Gomes H1 , Takla A2 , Sanchez-Vivar A3 , Jansen A1 , Harder T4
European Centre for Disease Prevention and Control, Sweden;
Robert-Koch-Institute, Germany; 3 Health Protection Scotland, UK;
4 Robert-Koch-Institute, Germany, and the PRECEPT consortium
Background: ECDC provides independent scientific expertise to
European Union (EU) bodies and Member States (MS) in the field
of communicable diseases. Randomized controlled trials (RCT) are
accepted as the gold standard to study the efficacy of interventions.
They are not always feasible, however, in the public health context,
including the area of communicable diseases where the typical
questions potentially raised during the investigation and control
of an outbreak (e.g. disease burden or risk of transmission) are
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
more likely to be addressed by non-interventional studies. Effective
policy-making and decision-making within this context should also be
rigorous and transparent. Objectives: The aim of this ECDC project
was to develop an evidence rating framework that would support a
systematic and transparent methodology to appraise the evidence that
would inform public health decisions—from non-randomized and/or
non-interventional studies, to surveillance data, aetiology studies
and case studies. Methods: A workshop was organized in 2009
and a working group established in 2010 that brought together
experts in the fields of public health, epidemiology, communicable
diseases and evidence-based methodology to identify the challenges
in grading evidence in public health, particularly in infectious diseases
prevention and control. In 2012, the ‘Project on a Framework for
Rating Evidence in Public Health’ (PRECEPT) was initiated by ECDC
and commissioned to a European consortium. Within PRECEPT,
common research questions that usually arise during decision-making
processes in public health were collected and matched against most
appropriate study designs. Published quality appraisal and evidence
rating systems were assessed to identify already existing and/or still
missing components. Subsequently, a draft-framework on rating
evidence in public health has been developed. Next steps: The draft
framework will be peer reviewed and piloted in spring and summer
2013 in collaboration with international public health experts. First
results from the peer review and pilot phase are expected in autumn
From summary to synthesis: a review of
statistical synthesis and presentation methods
used in complex reviews
McKenzie JE1 , Brennan S1 , Page MJ1 , Chau M2 , Kramer S1 , Bosch M2
School of Public Health and Preventive Medicine, Monash University,
Australia; 2 Central Clinical School, Monash University, Australia
Background: Systematic reviews evaluating policy, public health,
and health service delivery interventions involve additional complexity
compared with clinical reviews. This complexity arises from multifaceted interventions being evaluated across a wide range of settings,
conditions, outcomes, and study designs. Application of meta-analytical
methods in these reviews can be challenging, and the use of ad hoc
approaches (e.g. counting the number of studies with statistically
significant results) may under-utilise or misrepresent available research.
To date, there has been no evaluation of the different synthesis and
presentation methods being employed in complex systematic reviews.
Objective: 1. To describe and estimate the prevalence of different
synthesis and presentation methods used in a sample of complex
systematic reviews. 2. To describe the advantages and disadvantages of
each of the identified synthesis and presentation methods. Methods:
Systematic reviews published between 2008 and 2012 were identified
from the Health Systems Evidence Database and the Effective Practice
and Organisation of Care Group. The resulting sampling frame was
stratified by two types of reviews, those produced within, and externally
to, The Cochrane Collaboration. A sample of 50 reviews from each
stratum was randomly selected. Data extracted included: diversity
of interventions, settings, conditions, outcomes, and study designs;
use of outcome categories; synthesis and presentation methods; and
Cochrane Database Syst Rev Suppl 1–212 (2013)
rationale for the choice of methods. Results will be summarised
using descriptive statistics. The advantages and disadvantages of
each of the identified methods will be sought from methods literature.
Results: Data extraction is ongoing. Results will be available at the
Colloquium. Conclusion: Systematic reviews used to inform policy
and public health decision making have broad population impact.
Synthesis and presentation methods are needed that offer effective and
fair presentation of results, and make best use of available research.
This research will describe and quantify the use of different methods,
identifying where guidance is needed.
Using a theory driven mixed-method
review to assess the benefits of complex
environmental-health programmes. Cochrane
Public Health Group review CD010351
Lovell R1 , Husk K1 , Cooper C2 , Garside R1
ECEHH University of Exeter Medical School, UK; 2 PenTAG University of
Exeter Medical School, UK
Background: This presentation will describe our use of a novel
approach to synthesising disparate bodies of quantitative and qualitative evidence to understand both the benefits and pathways to impact
of outdoor environmental enhancement and conservation activities
to health and wellbeing. Objectives: Environmental enhancement
programmes are complex and heterogeneous, particularly in setting,
intervention specifics, participant population and motivation, and
evaluatory technique. We therefore sought to use an innovative model
of synthesis suitable to assess the potential impacts of activities to
health and wellbeing, whilst developing an understanding of how,
why and where these impacts may occur. Methods: For this
Cochrane Review (CD010351) we used a theory driven mixed-method
approach. Evidence was sought through traditional database searches
and, reflecting the origin of much of the evidence, through extensive
searches of grey literature and direct contact with over 200 relevant
organisations. Quantitative evidence was used to assess effectiveness,
qualitative evidence to illuminate the processes and mechanisms
contributing to the observed outcomes. Evidence was brought together
to develop a conceptual model of impact with additional high-level
evidence used to populate the potential pathways between intervention
and impact. Results: We identified 30 papers referring to 21 unique
interventions from the UK, Australia and Canada. The evidence
identified was unsuitable for meta-analysis; we therefore used narrative
synthesis which revealed limited quantitative evidence of positive
impacts to health achieved, and qualitative evidence that allowed
us to map potential mechanisms through which these might be
achieved, as illustrated in the conceptual model (Fig. 1, Conceptual
Model). Conclusions: The theory driven mixed-method review
approach facilitated a more comprehensive understanding of the
potential of environmental enhancement interventions to promote
health and wellbeing than may have been possible using traditional
review methodologies. Theory driven mixed-method reviews may
therefore have potential as an effective approach in the synthesis of
evidence relating to complex interventions.
Attachments: Figure 1. Conceptual Model.png
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Surgical trials and trial registries: a
cross-sectional study of RCTs published in
journals requiring trial registration in their
author instructions
Hardt JLS1 , Metzendorf M2 , Meerpohl JJ3
1 Department of Surgery, University Medical Centre Mannheim, University
of Heidelberg, Mannheim, Germany; 2 Library, University Medical Centre
Mannheim, Mannheim, Germany; 3 German Cochrane Centre, Institute
of Medical Biometry and Medical Informatics, University Medical Center
Freiburg, Freiburg, Germany
Background: Trial registries and results databases aim at preventing
incomplete and delayed reporting, thus facilitating systematic reviews.
Objectives: To assess 1. Whether RCTs published in surgery journals
requiring trial registration in their author instructions were indeed
registered, 2. Whether study results of registered RCTs were submitted
to the registry, thus publicly available. Methods: Two authors analyzed
author instructions of surgery-related journals with the highest impact
factor (Journal Citation Reports 2011) regarding endorsement of trial
registration in 01/2013. The 10 highest ranked journals requiring trial
registration were chosen and a MEDLINE search for RCTs published in
the included journals between June 1, 2012 and December 31, 2012
was conducted. Trials recruiting participants before 2004 were excluded
because the International Committee of Medical Journal Editors first
proposed comprehensive trial registration in September 2004. Then,
the International Clinical Trials Registry Platform (ICTRP) was searched
to assess whether RCTs identified were indeed registered and whether
for registered RCTs results were available in the registry. Results: Our
search retrieved 588 citations. 460 clearly irrelevant references were
excluded. Further 25 of the remaining 128 citations were excluded by
full-text screening, e.g. because they had started patient recruitment
prior to 2004. A total of 103 RCTs was finally included. 85 of these
RCTs (83%) could be identified in the ICTRP (see Table 1). 49 RCTs
registered on ClinicalTrials.gov were clearly obligated to submit results
(> 12 months since completion date), but for only 7 (14%) of them
results had been submitted to the Results Database (see Table 2).
Conclusions: Though still not fully implemented, trial registration in
surgery has gained momentum. Nonetheless, further efforts should be
made to achieve complete trial registration. Submitting study results to
ClinicalTrials.gov remains poor. However, searching trial registers for
results as part of a systematic review might complement information
provided by journal publications.
Attachments: Table 1 Registration of RCTs.pdf, Table 2 Results availability of registered RCTs.pdf
Clinical trials of traditional Chinese medicine
need core outcome sets
Zhang L, Zhang J, Zheng W, Xing D, Shang H
Evidence-Based Medicine Center, Tianjin University of Traditional Chinese
Medicine, China
Background: Outcome measure is one of the most important
factors about clinical trials. However, several problems with outcome
Cochrane Database Syst Rev Suppl 1–212 (2013)
measures (e.g. selective reporting bias, heterogeneity among studies,
and insignificant for health decision making) were ignored. As
a consequence, it is difficult for systematic reviewers to perform
meta-analysis. Core outcome set (COS), which should be measured
and reported in all clinical trials of a specific condition, was proposed
to solve these issues. There are similar problems in clinical trials
of Traditional Chinese medicine (TCM). Objectives: To clarify the
basis and problems with outcome measures in clinical trials of TCM.
Methods: Electronic databases in Chinese were searched to collect
intervention reviews of TCM. Protocols and quality assessment papers
were excluded. Information on outcome measures were extracted and
summarized. Results: Problems with outcome measures in clinical
trials of TCM were summarized as follows: (1) Outcome measures in
clinical trials of the same condition varied greatly. (2) Measurement
data was arbitrarily transformed into ranked data and reported by
percentages. (3) Subjective outcome measures were in a dominant
position; while objective outcome measures were less frequently
adopted. (4) There were lack of standardized evaluation criteria for
TCM-related outcomes (e.g. tongue and pulses). (5) Intermediate
indicators not related to clinical practice and decision making, such as
biochemical indicators, were widely adopted; while endpoint outcomes
were rarely used. (6) Less attention has been paid to the adverse event
associated with herbal medicines. Conclusions: It is necessary to use
COS to improve the quality of clinical trials of TCM. Furthermore, the
special characteristics of TCM should be concerned while developing
COS for clinical trials of TCM.
Generating empirical evidence to support
methods for overviews of reviews
Hartling L1 , Dryden D1 , Vandermeer B1 , Fernandes R2
University of Alberta, Canada; 2 Hospital de Santa Maria, Portugal
Background: Overviews of reviews (overviews) compile data from
multiple systematic reviews (SRs) and provide a single synthesis
of relevant evidence for decision-making. Current methodological
guidance for overviews is driven by personal experience and ‘good
practice’. Objectives: To examine methodological considerations
when conducting overviews focusing on inclusion criteria, statistical
synthesis, and grading evidence. Methods: We selected four overviews
published in Evidence-based Child Health: A Cochrane Review Journal
(acute otitis media, croup, bronchiolitis, gastroenteritis). We examined
issues related to including SRs published outside of the Cochrane
Database of Systematic Reviews (CDSR), including how to deal with
multiple SRs of the same intervention. We explored the feasibility of
conducting network meta-analyses and issues related to grading the
evidence based on data reported in SRs. Results: We found a number
of SRs published outside of the CDSR. For example, 6 Cochrane and
8 non-Cochrane SRs examined acute otitis media; and, 3 Cochrane
and 15 non-Cochrane Reviews examined gastroenteritis. Some SRs
overlapped in content while others examined different interventions
or populations. Methodological questions that arose in selecting SRs
for an overview were whether to include SRs on the same topic
and the basis for selecting SRs (i.e., methodological quality, search
dates, organization producing SR). We also identified issues about
how to assess methodological quality of SRs and limitations of existing
tools. Network meta-analyses were possible where there was clinical
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
homogeneity; however, analyses were reliant on data presented in the
SR and decisions made by SR authors. A challenge for grading the
evidence based on SRs was inconsistency in methods used to assess
risk of bias of primary studies. Conclusions: We identified a number of
methodological issues when conducting overviews. Many issues stem
from reliance on methods and decisions made at the SR level. These
findings contribute to an evidence base to guide overview methods.
Scoping reviews: a valuable first step
in knowledge synthesis
Hartling L, Hamm M, Milne A
University of Alberta, Canada
Background: Scoping reviews identify, collect and summarize
knowledge in broad topics. We conducted a scoping review on
the use of social media in healthcare to identify the extent and nature
of available evidence. Objectives: To present the information we
gained from the review and discuss its value in delineating the focus
and methods for more in-depth systematic reviews (SRs). Methods:
We conducted a comprehensive search and identified 371 studies. We
mapped these according to user groups, types of evidence, clinical
areas, purpose of social media, and outcomes examined. Results: This
process was valuable for: (1) defining the search strategy; (2) defining
the intervention and its scope; (3) identifying areas where in-depth
synthesis is appropriate; and (4) providing a foundation to specify
the focus and methods of subsequent SRs. Given the newness of
this area, MeSH headings for searching were limited. We iteratively
identified studies and examined their indexing to build a list of key
words. We identified sources of grey literature and specific journals
to hand-search. We found that research in this area is emerging at
a rapid pace; therefore, timing of the search and updates is critical.
Social media encompasses a number of different online applications,
is not consistently defined, and is constantly evolving. This work
allowed us to more clearly define terms and identify challenges that
may be encountered in conducting a Sr. Mapping identified the types
of evidence available and areas where there is sufficient evidence to
warrant further in-depth SRs. The scoping work provided a solid basis
for successful grant applications to conduct SRs in specific clinical
areas. Conclusions: A scoping review allowed us to map the evidence
for a broad topic. This exercise was valuable in terms of delineating
the search, defining terms, and identifying topic areas where further
SRs are appropriate and worthwhile.
Characteristics of published scoping reviews: a
scoping review of scoping reviews
Pham M1 , Rajic A2 , Greig J3 , Scott M1
University of Guelph, Canada; 2 University of Guelph, Canada; Public
Health Agency of Canada, Canada; 3 Public Health Agency of Canada,
Background: Scoping reviews are a type of literature review that
aims to provide an overview of the type, extent and quantity of
research available on a topic. By ‘mapping’ the existing research,
Cochrane Database Syst Rev Suppl 1–212 (2013)
they can identify potential research gaps and future research needs.
They employ systematic and transparent methods, and can thus be
used as a standalone project or as a preliminary step to a systematic
review. Objectives: The objective of this study is to describe
the methodological characteristics and use of published scoping
reviews, and the opportunities and challenges for their methodological
standardization and wider use. Methods: A scoping review was
conducted using the Arksey & O’Malley (2005) framework and ensuing
recommendations by Levac et al. (2010). An initial search was
conducted in four electronic databases and the grey literature to
identify scoping reviews published up to June 2011. The search
was updated in October 2012. Review selection and characterization
were performed by two independent reviewers using pre-tested forms.
Results: The initial search identified 182 scoping reviews published
from 1999 to 2011. 162 additional reviews were identified in the
updated search. The included reviews varied in terms of purpose,
methodological rigor, and quality of reporting. A range of terms were
used to refer to the methodology, with ’scoping review’being the most
frequently reported (62%). 58% were conducted in the health sector.
Study implementation varied from 2 weeks to 20 months, and 51%
utilized a published methodological framework. Quality assessment of
included studies was infrequently performed (22.38%). 40% consulted
stakeholders or experts as part of the review process. Conclusions:
Scoping reviews are a relatively new synthesis approach that can be
useful for mapping broad public health topics. Due to variability in
their conduct, there is a need for their methodological standardization
to ensure the utility and strength of its evidence.
Attachments: Figure 1.pdf
Using a bibliometric approach for a clinical
question that generates a large volume of
Shaw S M1 , Skoretz S1 , Martino R1
University of Toronto, Canada
Background: Systematic reviews synthesize the highest quality
evidence available pertaining to a given topic. Bibliometric reviews,
on the other hand, seek to quantify aspects of the literature, without
taking quality into account. Objectives: For this study, we ran
a literature search with the intention of conducting a systematic
review, the purpose of which was to assess the association between
chronic oropharyngeal dysphagia and fibrosis in patients treated with
radiotherapy for head and neck cancer. Because of the large volume
of literature captured, we took a bibliometric approach to delineate
common themes in the literature and to identify major knowledge
gaps. Methods: Nine electronic databases were searched to find
primary research articles published between 1980 and June 2011.
Abstracts that met the selection criteria underwent full article review,
during which the following data were extracted: first author, year of
publication, university/ research facility, country, journal name, and the
presence or absence of specific dysphagia-related toxicities reported
acutely (< 3 months post-radiation) and chronically (≥ 3 months
post-radiation). Results: 7646 unique citations were retrieved. 5791
were rejected based on review of the citation/abstract. Of the remaining
1855 articles, 72 have to date been reviewed in full. 28 did not meet
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
inclusion criteria and have been excluded. Data were collected from
the remaining 44 studies. Using this data as a starting point, several
trends and potential knowledge gaps have been identified. For
example, the volume of literature has increased exponentially over
time. However, very few articles report on toxicities considered to
be ‘consequences of dysphagia’, such as pneumonia, malnutrition, or
dehydration. Conclusions: Using a bibliometric approach to review
a large volume of clinical literature can be beneficial to map common
trends and identify areas where further research is needed.
Building a database of validated pediatric
outcomes: an investigation of compliance with
established reporting standards
Adams D, Bhaloo Z, Hartling L1 , Vohra S
1 University of Alberta, Canada
Background: Pediatric populations have increasingly been included in
clinical research, which relies on the availability and use of appropriate
outcome measurement tools. Objectives: (i) To develop an inventory
of valid and reliable pediatric outcome measurement tools and (ii)
to identify gaps in outcomes reporting in publications of pediatric
randomized controlled trials (RCTs). Methods: Electronic searches of
MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials
databases were conducted. The top six general medicine journals and
top four pediatric journals were searched for pediatric RCTs published
since 2000. RCTs of a single phase/step in a single publication with
outcome(s) measured solely in participants under 21 years of age
were included. Diagnostic, screening and pilot studies were excluded.
Two independent reviewers conducted screening and data extraction.
Variables to be extracted included: journal , population age, sample
size, condition of interest, intervention, control, primary outcome,
outcome measurement tools, and information on psychometric testing.
Results: Searches identified 2229 unique references. Most (76%) were
identified from pediatric journals, with ages ranging from 23 weeks
gestation to 20 years. Half (48.5%) reported one primary outcome,
while 27% did not identify a primary outcome, and 24% identified
more than one. Of the 100 trials reporting a single primary outcome,
20 used an instrument to measure their primary outcome, but only
7 (35%) reported its psychometric properties. Conclusions: A
wide variety of pediatric outcome measurement tools are in use
by researchers. Psychometric properties of measurement tools are
inconsistently reported in pediatric RCTs, thus it is unclear to readers if
the tools are of high quality. Developing a comprehensive database of
validated pediatric outcome measures may facilitate use of high quality
pediatric research.
A user-friendly alert service of high-impact,
pre-filtered literature for obstetrics
and gynaecology
Skidmore B, Bell H, LeBlanc N1 , Paquette S1
1 Society of Obstetricians and Gynaecologists of Canada (SOGC), Canada
Cochrane Database Syst Rev Suppl 1–212 (2013)
Background: Medical specialty society members work and reside in
geographically disparate and varied surroundings. Access to reliable,
up-to-date, and publicly-accessible evidence-based information is
variable. Objectives: To provide a timely and credible resource
of current literature citations in obstetrics and gynaecology (OBGYN) in
particular, and other topics (e.g., ethics, methodology, social media),
when relevant; to build and maintain a database of best-evidence
references for future consultation. Methods: Update services
from the National electronic Library for Medicines (NeLM), BMJ,
Health-evidence.ca, Centre for Reviews and Dissemination (CRD),
Turning Research Into Practice (TRIP), AMEDEO, selected BMC journals,
evidence-based listservs, and other ad hoc resources are monitored
for potentially relevant items on an ongoing basis. Relevant citations
are downloaded or entered into Reference Manager, date stamped,
and broad categories assigned. Abstract or full-text URLs, when
available, are included. Links to accompanying material, including
editorials or evidence syntheses (e.g., ratings, critical appraisals,
quality assessments) are also incorporated. Targeted alerts are sent
to select committees or individuals as received. A formatted, monthly
compilation, the ‘Scientific Review’, is circulated to members. Alerts
include conclusions or key summary points when publicly available.
Members are notified by email at the time of publication. Results: A
manageable monthly list (approximately 60–80 items) of pre-filtered,
high-impact citations and value-added links, arranged alphabetically
or by category, is available for download. Separate packages grouped
by broad topic are available on request. New categories are added
as needed (e.g., technology). Conclusions: Ongoing monitoring and
filtering of high-impact literature from existing scanning services is
identified and formatted specifically for OBGYN. Member feedback is
overwhelmingly positive. Journal club, rotating guest editors, blogs,
continuing medical education (CME) accreditation, top ten list, and a
mobile application for distributing content are all under exploration.
A review of online evidence-based practice
point-of-care information summary providers:
an update
Moja L1 , Gonzalez Lorenzo M2 , Tagliabue L3 , Banzi R4
University of Milan; IRCCS Galeazzi Orthopedic Institute, Italy;
Department of Biomedical Sciences for Health, University of Milan,
Italy; 3 Istituto Auxologico Italiano, Italy; 4 Mario Negri Institute for
Pharmacological Research, Italy
Background: Reliable information to solve clinical doubts at the
point-of-care is a pillar of modern practice. In 2008, a previous
study assessing online evidence-based practice (EBP) point-of-care
summaries showed that most products were deficient in respect to at
least one dimension in breadth, content development, and editorial
policy. Objectives: To review online EBP point-of-care summaries
against their claims of being ‘evidence-based’ and assess whether
there has been progress in 2012. Methods: We searched Medline,
Google, and other sources from January 2009 to August 2012.
We included English web-based point-of-care summaries designed to
deliver pre-digested, rapidly accessible, comprehensive, periodically
updated, and evidence-based information to clinicians. We independently extracted data on the general characteristics and content
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
presentation of summaries. We assessed and ranked point-of-care
products according to three desirable dimensions for medical information: coverage (volume) of conditions, evidence-based methodology,
and editorial quality. We explored how these factors were associated.
Results: We retrieved 42 eligible summaries; 21 products met
our inclusion criteria, six of which were new products. Most
summaries (n = 15) were produced in United States, a minority
(n = 5) in Europe, one in Australia, and none in developing or
poorest countries. Products top-ranked for desirable dimensions in
2008, again, scored among the best: Dynamed, EBM guidelines
and UpToDate. Best Practice (formerly Clinical Evidence) largely
improved its volume. The association between editorial quality and
evidence-based methodology was statistically significant (p = 0.0093),
whereas the other associations were not. Conclusions: The quality
of medical information by point-of-care services improved over time,
although many products are still unsatisfactory in basic desirable
criteria. Publishers have the responsibility of providing users with
the highest standard of editorial contents without over claiming their
quality features. These results may have implications when developing
new products, including the Cochrane Clinical answers.
The CONSENSUS study—squamous cell
carcinoma of the oropharyNx: late phase clinical
trials; core outcomes
Tudur-Smith C1 , Young B2 , Jones TM3
Department of Biostatistics, University of Liverpool, UK; 2 Department of
Mental and Behavioural Health Sciences, Institute of Psychology, Health
and Society, University of Liverpool, UK; 3 Department of Molecular and
Clinical Cancer Medicine, University of Liverpool and Department of
Otolaryngology, Head and Neck Surgery, Aintree University Hospitals NHS
Foundation Trust, Liverpool, UK
Background: Patients and those involved in their care are rarely
involved in outcome selection in clinical trials. As a result, the
outcomes chosen are often not relevant to patients or may have
little clinical application. Furthermore, there is no standardisation of
outcome selection and reporting, even amongst trials of comparable
interventions. This reduces the data available for meta-analyses leading
to difficulties in interpreting a treatment’s effectiveness and in making
evidence based healthcare decisions. Outcome reporting bias has also
been highlighted as a significant problem in the healthcare literature
(1). Human Papillomavirus type-16 (HPV) related Oropharyngeal
Cancers (OPSCC) have doubled in incidence in the UK over the last
decade (2), and this trend is mirrored in other developed countries
(3). These cancers occur in a younger patient population than HPV
negative cancers, and have vastly better survival outcomes, with 5-year
survival in some centres reported at > 90% (4). When assessing
interventions for the treatment of these cancers, the measurement and
reporting of clinically important and patient relevant outcomes is more
important than ever, because more patients will live for longer with
any side-effects of their treatment (5). It is therefore with some degree
of urgency that efforts must be made to establish what the important
outcomes are, and to ensure that these are measured. Objectives: To
develop a Core Outcome Set (COS) for OPSCC clinical trials. Methods:
A systematic review will identify which outcomes are reported in OPSCC
Cochrane Database Syst Rev Suppl 1–212 (2013)
RCTs. Semi-structured qualitative interviews with patients and their
carers will aim to establish which outcomes they deem most important.
We will aim to achieve consensus on the contents of the final COS
in a Delphi consensus survey and consensus meeting involving major
stakeholders. Results: Outcomes identified through the systematic
review will be presented along with the preliminary analysis of the UK
Attachments: Abstract Cochrane Colloquium 2013.pdf
What’s in ‘Dr Cochrane’ for family physicians?
Evaluation of an online Cochrane Learning
programme with the Information Assessment
Method (IAM)
Urquhart B1 , Grad R2 , Pluye P2 , Shulha M3 , Granikov V3
Wiley, Chichester, UK; 2 Department of Family Medicine, McGill University,
Montreal, Canada; 3 Information Technology Primary Care Research Group,
McGill University
Background: ‘Dr Cochrane’ is an online Continuing Medical Education
(CME) programme based upon Cochrane Reviews. The Information
Assessment Method (IAM) systematically documents physicians’
reflections on the value of clinical information for practice. We adapted
the IAM for incorporation into the Dr Cochrane CME programme to
assess the relevance and use of clinical information from learning
modules for patients, and patient health benefits of using this
information, 6 months after physicians completed this learning activity.
Objectives: To determine the value of Dr Cochrane learning activities
by deploying a modified IAM 6 months after completion of an online
learning module. Methods: Group 1: 50 family physicians from
Canada will be recruited to participate in at least one Dr Cochrane
learning module, including a mandatory IAM evaluation 6 months
after completion of the learning module. Group 2: all participants
registered in Canada who complete a Dr Cochrane module will be
sent a non-mandatory IAM evaluation 6 months after completion of
the learning module. Results: The IAM was adapted to ensure
participants reflected upon the clinical relevance, information-use and
patient health benefits in the 6 months between learning activity and
evaluation. We expect all 50 recruited physicians to complete at least 1
IAM evaluation. We will present descriptive statistics on the relevance,
use and benefits associated with the application of clinical information
from Dr Cochrane modules. Conclusions: When establishing an online
learning programme it is essential to be able to measure the clinical
value of the information in routine practice. In this regard, the IAM will
help to evaluate Dr Cochrane modules, compare outcomes with other
online resources, and to plan future online learning developments.
A study of evidence sources used in midwifery
training and practice
Alderdice F1 , McNeill J1 , Lasserson T2 , Clarke M1
1 Queens University Belfast, UK; 2 Cochrane Editorial Unit, UK
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: Reports across various settings show significant barriers
still exist to the use of reliable evidence sources by health professionals
in training and in practice. Objectives: (1) To describe the attitudes of
midwifery students to evidence based practice (EBP). (2) To identify the
evidence sources that midwifery students access most frequently. (3) To
explore the views of midwifery students, teachers and practitioners
to different summary evidence formats. Methods: A survey was
completed by 118 student midwives training at a university in the UK to
explore attitudes to EBP and evidence sources used. Three focus groups
were also conducted with midwifery educators, midwifery students,
and midwives in practice. Both the survey and focus group schedule
contained examples of abstracts and plain language summaries of
Cochrane Reviews to explore participants’ views on content and
format. Results: Students were positive about EBP however lack
of time (34%), lack of training (20%) and lack of awareness (11%)
were perceived to be the biggest barriers to using evidence in practice.
Out of a list of 17 possible sources of evidence, students reported
using the following most often/always: professional guidelines (91%),
NHS guidelines (90%), research articles (87%), hospital guidelines
(84%), textbooks (80%), consulting with colleagues (71%), expert
opinion (65%) and Cochrane Reviews (51%). Three common themes
were identified across the focus groups: Conflict in Communicating
Evidence, Barriers to Using Cochrane Reviews and Presentation of
Review Evidence Summaries (content and format). Conclusions:
Despite positive attitudes to using evidence in practice, barriers to
using sources such as Cochrane Reviews need to be addressed. The
content and format of evidence summaries were perceived to be
important to enhancing use of review evidence and an RCT is currently
being conducted to see what data midwives extract accurately from
different summary evidence formats.
Strategies to fill knowledge gaps in health
care—experiences from the Swedish Council
on Health Technology Assessment (SBU)
Jacobson S, Mowafi F, Tranaeus S, Heintz E
SBU, Sweden
Background: Eliminating knowledge gaps in health care is important
to avoid spending resources on potentially ineffective or even harmful
treatments. In 2010, the Swedish Government assigned the Swedish
Council on Health Technology Assessment (SBU) to identify health
technologies whose effects have been insufficiently assessed. The
platform of this work consists of an official database on SBU’s website.
However, a database alone has no intrinsic value unless the information
is used either to stimulate new research that can fill the knowledge
gaps or for setting priorities in health care. Here, some of SBU’s efforts
to stimulate new clinical research are summarized. Collaboration
with stakeholders: With the purpose of forming a strategy to fill
knowledge gaps in specific medical fields SBU has gathered clinical
experts, decision makers and patient associations on a national level.
An example of this was a national workshop focusing on how to
strengthen research in dental care in Sweden. This resulted in a
national research school in clinical odontology. Based on this positive
experience SBU aims to initiate similar working groups in other medical
fields. Collaboration with the Swedish Research Council: SBU has
also initiated collaboration with the Swedish Research Council (SRC).
Cochrane Database Syst Rev Suppl 1–212 (2013)
SRC has an annual call for grant applications for research with the
purpose of filling identified knowledge gaps in health care. The
collaboration with SBU was initiated to ensure that applications fulfill
the definition of a scientific uncertainty. The questions addressed must
be submitted to SBU or registered in the UK Database of Uncertainties
about the Effects of Treatments (DUETs). SBU will consider initiating
similar collaborations with other research funds. Conclusions: To fill
identified knowledge gaps there is a need for collaboration on all levels
in health care, as well as with research funds. Such collaborations will
hopefully lead to a more effective health care.
Sharing tacit knowledge to build capacity for
knowledge translation: lessons learned from
pan-Canadian public health webinars
Sears K, Chera S, Dobbins M, Forsyth P
National Collaborating Centre for Methods and Tools, Canada
Background: The National Collaborating Centre for Methods and
Tools (NCCMT) recently launched a webinar series, ‘Spotlight on
KT Methods & Tools’ which features popular knowledge translation
(KT) resources to support public health professionals in moving
research evidence into practice. Webinars bring together the KT tool
developer, who highlights the tool’s development and implementation
information, as well as a health practitioner, who shares how the
resource has been used in practice. Sharing tacit knowledge and
implementation information on KT resources may be a key prerequisite
to use research evidence in public health. Objectives: The aim of
the webinar series is to build awareness and promote uptake of KT
methods and tools among public health professionals. Methods: An
online survey was administered to NCCMT users to determine which KT
methods and tools to feature in the webinar series. NCCMT partnered
with CHNET-Works!, University of Ottawa, to offer the webinars to
a broad network of decision-makers, practitioners and researchers
from across Canada and internationally. Post-event online surveys,
with open and closed-ended questions, were administered to assess
participant awareness and intentions to use KT resources in their
work. Descriptive statistics were used to analyze quantitative data, and
qualitative data were coded and analyzed by content analysis. Results:
NCCMT has hosted 6 webinars reaching more than 775 public health
professionals. Feedback from 230 participants (30% response rate)
revealed that 63% participants were unaware of the featured KT tool
and 70% had not used the tool in their work prio to the webinar. Most
participants (83%) reported the webinars increased their motivation to
explore the tool and use it in practice (67%). Conclusions: Webinars
effectively increase accessibility of KT methods and tools by sharing
tacit knowledge on how to apply KT resources in public health, and
may increase resource uptake.
Systematic reviews and meta-analyses in eyes
and vision: first steps in identifying gaps in
ophthalmology research
Ssemanda E Li T, Dickersin K
Cochrane Eyes and Vision Group, USA
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: Systematic reviews are the highest level of research
evidence. Identifying and characterizing all systematic reviews in
eyes and vision will help to detect gaps in ophthalmology research.
Objectives: We developed a database of systematic reviews and
meta-analyses in eyes and vision and described the reports. Methods:
We identified systematic reviews, using a detailed search strategy in
PubMed, EMBASE, and The Cochrane Library in 2009, and updated
the search in 2012. We imported systematic reviews into an EndNote
database and retrieved the full-texts. We considered a systematic
review to be eligible if it examined a specific question and used
explicit, pre-specified scientific methods to identify, select, assess, and
summarize similar but separate studies. To ensure the identification
of all systematic reviews, we considered reports with systematic
review or meta-analysis in the title, subheading or text. We included
co-publications and previous versions of Cochrane Reviews. One
author assessed the characteristics of each report. Results: Our
search found 7676 citations, of which, we included 1005 systematic
reviews. Nearly 19% of reports were current or previous versions of
Cochrane Reviews. Most systematic reviews focused on glaucoma
(18%), age-related macular degeneration (13%), cataract (9%), or
diabetic retinopathy (7%). Systematic reviews were published from
1985 to 2012. The number of systematic reviews rose from four
reports published in 1980–1989 to 58 reports available in 1990–1999
and 542 reports issued from 2000 to2009. While nearly 68%
of systematic reviews examined an intervention, 13% of reviews
investigated etiology. Approximately 12% of reviews focused on
diagnostic tests or prognosis. Only 7% of reviews had another focus
(e.g. cost-effectiveness). Conclusions: We developed a database of
systematic reviews and meta-analyses in eyes and vision. Most reviews
focused on common eye diseases and assessed interventions. The
number of systematic reviews in ophthalmology has increased in recent
Finding research on websites—experiences
and solutions from the field of international
Stansfield C, Dickson K, Stewart R, Vigurs C, Tripney J, Bangpan M,
Oliver S, Hauari H
EPPI-Centre, SSRU, Institute of Education, University of London, UK
Background: Previous analysis indicates a third of research studies
for health-related reviews on international development topics are
identified outside bibliographic databases(1). Searching websites is
an important method to identify research and involves a range of
techniques. There are no acknowledged standards for documentation
of website searches. Aims: To promote debate on the challenges
and solutions of website searching and promote standards of conduct
and reporting. Methods: We draw together our learning from
undertaking and supporting reviews on a range of topics in international
development since 2010, to inform recommendations for practice.
Results: We present some problems, share a range of solutions,
and propose a template to aid the conduct and documentation
when using these resources. Challenges include retrieving large
numbers of records; identifying empirical research; using appropriate
vocabulary. A taxonomy of techniques is proposed, including: browsing
sections of web sites; searching an entire site; searching through a
Cochrane Database Syst Rev Suppl 1–212 (2013)
database; searching with pre-defined keywords. Distinctions are drawn
between research centres, international organisation, international
development specialist resources, topics and government departments.
Conclusions: A template could facilitate consistent searching, help
aid transparency and quality assurance of the search process. Limited
functionality of searching and exporting options pose challenges for
the review. There is a need to raise awareness to websites and
organisations in order to make their empirical research more accessible
to reviewers. (1) Stansfield C, Dickson K (2011) Locating evidence for
developing countries: a case study of three health promotion reviews
(poster presentation) 19th Cochrane Colloquium, Madrid.
What’s in it and how do users find it?—challenges
of knowledge transfer through specialised
registers of health promotion effectiveness
Stansfield C, Brunton G, Kavanagh J
EPPI-Centre, SSRU, Institute of Education, University of London, UK
Background: Health promotion effectiveness studies are challenging
to identify. Since 2004, the EPPI-Centre has populated two publicly
available citation registers through quarterly searches: Trials Register
of Promoting Health Interventions (TRoPHI) and Database of Promoting
Health Effectiveness Reviews (DoPHER). Studies are coded with
descriptive keywords. Coding is based on abstract for trials, and
full text for reviews. Users can search using codes, freetext or both.
Aims: To describe content coverage and user behaviour of the two
registers. Methods: A retrospective analysis of (1) keywording on
topic, study design, settings; and (2) user activity during 3 monthsin
2013. Results: (1) Trials: TRoPHI comprised of 70% (n = 4357/6232)
RCTs. Over one-third from USA, almost a third (29%) from unspecified
locations; 5% from UK; over 10% from developing countries. Top
five topics contributing 8–10% of studies: healthy eating, physical
activity, tobacco, mental health and sexually transmitted diseases.
Intervention setting is unspecified in 44% of abstracts; where stated,
the most common are in school, home, community or workplace.
(2) Reviews: DoPHER contained (69% (n = 2171/3130)) systematic
reviews (e.g. stated methods and inclusion criteria). A meta-analysis
was undertaken in 29% of reviews. Topics followed similar trends to
the trials. (3) Users searching: Over 75% (n = 285) of searches were
freetext only. Incorrect syntax was common in wildcard searches. Users
were interested in diverse topics. Nine percent of searches were repeat
visits. Conclusions: Health promotion effectiveness research covers a
diversity of topics. Authors could improve abstracts by including more
detail on the intervention setting, country and intervention provider.
Opportunities exist to make users more aware of the ability to search
more effectively using topic keywords and correct syntax.
Searching for indirect evidence: advantages and
challenges of extending the network of studies
Sutton AJ, Abrams KR
University of Leicester, Leicester, UK
Background: Methodological guidelines for conducting network
meta-analysis (NMA) suggest that an iterative search of the literature,
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
progressively including additional comparator treatments, may improve
the identification of indirect evidence to be included for analysis (Hoaglin
2011). Objectives: Using the case study of apixaban (Eliquis), we
explore the potential advantages of searching for indirect evidence and
evaluate the impact of study identification methods and network size on
indirect and mixed treatment comparisons in venous thromboembolism
(VTE) prophylaxis following major orthopaedic surgery. We also
compare our methodology and summary findings to the previously
published example by Hawkins et al. (2009a). Methods: We adapted
the breadth-first search strategy from Hawkins et al. (2009b) to perform
a stepwise systematic search in Medline, Medline-in-Process, and
EMBASE for indirect evidence in VTE prevention. Table 1 details
the multiple search orders included. Fixed-effects NMA models were
run in WinBUGS (Lunn 2000) for clinical outcomes of interest for
three different network sizes. Results: Figure 1 summarises the
search results. Additional search orders and wider selection criteria
maximised the number of indirect comparisons identified between
existing VTE interventions. The NMA showed precision was increased
from base case to first order as additional studies generally reduced
the uncertainty around mean odds ratios for deep vein thrombosis,
all VTE/death, and all bleeds. Estimates became more stable as
fewer studies were included in the networks with each subsequent
search order. No increase in inconsistency was noted across network
sizes. Conclusions: Using a search strategy designed to optimise the
identification of indirect evidence allowed us to extend the network of
relevant studies for analysis. However, we find the methodology to be
highly dependent on the definition of comparators in the first search
order and suggest that the incremental value of subsequent network
orders in NMA should be weighed against the associated additional
search and analytical burden.
Attachments: Figure 1 –Study selection flow diagram.png, Table 1 –
Breadth-first search strategy.png
Search filter for retrieving overviews
of systematic reviews in The Cochrane Library
Silva V, Puga MES, Grande AJ, Porfı́rio GJM, Martimbianco ALC, Torres
MFS, Costa MB, Carvalho MR, Fioretti BTDS, Costa CS, Peccin MS, Riera
R, Torloni MR, Atallah Á
Brazilian Cochrane Centre, BR
Background: Overviews of systematic reviews (OoRs), a new type of
study, are considered as the ‘friendly front end’ to The Cochrane Library
for healthcare decision-making. The Cochrane Library is a collection of
six databases, one of which is the Cochrane Database of Systematic
Reviews (CDSR) that is the leading resource for systematic reviews in
healthcare. There are 7819 references in the CDSR until 2013 Issue
3, but find an OoR can be a challenge. Objectives: To develop and
validate an optimal search filter for retrieving overviews of systematic
reviews via The Cochrane Library. Methods: We performed an
analytical survey in The Cochrane Library and performed a handsearch
at 7779 systematic reviews (published reviews and protocols) recorded
in the CDSR database until 2013 Issue 2. The main outcome measure
was the search filter capacity retrieving OoRs assessed by the screening
test of terms and its combinations. The 95% confidence interval was
applied with the screening test. Results: The proportion of OoRs in
the CDRS database was 0.39% (95% IC 0.27, 0.56). The first search
Cochrane Database Syst Rev Suppl 1–212 (2013)
filter developed presented a high capacity for retrieving OoRs (Table 1).
After combining terms the search filter capacity was maximized,
reducing false positives and negatives (Table 1). Conclusions: New
empirical search strategies have been validated to optimize retrieval
from the Cochrane Database of Systematic Reviews (via The Cochrane
Library) of a new type of study, the overview of systematic reviews,
called as ‘friendly front end’ to The Cochrane Library for healthcare
Attachments: Table 1. Optimal search filter for retrieving overviews
of systematic reviews via The Cochrane Library.pdf
Interobserver reliability for application of tools
for assessing quality and susceptibility to bias in
observational studies
Mota B1 , Bevilacqua JL2 , Silva V3 , Barrett J4 , Riera R5
Brazilian Cochrane Group/Disciplina de Ginecologia FMUSP, Brazil;
Hospital Sirio Libanes, Brazil; 3 Brazilian Cochrane Group, Brazil; 4 Institute
of Public Health, University Forvie Site, UK; 5 Brazilian Cochrane Group, UK
Background: The decisions for medical practices are being encouraged
based on scientific evidence from systematic reviews and meta-analyses.
Usually, such reviews have concentrated exclusively on randomized
trials. Indeed, some investigators have the opinion that non-randomized
(or observational) studies should be excluded from all reviews because
of the greater difficulties in assessing their methodological quality.
However, in many areas of health care few randomized controlled trials
exist and meta-analyses of observational studies may be important
for healthy politics decision, mainly when the feasibility to perform
randomized study is extremely difficult. For assessing the quality of
evidence from observational studies and try to reduce potential bias
numerous tools have been proposed for evaluation of methodological
quality. Objectives:To evaluate two tools for assessing quality and
susceptibility to bias in observational studies. Methods: Two authors
independently applied questionnaries (Black instrument and New castle
Ottawa) in three cohort studies from a systematic review of breast
cancer group. Interobserver reproducibility was analyzed using kappa
statistics. Results:The average of kappa values was 0.3 95%CI
(0.12–0.46) for Black and Downs instrument and average of kappa
for NOS 0.39 95%CI(0.01–0.79). Conclusions: The interobserver
reliability was not observed in our study. The tools seem useful to
analyze the risk of bias. However a larger sample is needed to show
the interobserver reproducibility.
Evidence-based physiotherapy: mapping
Cochrane Systematic Reviews with practical
implications for clinical practice
Torres MFS, Porfı́rio GJM, Silva V, Grande AJ, Martimbianco ALC, Costa
MB, Carvalho MR, Fioretti B, Costa CS, Torloni MR, Riera R, Atallah Á
Brazilian Cochrane Centre, BR
Background: The major objective of physiotherapy is to rehabilitate
the patient and improve his quality of life. There has been an
increase in the search for evidence-based physical therapies that are
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
effective and could therefore be useful for clinical practice. In order to
identify these interventions, it is necessary to map the existing Cochrane
Systematic Reviews on physiotherapy and select those that are effective.
Objectives: Identify Cochrane Systematic Reviews in physiotherapy
that report effective interventions from a clinical perspective. Methods:
We developed a search strategy to identify complete Cochrane Reviews
on physiotherapy publisehd in the Cochrane Library up to Issue 2,
2013. Inclusion criteria: reviews related to evaluate the effectiveness
and safety of physiotherapy techniques [‘Physical Therapy Modalities’
(Mesh)]. Exclusion criteria: invasive procedures, pharmacologic therapy
and complementary therapies (i.e., acupuncture, antiinflammatories,
balneotherapy, music therapy). Retrieved reviews were screened by
two independent investigators (GP and MFST) to select potentially
relevant reviews. Disagreement was arbitrated by a third author (VS).
Results: The search strategy identified 245 reviews, 66 were excluded
and 181 reviews were selected for full-text reading resulting in 52
reviews (28.7%) with effective interventions that could potentially be
used in clincal practice. Conclusions: Only 28.7% of Cochrane
Systematic reviews on physiotherapy report effective interventions that
could potentially be used in clinical practice.
Attachments: Flow chart of the process of review identification and
Mapping the Cochrane evidence in infectious
Almeida R, Cavalcante R, Ferreira-Filho S, Kim A, El Dib R
Faculdade de Medicina de Botucatu-UNESP, Brazil
Background: Everyone engaged in research knows that systematic
reviews are the best study to map existing knowledge on intervention,
prognosis and diagnosis of a certain disease. However, few studies
have raised attention for the large number of reviews with insufficient
evidence to answer the questions around therapeutic strategies for
treatment and prevention of diseases. Infectious diseases (IDs) are
associated with high morbidity and mortality. The best scientific
evidence is an essential tool to control IDs. Objectives: We evaluated
the conclusions from all Cochrane systematic reviews related to IDs of
randomized controlled trials (RCTs) in terms of their recommendations
for clinical practice and research. Methods: A cross-sectional study of
systematic reviews published in the Cochrane Library (Issue 11, 2012)
was conducted. We divided 5074 in two and did the selection in four
authors (two pairs, disagreements settled by one author from the other
pair) with the aim to select all reviews related to IDs. Results: We
analyzed 718 (14.2%) of the completed systematic reviews published
in the Cochrane Library, Issue 11, 2012. This study has found that the
majority of Cochrane Reviews related to IDs highlight the absence or
poor evidence, i.e., lack of RCTs around the questions on health care
that has been covered by them. Conclusions: Cochrane systematic
reviews related to infectious diseases are a great tool in the process of
developing recommendations and making decision, however we cannot
ruled out the overall absence of evidence found in our study and, we
reaffirms the need for the conduction of higher-quality primary studies.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Do patient decision aids improve patient
adherence? Considering definitions and
measures when interpreting systematic review
Selva A1 , Desroches S2 , Singh K3 , Bissonnette J4
1 Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; 2 Institute of
Nutrition and Functional Foods, Laval University, Quebec City, Quebec,
Canada and CHU Research Center, Quebec University Hospital Center–
Hospital St-François d’Assise, Quebec City, Quebec, Canada; 3 Ottawa
Hospital Research Institute, Ottawa, Canada; 4 The Ottawa Hospital,
Ottawa, Canada
Background: Although adherence is an outcome in trials of patient
decision aids (DAs), little is known about how it is defined or measured
within these trials. Objectives: To assess the impact of DAs on
patient adherence to the chosen treatment option, and to describe
the definitions and measures for adherence used in these trials.
Methods: A sub-analysis of randomized control trials included in
the 2011 Cochrane Review of DAs for people facing health treatment
or screening decisions was conducted. Two reviewers independently
screened 86 trials for eligibility (e.g., measured adherence), extracted
data (e.g. study characteristics, type of DA, results), and assessed
risk of bias. Reviewers also extracted data on adherence definitions
and measures, length of follow-up, and use of adherence as the
primary outcome and/or for calculation of the sample size. Results:
Eight eligible trials measured adherence to medications for menopause
symptoms, atrial fibrillation, osteoporosis, depression, dyslipidemia,
hypertension, and diabetes. Six trials compared DAs to usual care
and two compared a detailed versus simple DAs. Each trial defined
adherence differently. Three measured adherence to the chosen option,
and five measured adherence to taking prescribed medication. All trials
measured patient-reported adherence using three different instruments
or their own question, and two also used pharmacy records. Follow-up
was 2–36 months (median 6). Sample size was not calculated for
adherence despite being a primary outcome in four trials. Although
near perfect in both groups, one trial showed adherence to diabetes
medications at 6 months based on pharmacy records was significantly
better in the usual care group; while patient-reported adherence did
not differ. The other seven trials reported no significant differences
on adherence between groups. Conclusions: Adherence has been
inconsistently defined and measured in trials of DAs. Therefore, the
effectiveness of DAs for improving adherence to a chosen option
remains unclear.
Screening for decisional conflict in clinical
practice: validation of SURE
Ferron Parayre A1 , Labrecque M1 , Rousseau M2 , Turcotte S3 , Légaré F1
Université Laval - CRCHU de Québec, Canada; 2 Université Laval, Canada;
CRCHU de Québec, Canada
Background: Assessing decisional conflict in patients is a shared
decision making competency. Objectives: We sought to determine
the psychometric properties of SURE, a four-item checklist designed
to detect for clinically significant decisional conflict (CSDC) in clinical
practice. Methods: This study was a secondary analysis of a
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
clustered randomized trial assessing the effect of DECISION+2, a
2-hour online tutorial followed by a 2-hour interactive workshop on
shared decision making, on decisions to use antibiotics for acute
respiratory infections. Patients completed SURE and also the Decisional
Conflict Scale (DCS), as the gold standard, after consultation. We
evaluated internal consistency of SURE using the Kuder-Richardson 20
coefficient (KR-20). We compared DCS and SURE scores using the
Spearman correlation coefficient. We assessed sensitivity, specificity,
predictive values and likelihood ratios of SURE scores (cut-off score
≤ 3 out of 4) by identifying patients with and without CSDC (DCS
score > 37.5 on a scale of 0–100). Results: Of the 712 patients
recruited during the trial, 654 completed both tools. The prevalence
of CSDC, as diagnosed by the DCS, was 5.2% (95% CI: 3.7–7.3).
SURE showed adequate internal reliability (KR-20 coefficient of 0.7).
There was a significant correlation between DCS and SURE scores
(Spearman’s ρ = −0.45, p < 0.0001). The sensitivity and specificity
of SURE were 94.1% (95% CI: 78.9–99.0) and 89.8% (95% CI:
87.1–92.0), respectively. The negative predictive value was 99.6%
(95% CI: 98.6–99.8) and positive predictive value was 33.7% (95% CI:
24.5–44.2). The positive likelihood ratio was moderately high (9.26),
whereas the negative likelihood ratio was clinically more significant
(0.07). Conclusions: SURE has the potential to be a useful tool for
practitioners, responding to the growing need for detecting decisional
conflict in patients. SURE should be tested in high decisional conflict
prevalence populations of patients and in different clinical contexts.
Attachments: SURE Acronym.pdf
Challenges in SDM education: the heterogeneity
of SDM training programs and the search for
consensus on core competencies
Légaré F1 , Drolet R1 , Stacey D2 , Moumjid-Ferdjaoui N3 , Härter M4
1 Centre de recherche du CHU de Québec, Québec, Canada; 2 School
of Nursing, Faculty of Health Sciences, University of Ottawa, Canada;
Lyon 1 University, GATE (UMR 5824 CNRS), Centre Léon Bérard, Lyon,
France; 4 Center for Psychological Medicine, University Medical Center,
Hamburg-Eppendorf, Hamburg, Germany
Background: One obstacle to integrating shared decision making
(SDM) into routine clinical practice is the lack of standardized
training for healthcare professionals. No international consensus
exists about core competencies required to involve patients in medical
decision making. We present an update of an inventory of SDM
training programs for healthcare professionals and share reflections
on SDM core competencies that emerged during an international
interdisciplinary workshop. Methods: In 2010, we performed an
international environmental scan to identify and analyze SDM training
programs for healthcare professionals. We created an inventory of the
programs (contact, date, language, country, objectives, target users)
that is regularly updated. We also organized an interdisciplinary,
international workshop in April 2012 and asked participants to identify
core competencies for SDM training programs. Results: The inventory
lists 80 training activities conducted between 1996 and 2012 in
15 countries and 11 languages. Fifty programs targeted licenced
professionals, 15 targeted pre-licensure, 12 targeted both, and 3
did not report. Most programs (45/80) were developed after 2010.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Components of 54 programs were analyzed in detail. Teaching
methods and program duration vary greatly. Few programs (12/80)
were rigorously evaluated. The international working group did not
reach a consensus on a core set of competencies for SDM training
programs. Some participants believed that existing SDM models
should now be translated into core competencies for training, while
others argued that without consensus on the definition of SDM this is
premature. In discussing the desirability and feasibility of developing
core competencies, two essential skill categories nevertheless emerged:
relational and risk communication. Conclusions: Rapid development
of new SDM training programs worldwide and lack of evidence on
their effectiveness represent a challenge for reaching a consensus
on core competencies for SDM training. An international research
strategy is needed to establish solid evidence for recommending core
competencies for SDM training.
results demonstrating either a small effect or large effect for each of
the six presentation approaches. We asked six questions addressing
understanding and six questions addressing preferences. We randomized participants to size of effect and order. Results: 188
clinicians responded (Table 1), with 175 providing completed surveys
(87% response rate). Risk Difference was the approach best understood
by clinicians, followed by the Ratio of Means and Relative Risk
(Table 2). Clinicians generally found dichotomous presentation of
continuous outcomes (Relative Risk; Risk Difference) very useful, and
other approaches less useful (Table 3). Conclusions: Clinicians
best understood continuous outcomes when presented as dichotomies
(relative and absolute risk differences) and found these presentations
most useful. Presenting results as SMD, the longest standing and most
widely used approach, was poorly understood and not perceived as
useful. Data collection is ongoing and full results will be available at
the colloquium.
Presentation of continuous outcomes
in meta-analysis: a survey of clinicians’
understanding and preferences
Attachments: Johnston Survey Tables, References.pdf
Johnston B1 , Bandayrel K1 , Friedrich J2 , Akl EA3 , da Costa BR4 ,
Neumann I5 , Adhikari N6 , Alonso-Coello P7 , Crawford M8 , Mustafa RA9 ,
Svendrovski A10 , Thabane L5 , Tikkinen KA5 , Vandvik PO11 , Guyatt GH5
Hospital for Sick Children Research Institute, Toronto, Canada; 2 Keenan
Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital,
Toronto, Canada; 3 Department of Internal Medicine, American University
of Beirut, Beirut, Lebanon; 4 Division of Clinical Epidemiology & Biostatistics,
Institute of Social and Preventive Medicine, University of Bern, Bern,
Switzerland; 5 Department of Clinical Epidemiology & Biostatistics,
McMaster University, Hamilton, Canada; 6 Sunnybrook Health Sciences
Centre, Toronto, Canada; 7 Iberoamerican Cochrane Centre. Institute
of Biomedical Research (IIB Sant Pau) Barcelona, Spain; 8 Department
of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto,
Canada; 9 Department of Internal Medicine, University of Missouri-Kansas
City School of Medicine, United States; 10 Hospital for Sick Children,
Toronto, Canada; 11 Norwegian Knowledge Centre for the Health Services,
Oslo, Norway
Background: When pooling results of trials addressing continuous
outcome using different instruments to measure the same construct,
authors typically report differences between intervention and control
as a Standardized Mean Difference (SMD). Recently, authors have
proposed alternative summary estimates that they postulate clinicians’
will more easily interpret than SMD (1–4). The GRADE Working
Group recently provided an overview of methods for presenting pooled
continuous data (5). Thus far, claims of improved understanding
with allegedly clinician-friendly presentations are supported only by
anecdotes. Objectives: To determine clinicians’ understanding and
perceptions of six approaches (SMD, Minimal Important Difference
Units, Natural Units, Relative Risk, Risk Difference and Ratio of Means)
to the presentation of continuous outcomes from meta-analyses.
Methods: We invited 201 staff, residents, and trainees in family
medicine and internal medicine academic programs in Canada,
Switzerland and Lebanon to participate. Participants received
paper-based self-administered surveys presenting summary estimates
of hypothetical interventions versus placebo for chronic pain, with
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Permutation based resampling for deriving
p-vlaues for pooled effect estimates
in meta-analsyes
Gagnier J1 , Beyene J2
University of Michigan, USA; 2 McMaster University, Canada
Background: In meta-analyses as the number of trials in the pooled
effect analyses decreases, the risk of false positives or false negatives
increases. This is partly due to the assumption of normality that
may not hold in small samples. Creation of a distribution from
the observed trials using permutation methods to calculate P values
may allow for less spurious findings. Permutation has not been
empirically tested in meta-regression. Objectives: The objective of
this study was to perform an empirical investigation to explore the
differences in results for meta-analyses on a small number of trials
using standard large sample approaches verses permutation-based
methods for pooled effect estimates. Methods: We isolated a sample
of systematic reviews with varying number of included studies. Finally,
we performed meta-analyses on the primary outcome of meta-analysis,
collected p-values and confidence intervals. Next we used permutation
based resampling to arrive at p-values and bootstrapping to arrive
at confidence intervals. We then compared final P values between
methods. Results: We are currently collecting all meta-analyses and
will conduct the analyses by June. Conclusions: We will present
empirical data comparing permutation based resampling to standard
methods on p-values for pooled effects in meta0analyses. These finding
may influence methods.
Consistency of outcome and statistical reporting
of time-to-event data: the impact on Cochrane
Reviews and meta-analyses in epilepsy
Nolan SJ1 , Sutton L1 , Marson A2 , Tudur-Smith C1
1 Department of Biostatistics, University of Liverpool, UK; 2 Department of
Molecular and Clinical Pharmacology, University of Liverpool, UK
Cochrane Database Syst Rev Suppl 1–212 (2013)
Background: Inadequate reporting of time-to-event (censored)
outcomes and statistical analyses in individual randomised controlled
trials is well documented. Therefore, meta-analyses of such outcomes
frequently require the re-analysis of individual participant data (IPD).
This approach has been undertaken in seven Cochrane Reviews in
epilepsy, with 60–100% of IPD made available by original trial
authors for meta-analysis. When an IPD approach is not feasible
or practical or if a proportion of IPD is unavailable for inclusion in
meta-analysis as in the epilepsy reviews, methods of meta-analysing
study level aggregate data, including indirect estimation methods, are
required. The feasibility of indirect estimation methods also depend
on the extent and quality of statistical reporting in individual trials.
Objectives: We aim to investigate the consistency and quality of
reporting of outcomes and statistical analyses of time-to-event data
in the context of published epilepsy monotherapy designed studies
in order to determine if we can make use of any published summary
statistics via indirect estimation or otherwise and therefore avoid biases
related to unavailability of IPD. Methods: A systematic search of the
Cochrane Epilepsy Group Specialised Register has been conducted to
identify all epilepsy monotherapy designed studies which report at
least one time-to-event outcome. Quality and consistency of reporting
will be assessed according to ILAE recommendations for the reporting
of outcomes in monotherapy studies and according to statistical
recommendations for the reporting of survival analyses. Results and
Conclusions (to date): 111 epilepsy monotherapy studies have been
identified and the systematic review is underway. Updated results and
conclusions will be presented at a later date.
Framing minimal important difference
in measuring of quality of life: absolute
or relative?
Zhang Y1 , Zhang S1 , Thabane L1 , Zhou Q1 , Furukawa TA2 , Johnston B3 ,
Guyatt GH1
Department of Clinical Epidemiology & Biostatistics, McMaster University,
Canada; 2 Department of Health Promotion and Human Behavior, Kyoto
University Graduate School of Medicine/School of Public Health, Yoshida
Konoe-cho, Sakyo-ku, Kyoto, Japan; 3 SickKids Research Institute &
Department of Anaesthesia & Pain Medicine, The Hospital for Sick Children,
Toronto, Canada
Background: Defining the minimal important different (MID) (the
smallest improvement that would lead to consideration of an
intervention) plays a crucial role in interpreting results of health related
quality of life (HRQL) instruments. Some instruments frame the MID as
an absolute difference (e.g. 10 points on a 100 point scale) and some
as a relative difference (e.g. 15% change in score). Empirical evidence
regarding the merits of the two approaches is unavailable. Objectives:
To determine, optimal method of framing minimal important difference
in measuring of quality of life outcome. Methods: We correlated
the absolute and relative results with a global rating of change (GRC
- a transition question that addressed the degree of improvement or
deterioration from a prior visit, from much better to much worse).
We judged that whatever standard (absolute or relative) on the target
instrument (the HRQL measure of interest) had a higher correlation with
the GRC would be preferable. We reviewed the pre-existing databases
recording measures of HRQL available in the department of Clinical
Epidemiology and Biostatistics at McMaster University and identified
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
studies in which at least two serial measurements of HRQL and a GRC
at follow-up were available. We extracted data from each eligible
dataset and calculated the correlations between the target instrument
and the GRC and generated a pooled estimate of correlations through
a meta-analysis. Results: We identified 320 databases from 1987 till
2004 of which, thus far, 7 proved eligible. The meta-analyses thus
far suggest no significant difference between correlation coefficient
of absolute and relative difference on HRQOL instrument with GRC
on symptoms, emotional function, physical function, and cognitive
function, but a significantly higher correlation with absolute differences
in the fatigue subdomain. Additional data will be available at the
Colloquium. Conclusions: This project will provide insight into the
merits of relative versus absolute measures in determing MIDs.
The current situation of the publication
of Cochrane Systematic Reviews
Ma JC, Sun X, Zhao Y, Tian JH
Evidence Based Medicine Center, School of Basic Medical Sciences of
Lanzhou University, China
Background: Cochrane Systematic Reviews (CSRs) are highly
structured and systematic, with evidence included or excluded on
the basis of explicit quality criteria, to minimize bias. Cochrane Reviews
are designed to facilitate the choices that practitioners, consumers,
policy-makers and others face in health care. Objectives: To survey
the current situation of CSRs published on Cochrane database of
systematic reviews, so as to regulate the development of CSRs and
provide recommendations for the improvement of Cochrane library.
Methods: An electronic literature search of all CSRs from inception
to December 2012 was conducted using the Cochrane Library and
Web of Science. Two reviewers independently determined study
eligibility and extracted details on published year, authors,country,
funding agencies,institutions,and journal, group, citation information
and search detail et al. Disagreements were resolved by the third
author. Results: 5647 studies were included. Figure 1 showed that
the frequency of CSRs were found to increase over time, as well as the
involved authors, countries, institutions, majority authors of CSRs were
UK (36.43%), Australia (14.73%), Canada (11.44%), USA (11.42%),
27.28% were Netherlands (6.50%), Scotland (5.14%), China (4.96%),
Italy (4.07%), Germany (3.35%), New zealand (3.26%); each year,
about 80% of the authors published one article, the amount of involved
authors reduced with the increase of the quantity of the published
articles; the Cochrane Pregnancy and Childbirth Group accounts for
the largest proportion (7.70%) of the reviews, followed by Cochrane
Peripheral Vascular Diseases Group (4.86%), Cochrane Neonatal Group
(4.06%), Cochrane Depression, Anxiety and Neurosis Group (3.99%),
and Cochrane Airways Group 3.99%) (Table 1).The average frequency
of each CSR cited by other magazines is about 8.56. Conclusions:
CSRs are relatively completed and still being refined. Although the
number of CSRs showed an increased annual trend, the development of
area distribution and group composition were imbalanced. Therefore,
there are still many problems that need to be resolved.
Attachments: Table 1 the number of articles in different groups.pdf,
Figure 1 the number of authors, institutions and articles from 2005–
Cochrane Database Syst Rev Suppl 1–212 (2013)
Accuracy of blood pressure data abstraction
from graphs
Soufi S1 , Zhang X2 , Musini V3
Faculty of Science, University of British Columbia, Canada; 2 Medical
School, University of Oxford, UK; 3 Department of Anesthesiology,
Pharmacology, and Therapeutics, University of British Columbia, Canada
Background: Assessing hourly blood pressure (BP) measurements
from graphs presents a challenge in making reliable measurements.
The Hypertension Review Group has undertaken a series of time-course
reviews to assess the temporal BP lowering efficacy of various
antihypertensive medications. The majority of included studies
represented 24-hour BP data only in the form of a graph. This
would involve manually printing the graph and taking measurements
with a ruler, which differed between two reviewers. Objectives: To
develop a new electronic method for the reliable measurement of BP
data from graphs. Methods: We developed a simple method of data
extraction whereby the image of the graph from the PDF file of the
study is captured via the ‘Snapshot’ tool in Adobe Acrobat (Fig. 1). The
image is subsequently opened in Microsoft Paint, having enabled the
‘Rulers’ and ‘Gridlines’ options under the ‘View’ tab. This overlays a
scaled grid on the image to take a direct measurement of the difference
of BP and compare it to the scale that appears on the BP axis (Fig. 2).
The Line Tool is used to draw horizontal lines from the data points
to the graph axis, consistently choosing either the top or the bottom
of the line itself as the marker and counting all the grid squares that
appear in between the lines to measure the BP difference from baseline
(Fig. 3). The formula for this scale can then be inputted into a Microsoft
Excel spreadsheet to systematically tabulate the finalized BP difference
measurements. Results: We anticipate that this new method will
save time and improve the reliability of measurements of data taken
from graphs. Two reviewers extracted identical data using this method
(Fig. 3). Conclusions: This process may be a useful tool for Cochrane
Reviewers when extracting graphical data from included studies.
Attachments: Figure1.png, Figure2.png, Figure3.png
The challenges of establishing and maintaining
a multilingual clinical trials register
Long L, Stern C, Pearson A
Cochrane Nursing Care Field, Australia
Background: One of the elective functions of a Cochrane Field is
to establish and maintain a register of trials specific to the field’s
specialty and to submit this register to the Cochrane Central Register of
Controlled Trials. To ensure the register is comprehensive, non-English
language sources can be searched and where necessary translations of
records are undertaken and incorporated into the register. Objectives:
To develop and launch a multilingual clinical trials register for the
nursing care community to inform nursing practice and to identify gaps
in nursing knowledge. Methods: Funding was received to establish
a trials register for the Cochrane Nursing Care Field (CNCF). Initial
planning of the register included defining the scope and topics to be
covered by the register, developing a search strategy, establishing the
keywords and headings to be used in the search, determining the
databases to be searched, deciding on the time period for studies
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
to be included in the register, documenting the types of studies to
be included in the register, determining the details to be included
for each study entered into the register and entering the studies
into the Cochrane Register of Studies. Results: The CNCF Trials
Register was launched in 2013. While preliminary planning focused
on standardization of processes, the next phase revolved around
developing methods for incorporating data from non-English language
sources. Collaboration with our Chinese colleagues to integrate
simplified Chinese records resulted in a number of challenges. Issues
regarding current variation in practice, criteria development, quality
control, updating and communication arose. Conclusions: The CNCF
has developed and launched a trials register that includes records from
non-English language sources. Consequently a number of challenges
have arisen as a result and may serve as a guide for other entities.
Effectiveness of a brief course in evidence-based
medicine for knowledge of the best sources of information in health care among health care workers: first results of the beginningofevidencebased medicine in the Amazonian region
Fonseca RMDM1 , Martins MDA1 , dos Santos CL1 , Pereira IV1 , Andriolo
BNG2 , Atallah Á3 , Andriolo RB4
1 Universidade do Estado do Pará, Brazil; 2 Universidade Federal de São
Paulo, Brasil; 3 Universidade Federal de São Paulo, Brazil; 4 Universidade
do Estado do Pará
Introduction: The frequent absence of scientific rigor in expert
opinions, textbooks, and the majority of scientific meetings limits
effective, safe, and efficient decision making in public and private
health care services. Objectives: To evaluate the effectiveness of
a brief course in Evidence-Based Medicine that informs health care
workers about the best sources of information to use when making
decisions about health care. Methods: Sixty health care workers were
evaluated before and after attending a 4-hour course in Evidence-Based
Medicine at a teaching primary care health service in the Amazonian
Region (Belém City, Pará State, Brazil). A multiple-choice question
about the sources of information to use in decision making in health
care was delivered before and 5 months after the course. The available
alternatives were ‘congress’, ‘textbooks’, ‘expert opinions’, ‘Google’,
and ‘other sources of information’ (an open-ended alternative). Because
of the absence of personal identification in the questionnaires, we used
the qui-square test for independent samples. Results: The participants
were physiotherapists (23.3%), undergraduate students from different
health courses (21.7%), occupational therapists (15%), physicians
(5%), and other health professionals and administrative team members
(35%). Only 51/60 participants provided information 5 months after
the course. At that time, the percentage of answers that referenced
‘congress’ as a reliable source of health care information was reduced
from 28.3 to 11.7% (p = 0.04), the choice of ‘text books’ and ‘expert
opinions’ were reduced but without statistical significance from 75 to
58.8% (p = 0.07), and 8.3 to 3.9% (p = 0.35), respectively (Fig. 1).
No participant referred evidence-based-guidelines, systematic reviews
or randomized controlled trials as reliable sources of information
when making health care decisions. Conclusions: According to
our results, educational strategies on Evidence-Based Medicine should
be continuously offered to health care workers, especially those in
Cochrane Database Syst Rev Suppl 1–212 (2013)
low-income regions around the world, to achieve more effective,
efficient, and safer health service.
Attachments: Figure 1.jpg
Online capacity building in translating research
into practice for Latin American researchers
Villanueva EC1 , Tzanova M2 , Cuervo LG1 , Urrútia G2 , Ueffing E3
Pan American Health Organization; 2 Iberoamerican Cochrane Centre;
Canadian Cochrane Centre
Background: Researchers in Latin America and the Caribbean (LAC)
encounter several constraints that hinder the better use of research for
health improvement of the region’s population; research methodologies
are not integrated in the medical school curricula and materials in
Spanish are not available among others. To address this situation, the
Pan American Health Organization (PAHO) partnered with Cochrane
(the Iberoamerican and Canadian Cochrane Centres) and for the
first time provided webinars on key research topics for non-English
speaking researchers. Objectives: To allow LAC researchers with
limited knowledge in health research methodologies and/or non-English
speaking researchers to attend free online webinars, conducted in
Spanish, from their desks. These activities are ultimately aimed at
translating research into practice. Methods: Research training needs
according to the national health priorities were identified. Specific
topics were defined based on the PAHO research policy and surveying
PAHO research focal points in LAC and potential participants. The
Iberoamerican Cochrane experts designated tutors and a facilitator.
The Blackboard Collaborate platform was used. The sessions were
structured as 45-minute lectures with 15 minutes of Q/A. The recordings
of the sessions were later posted online and the participants were
surveyed on the quality and delivery of the webinar. Results: Twelve
webinars delivered in 2 series of 6 each (2010 and 2011). Over 1000
participants from LAC and from outside the Americas attended the
webinars; profiles ranged from students to seasoned researchers (over
5 publications in peer-reviewed journals); over 600 provided positive
feedback. Conclusions: Online webinars are excellent for capacity
building owing to their quality and convenience for the users who
have rated the webinars as very useful for different reasons. In the
future, a more encompassing strategy would be possible. Options for
certification are being explored.
Enhancing evidence-based health care (EBHC)
knowledge and skills of medical student interns
at Stellenbosch University’s Rural Clinical School
in Worcester
Rohwer A1 , Schoonees A1 , Engel M1 , Young T2
Centre for Evidence-based Health Care, Faculty of Medicine and Health
Sciences, Stellenbosch University, South Africa; 2 South African Cochrane
Centre, South African Medical Research Council, South Africa
Background: Stellenbosch University (SU), via the Stellenbosch
University Rural Medical Educational Partnership Initiative (SURMEPI),
aims to enhance skills of medical professionals in HIV/AIDS and TB
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
care, as well as increase research capacity in these fields. Strengthening
evidence-based health care (EBHC) knowledge and skills is important
within this context. Since 2011, final year medical students at SU
have the opportunity to do their student internship at the Rural Clinical
School in Worcester. As part of the SURMEPI project, we delivered five
EBHC tutorials to these students in 2012. Objectives: To reinforce
student interns’ knowledge and skills related to the basic principles of
EBHC and the application thereof. Methods: The five 2-hour sessions
covered the following topics: Principles of EBHC and formulating
questions; searching scientific databases for relevant studies; and
critical appraisal of randomised controlled trials, systematic reviews
and clinical guidelines. Tutorials consisted of a combination of didactic
input, hands-on class exercises and discussions. Students completed a
questionnaire on their self-perceived confidence in practicing EBHC and
their attitude towards EBHC before the first and after the last tutorial.
Students also completed an evaluation form after each session. An
online learning site was used as a repository of relevant resources,
presentations and screencasts; and as a platform for discussions
and sharing of new developments. Results: Tutorials were well
received and students found it very useful. Most students accessed
e-learning resources easily and participated in interactive e-learning.
There was an overall increase in students’ self-perceived confidence in
practicing EBHC as well as an increase in positive attitudes towards
EBHC. Conclusion: EBHC tutorials were effective to teach EBHC
to undergraduate students. Further sessions could be incorporated
to expand the scope of principles taught and all final year MB,ChB
students should be exposed to the programme.
Attitudes towards evidence based medicine
among medical students of Universidad Nacional
del Sur Medical School of Argentina
Garcia Dieguez M1 , del Valle M1 , Jouglard E1 , Gazzoni C1 , Camila I1 , Sosa
Ridolfi A1 , Lauronce M1 , Durante E2
Universidad Nacional del Sur, Bahia Blanca, Argentina; 2 Insitituto
Universitario Hospital Italiano, Buenos Aires, Argentina
Background: It was proved that devolvement of competence in critical
appraisal is more effective if it stars during undergraduate education.
Most of developed instruments to assess knowledge are oriented to
graduate professionals. Knowing students attitudes is important to plan
strategies to improve critical appraisal skills of students. Objectives:
To describe the attitudes and knowledge towards Evidence-Based
Medicine (EBM) and Biostatistics among students in the middle and
end of medical pregame at the National University of the South (UNS).
Methods: Cross-sectional study. Voluntary and anonymous survey
applied to third and sixth year students from UNS (problem-based
community oriented program). Previous training in epidemiology
(measured as participation on extracurricular courses), participation
in research groups; hours per week devoted to reading of scientific
journals; and an 11 instrument to assess understanding of statistical
terms published in medical journals validated for graduated physicians
were assessed. KR-21, were calculated ji2 test was used to analyze
differences. Results: 71 students completed the survey (Year 3 = 39;
Year 6 = 34). Average age 23.17 (DS ± 1.37). 19.7% referred
extracurricular course in statistics and 17.1% in EBM. 35.5% voluntary
participate in research groups: Year 3 6/39 and Year 6 19/34
Cochrane Database Syst Rev Suppl 1–212 (2013)
(p < 0,001). Agreement of understanding of statistical terms on a
Likert scale was 3.15 (DS ± 0.84) no statistical difference among
years. Knowledge instrument reliability KR-20 0.39. Average of correct
answers 7.87 (DS ± 2.59) no statistical difference among years.
Conclusions: Attitudes are not related with amount of knowledge.
Low reliability suggest the need of specific instruments to assess
students knowledge.
Training Cochrane Systematic Reviews:
challenges and benefits of online training
Jahanfar S
University British Columbia, Canada
Background: On line training has become an inseparable part of
today’s learning and teaching efforts. Medical experts are facing
many challenges in their everyday clinical and academic life many
of which can be solved through online training. Traditional learning
opportunities are plenty, but are not affordable by some because of
financial and time constraints. Iranian scholars in particular are facing
new challenges to travel abroad. Objectives: This paper discusses
benefits and challenges of conducting Cochrane Systematic Review
webinars for Iranian scholars. Methods: Iranian specialists from eight
Medical Universities and Iranians living overseas were contacted to join
the webinars. I have conducted weekly webinars for the last 2 years,
using self-paid software at first, and then Blackboard platform offered
by Australian Cochrane Centre. Results: Five series of standard author
training (12 sessions each) were conducted. I have invited experienced
Cochrane trainers and authors to encourage the audience and provide
hints for a successful registration. The presenters became mentors for
the registered titles. Sessions were recorded on CD and passed around
to be used by those who do not have internet access. The webinars
are free of charge and provide a strong bound between clinicians and
researchers in Iran and overseas. They provide the opportunity to
get involved with Iranians living abroad, to access search databases,
and to supply a strong motivation to join the Collaboration activities.
However, the efforts are not without challenges. Lack of speedy internet
connection in Iran, inadequate access to databases, language barriers
and lack of local support for the authors is some of the difficulties that
Iranians are facing. Strategies to overcome some of these challenges
will be discussed. Conclusion: On line training is not without challenge
but is fruitful and necessary for countries that lack local support.
Attachments: Cochrane Systematic webinars with Iranian scholars.
Building Capacity of Indian Scientists in Conduct
of Systematic Reviews: an Indian Council
of Medical Research (ICMR) Initiative
Sinha A1 , Thavraj V1 , Shah D2 , Sazawal S3 , David T4 , Tharyan P4 , Roy M1
1 Indian Council of Medical Research, New Delhi, India; 2 University College
of Medical Sciences, New Delhi, India; 3 Centre for Micronutrient Research,
New Delhi, India; 4 South Asian Cochrane Network and Centre, CMC,
Vellore, India
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: The Indian Council of Medical Research (ICMR), New
Delhi, the apex body in India for the formulation, coordination and
promotion of biomedical research, initiated a program to facilitate
the practice of Evidence-Based Medicine (EBM) at the national level.
Objectives: To harness the translational potential of secondary
research, by funding systematic reviews aligned to national health
priorities selected through a national competitive process; and to
provide training, mentoring, and quality assurance, in order to ensure
the timely completion of high-quality reviews. Methods: In May, 2012,
the ICMR advertised for letters of intent (LOIs)from Indian scientists
interested in carrying out systematic reviews in maternal, perinatal,
new-born, child, and adolescent health. A project review committee
(PRC), consisting of clinicians with expertise in the area of EBM, critically
evaluated the 36 LOIs received for their (1) suitability and relevance to
current national priorities; (2) potential to identify evidence-gaps for
initiation of primary research; (3) compliance with current best methods
in research synthesis; and (4) the expertise of the review team, and their
training needs. Results: Nine proposals reviewed were shortlisted
for development of full protocols, with appropriate funding assured,
contingent on the submission of the protocol. Twenty three prospective
authors were trained in a two-day protocol development workshop,
in using Review Manager (RevMan) and GRADE Profiler software. All
nine authors submitted protocols using RevMan, within 3 months. A
protocol-refinement workshop is scheduled to be held in April, 2013.
Full reviews are expected 6 months hence. Conclusions: Adequate
funding, careful pre-selection of review topics and author teams, the
provision of suitable training, and quality assurance can result in short
review production timelines. This ICMR initiative will help expand the
pool of trained systematic reviews authors in India. It will also help
identify knowledge gaps, and provide a list of research priorities to be
evaluated in primary research.
Current curriculum and training program
of evidence-based health care (EBHC) for
undergraduate students: Taiwan’s experience
Huang Y, Yang Y, Lin C, Tsai S, Lin W, Tsai J
National Cheng Kung University Hospital, College of Medicine, National
Cheng Kung University, Tainan, Taiwan
Background: Although evidence-based medicine has been promoted
for 20 years, there is considerable variation in the methods and
evidence-based health care (EBHC) curriculum in executive and
administrative aspect. Objectives: To discover the problems
encountered in teaching with current EBHC curriculum and in curriculum
design in Taiwan. Methods: We conducted a nation-wide medical
and nursing schools questionnaire survey of the current status of
the curriculum and training of evidence-based health care (EBHC)
for undergraduate students. Results: The questionnair return rate
from 17 medical school, 68 administration unit and 388 executive
department of teaching hospital was 94.1%, 63.2% and 47.7%.
Among medical schools, 81.2% offered EBHC related curriculum.
Among clinical departments, 74.3% provided teaching and training for
undergraduate students where EBHC teaching was offered to clerks in
84.8% and to interns in 87.1%. The course evaluation was mainly
based on feedback from students. The strategy for learning outcome
assessment included written test, written report, oral presentation,
Cochrane Database Syst Rev Suppl 1–212 (2013)
ability of collecting and integrating information, presentation skill,
attending of the course, the degree of participation and interaction.
The cognition and attitude of Taiwan educators towards current EBHC
program (Table 1) showed the items of over 90% agreement included
helpful in clinical practice, helpful in clinical practice, improving the
quality of health care, adjustment to the limitation of their hospitals in
the application of EBHC in clinical work, and helpful in clinical decision
and those between 80 and 90% included their clinical work being
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
evidence-based, and acceptance of patients’ participant and opinion
in clinical practice based on EBHC. The degree of satisfaction with the
teaching of EBHC was 50% less in teaching hospital in comparison
with that of in medical school. Conclusions: These results will be
valuable for the development of an EBHC centered new curriculum
to promote the competency of EBHC for undergraduate medical and
nursing students.
Attachments: Table 1.pdf
Cochrane Database Syst Rev Suppl 1–212 (2013)
Special Sessions
Wikipedia meets Cochrane: working to get
better evidence into mass use
Panelists: Bastian H, Heilman J, Tharyan P
There are several million visits to medical-related Wikipedia pages
every day. Surveys suggest that most doctors and medical students
(over 90% in one study) rely on the Wikipedia for medical information.
As Wikipedia expands in more languages, its critical importance as a
source of free information globally is increasing. Wikipedia’s Project
Medicine is eager to incorporate Cochrane reviews and contributors in
the Wikipedia. Ensuring the quality of the Wikipedia is a community
responsibility that is likely to be of interest to many Collaboration
members. In this session, the first presentation (James Heilman from
WikiProject Medicine) will focus on discussing the scope and use
of Wikipedia, as well as explaining WikiProject Medicine,Wikipedia’s
editorial processes and the opportunities for academic contributions to
the development of the WikiProject.The second presentation (Hilda
Bastian from Pubmed at the National Center for Biotechnology
Information at the NIH) will discuss the quality of medically-related
Wikipedia pages, and how to incorporate Wikipedia into research and
knowledge translation work, using PubMed Health’s Wikipedia-related
activities as an example.The third presentation (PrathapTharyan) will
discuss the relevance of Wikipedia for the Cochrane Collaboration
and the Collaboration’s plans for working with Wikipedia. He will
describe the project between the South Asian Cochrane Centre and
Target audience and level of expertise: Anyone interested in the
Wikipedia. No specific level of expertise.
Preventing overdiagnosis—can Cochrane and
systematic reviews help?
Chair: Henry D
Panelists: Henry D, Moynihan R, Moons KGM
Background: There is growing evidence that overdiagnosis presents
an important health challenge, along with associated problems of
overmedicalisation and overtreatment. Emerging evidence suggests
the problem of overdiagnosis may be highly significant—not only in
the screening setting, but also in clinical settings—across a range
of diseases. There is a growing debate about the best ways to
address its causes—which include expanding disease definitions and
more sensitive diagnostic and prognostic tests—and how to advance
solutions. The role of good evidence, either from primary studies
or systematic reviews, will be vital in this debate. As one of the
most trusted sources of high quality evidence internationally, the
Cochrane Collaboration, its review groups and/or reviewers, could play
important roles in helping to understand the nature and extent of the
problem and how to best address it. Potentially the Collaboration
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
could be engaged in more reviews of the evidence about overdiagnosis
and/or overtreatment, either in reviews of therapeutic interventions,
diagnostic tests and prognostic factors or models. More broadly, other
types of reviews—for instance reviews of studies that seek to define
disease boundaries—could help to provide reliable evidence on which
to base more appropriate diagnostic criteria and disease definitions.
Structure of the session: The session will open with two or three
short presentations, and then move through a structured interactive
discussion and debate with those attending, with one focus being
potential recommendations for systematic reviews of diagnostic tests
and of therapeutic interventions. Chair and panellists: The session
will be chaired by Professor David Henry, Chief Executive Officer of
the Institute for Clinical Evaluative Sciences, Toronto, Canada, with
brief presentations from Ray Moynihan, Senior Research Fellow, Bond
University, and a co-organiser of the 2013 Preventing Overdiagnosis
conference, and Karel Moons, University Medical Centre Utrecht, The
Target audience and level of expertise: The audience could
be any of those attending the Cochrane Colloquium—including
clinicians, researchers, reviewers, policy-makers, consumer/citizen
advocates and others interested in the problems of overdiagnosis and
Systematic reviews and guideline development
Chairs: Santesso N, Mustafa RA, Guyatt GH
Panelists: Chandler J, Chang S, Dickersin K, Glenton C, Lewin S, Labrecque
M, Norris S, Qaseem A, Santesso N, Tonelli M, Schünemann HJ
Researchers in the field of evidence synthesis, guideline developers
and policy makershave collaboratively achieved health care recommendations, in particular those in clinical practice guidelines, which
ought to be based on systematic reviews. However, best practice
of collaborating and implementing this laudable goal requires further
work.Better coordination between guideline developers and systematic
review authors is required to efficiently use resources (e.g. avoid
unnecessary duplication of efforts, delays and non-credible evidence
reviews). Conducting systematic reviews with the specific purpose of
utilizing them for health care recommendations can enhance motivation
of authors to conduct reviews, possibly open funding opportunities
and improve the Collaboration’s interaction with other health care
organizations. This, in turn, enhances the Collaboration’s profileby
making sure reviews have a specific purpose. This session will
explore these issues in-depth. It will be comprised of panellists
addressing these specific areas and the discussion portion will focus
on next steps: a) Examples of successful collaboration between
systematic review authors and guideline developers and summary
of challenges encountered b) What do guideline developers need
(in addition to information in typical Cochrane reviews)? c) What
do systematic review authors need and how can the collaboration
deliver this? d) Proposal for solving the institutional barriers and
challenges (two key stakeholders: Cochrane Collaboration and GIN
Target audience and level of expertise: Systematic review
authors, guideline developers
Cochrane Database Syst Rev Suppl 1–212 (2013)
Getting to grips with complexity in complex
Chair: Noyes J
Panelists: Petticrew M, Lewin S, Thomson H
Many current evidence synthesis methods and processes have potential
application to reviews where intervention complexity is considered
important. There is however a critical lack of application of existing
methods to better understands and synthesise/interpret evidence on
complexity. There are considerable gaps in current methods and
knowledge that require further methodological development and
testing. The Cochrane Collaboration undertakes systematic reviews
of complex interventions and interventions with varying degrees of
complexity. The Collaboration is currently developing guidance in the
form of a handbook chapter led by Mark Petticrew and Laurie Anderson.
Better understanding of these methodological and process issues is
therefore of high importance. In addition to developing guidance
for authors, the Methods Innovation Fund (MIF) has supported a
number of projects to develop/apply appropriate synthesis methods
and guidance for Cochrane authors. In January 2012, a meeting with
methodologists was held in Montebello, Canada (partly funded by
MIF), and a series of papers from this meeting will be published in
parallel with the Quebec Colloquium. This proposed special session
on complex interventions serves as an update to this work and an
opportunity to disseminate key developments and future plans. We will
set the scene, discussing why Cochrane is concerned with intervention
complexity and complex interventions. We will give a brief update from
the Montebello meeting and a series of papers published in JCE, and
the Methodological Investigation of Cochrane Complex Interventions
(MICCI) project. Mark Petticrewwill speak to the current state of
the art and science of synthesis methods to understand intervention
complexity and synthesise evidence from complex interventions. This
will be followed with a presentation on a new tool for unpicking
intervention complexity using the iCAT SR tool (Cochrane MIF project).
Lastly, we will share case studies of recently published Cochrane
reviews to show how complexity was identified and addressed and
current gaps in methods.
Target audience and level of expertise: Any person with an
interest in intervention complexity and complex interventions.
Using Cochrane Reviews in policy agenda setting,
choice and implementation
Panelists: Lavis JN, Dagenais P, Ouimet M
There is inconsistent use of research evidence in policy agenda setting,
choice and implementation. This is significant because policymakers
make decisions about which programs, services and drugs to provide
or cover, how to get these programs, services and drugs to those who
need them, and how to strengthen health systems generally. Failures to
find, use and contextualize the many types of research evidence needed
in each step of policy agenda setting, choice and implementation can
have negative consequences for citizens, patients, providers and the
health system. The Cochrane Collaboration produces large numbers
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
of reviews of effects that have tremendous potential to inform policy
agenda setting, choice and implementation and its contributors could
benefit from an understanding about how to better contextualize and
support the use of their work in the policymaking process. Dr.John
Laviswill speak on the policymaking process, types of decisions and
options for supporting the use of Cochrane reviews and other types of
research evidence. Pierre Dagenaiswill discuss using Cochrane reviews
and other types of research evidence to support decision makingabout
health technologies. Lastly Mathieu Ouimetwill elaborate on selecting,
assessing and packaging research evidence to support policymaking.
There will be time at the end for questions and discussion with the
delegates attending this session.
Target audience and level of expertise: Researchers interested in
supporting evidence-informed policymaking, as well as health system
policymakers and stakeholders. No past experience needed.
Synergy of systematic reviews of animal and
clinical studies: towards evidence-based
translational medicine
Chairs: Ritskes-Hoitinga M, Leenaars M
Panelists: Rovers M, Hooijmans C, Ritskes-Hoitinga M
The Cochrane Collaboration has mainly focussed on evidence-based
medicine through systematic reviews (SR) and meta-analysis (MA) of
clinical trials. Preclinical (animal) studies focus on mechanism-based
research for medical purposes and establishing safety and efficacy of
medical treatments for human patients. SRs and MA of animal studies
are not yet the routine, even though there are very good reasons
for doing so. For example, serious side effects occurring during trials
in patients could have been predicted when a MA of animal studies
had been performed (Horn et al. 2001, Pound et al. 2004). Within
medicine, animal studies are used to predict efficacy and safety of
new treatments, and establish possible mechanisms of human disease.
Surprisingly, animal studies are not analysed to the full extent before
clinical trials are performed, even though there are very good reasons
for doing so: see e.g. (1) Drug side effects: Horn et al., 2001; Pound
et al. 2004; (2) Evidence-based choice of animal model: de Vries
et al. 2012, Van Drongelen et al. 2012; (3) Translational value:
Hooijmans et al. 2012; Sena et al. 2010, Macleod et al. 2012.
By establishing synergy between SRs of animal and clinical studies, a
significant contribution to translational medicine comes within reach.
By performing SRs of animal studies, (1) transparency is created towards
a more evidence-based choice of animal models in relation to clinical
problems, (2) higher scientific quality of animal studies (more reliable
results) will be induced and (3) a better basis for the design of clinical
trials is created. Target audience and level of expertise: Anybody
interested in the design and conduct of SRs in animal studies.
Patient-centred decision making: using evidence
from bedside to health policies
Panelists: Stacey D, Shrier I, Gauvin F, Boivin A, Légaré J
Cochrane Database Syst Rev Suppl 1–212 (2013)
Although systematic reviews aim to improve patient outcomes, to
achieve this aim evidence needs to be used to inform decisions
by patients, the public, healthcare professionals, managers, and
policy makers. Moreover, challenges interfere with this goal. First,
current approaches to evidence production and dissemination typically
focuses on reporting the evidence but not in formats or language
that facilitates patient and public decision making. Second, patients
and the public are not aware of systematic reviews as an important
strategy for establishing best available evidence about interventions to
improve patient outcomes. Increasing patient and public input into
how systematic reviews or clinical practice guidelines are designed,
conducted, or translated may provide solutions. Therefore, to ensure
that reviews achieve their aim of improving patient outcomes, we need
to consider: (a) how patients and the public can participate in the
production of systematic reviews to ensure better alignment with their
priorities; and (b) how we can better support the use of synthesized
evidence to guide healthcare decisions from bedside to health policies.
The special session is being planned by an interprofessional team
including a patient and all team members will present during the
symposium. It will begin with a short conversation between a patient
and clinician discussing the evidence for management of low back
pain. This clinical vignette will highlight the challenges in getting
evidence to guide decisions in clinical practice through to health
policies. Three brief presentations will propose solutions to address
various challenges associated with engaging patients and the public
in evidence production and use. The session will conclude with an
open discussion/debate among the panel and the audience. Panellists
will be: (1) Dawn Stacey RN, PhD who holds a University Research
Chair in Knowledge Translation to Patients, is an Associate Professor
at the University of Ottawa, and Scientist at the Ottawa Hospital
Research Institute where she leads the Patient Decision Aids Research
Group. She is the principal author on the Cochrane Review of Patient
Decision Aids. (2) Ian Shrier MD, PhD is a practicing sport medicine
physician, Associate Professor and researcher at the Centre for Clinical
Epidemiology at the Jewish General Hospital, McGill University in
Montreal. His research is focused on general epidemiological methods,
and how people interpret systematic reviews. (3) François-Pierre
Gauvin, PhD, is the Knowledge Broker for the Cochrane Policy Liaison
Office and Lead Evidence Synthesis and Francophone Outreach of the
McMaster Health Forum. His area of expertise includes deliberative
dialogues, such as citizen panels and stakeholder dialogues, which
are promising mechanisms to find innovative solutions to collective
problems. (4) Antoine Boivin MD, PhD is a practicing family physician,
associate professor, and researcher at Université de Sherbrooke. His
research focuses on patient and public involvement in healthcare
improvement. He led the first trial of patient and public involvement in
healthcare priority-setting. (5) Jean Légaré is a retired business man,
healthcare consumer, and patient advocate. He served as the co-chair
of the Consumer Advisory Council for the Canadian Arthritis Network
Centre of Excellence, Master Trainer with the Arthritis Self-Management
Program, participant in the Patient Partners in Arthritis program,
steering committee member of the Best Medicines Coalition, and
is a patient representative on research studies. He founded the
Canadian Arthritis Patient Alliance. In 2008, he received an honorary
doctorate at Laval University for patient advocacy and partnerships in
Scaling up/boosting the production of scientific
evidence in low and middle income countries
Target audience and level of expertise: This session will be open
to all Cochrane Colloquium attendees. There is no required level of
expertise to participate.
A forward thinking ‘what if’ session comprising a series of short scene
setting presentations followed by panel discussion.What if access to
clinical study reports from industry sponsored trials becomes routine?
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Panelists: Coren E, Cuervo LG, Ciapponi A, Nair S, Kredo T, Waters E
The challenges facing all countries are significant; however the
challenges facing LMICs in terms of the economic, social and political
contexts, funding drivers for evidence production and decision making,
access to less than optimal evidence information systems, and the
chasm between available evidence and context for its application,
are particularly daunting. However, by comparison to 1993, the
Cochrane Collaboration has made significant advances: relationship
with WHO and PAHO, innovative active Centres, pan-country satellites
and regional capacity development, methodological developments,
equity oriented advocacy, reviews focused on needs of LMIC through
stakeholder advisory groups, and partnerships with funders
Session Objectives:
Participants will: a) understandsome of the opportunities, barriers
and diversity of contexts that exist across the continents, cultures,
populations and environments where LMICs are located. b) hear
speakers’ experiences with opportunities to catalyse activities that both
advocate for the use of transparent approaches of including research
findings in decision making, and commit to contemporary evidence
generation opportunities. c) discuss new directions that could be forged
together over the following 10–20 years, and in particular, strategies
that need to become embedded in available systems, and areas in
which new strategies and ideas are called for.
This session will be a panel-format; participants will anchor their
contributions and experience with a future orientation i.e. where
will we be in 2018, 2023 and 2028. We will discuss:influences on
evidence informed decision making, barriers and facilitators; examples
of contemporary projects and reviews, and critical success factors;
perspective from the South African Cochrane Centre—why reviews are
stalled and how we can support authors in our reference countries;
examples of collaborative projects to inform policies with current
evidence;changes in the big picture in evidence in LMIC contexts; and,
how new tools and policies can be used to frame Cochrane work in a
way that presents it as a contribution to what society is demanding.
This will include examples of how knowledge translation leading to
new policies improved health and policy making processes, and many
inputs came from Cochrane work (beyond just reviews).
Target audience and level of expertise: Participants with interest
in LMICs at any level of experience and expertise
Increasing access to trial data and the next
generation of Cochrane Reviews: a panel and
open floor discussion
Panelists: Stewart L, Dickersin K, Grimshaw JM, Rovers M, Tierney J,
Tovey D
Cochrane Database Syst Rev Suppl 1–212 (2013)
What if obtaining IPD becomes much more straightforward than at
present? How will Cochrane respond? Should all Cochrane reviews
use IPD, if available? Does the Collaboration have the expertise, skills
and tools required to undertake IPD reviews? What will Cochrane
reviews look like in 5–10 years time? There is intense ongoing debate
about improving access to clinical trial information, results and data,
including access to individual participant data (IPD). Several people
within The Cochrane Collaboration are playing leading roles in this
discussion and the Collaboration issued a policy statement in 2011
(currently under revision). It seems likely that in future there will be
increased opportunities to obtain and use new and different sources of
information, including IPD.Given widespread recognition of systematic
reviews that use IPD as a gold standard approach, if trialIPD do
become more readily available,best quality systematic reviews will use
these data. As the world’s largest producer of systematic reviews in
health care, the Cochrane Collaboration is supportive of access to trial
results and to individual participant data. However, few Cochrane
Reviews use IPD.It is timely for the Collaboration to consider how it
will approach incorporating new types of data into its reviews and plan
how to make the most of the opportunity afforded by more widespread
release of IPD, should it happen. The session will begin with a
series of short scene setting presentations (45 minutes) followed by a
panel discussions (45 minutes).The panel will include a researcher with
experience of investigating publication bias, a trialist with experience
of making IPD available, a researcher with experience of undertaking
IPD systematic reviews and meta-analyses, a Cochrane Co-ordinating
Editor, a member of the Cochrane Editorial Unit, and a member of the
Steering Group.
Target audience and level of expertise: Everyone interested in
improving the reliability of Cochrane Reviews, improving access to
data from trials, or both. No minimum level of expertise is required in
the context of a Cochrane Colloquium as the presentations would not
require more than a basic knowledge of systematic reviews and clinical
Health behaviour change
Chair: Shemilt I
Panelists: Godin G, Spence J, Marteau T, Waters E
In 2008, non-communicable diseases (NCDs) caused 36 million (63%)
of global deaths. A large proportion of NCD deaths occur prematurely,
imposing large and avoidable costs in human, social and economic
terms.Tobacco smoking, harmful use of alcohol, unhealthy diets and
low levels of physical activity are common behavioural factors in the
aetiology of the most prevalent and preventable NCDs, including
cardiovascular diseases, diabetes, certain types of cancers and chronic
respiratory diseases.Consequently, four of the five priority areas for
intervention proposed by the Lancet NCD Action Group and the NCD
Alliance (i.e. tobacco control, reduction of hazardous alcohol intake,
salt reduction, improved diets and physical activity) and the UN Draft
Political Declaration of the High Level Meeting on the prevention
and control of NCDs target these four areas of health behaviour.
Changing patterns of health behaviour to reduce the prevalence and
burden of NCDs is therefore one of the most important global health
challenges of the 21st Century. Correspondingly, the production and
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
synthesis of reliable evidence on interventions to promote effective
and efficient health behaviour change are major global challenges
for the next 20 years of better knowledge for better health. This
Special Session on Health Behaviour Change will aim to promote
shared understanding of priority questions that need to be addressed
to build the evidence base for interventions and policies to change
people’s health behaviour at individual- and population-levels,and
galvanise regional and international efforts to tackle them through
primary research, systematic reviews and related evidence synthesis
Target audience and level of expertise: Researchers interested in
supporting evidence-informed policymaking, as well as health system
policymakers and stakeholders. No past experience needed.
Developing evidence in a responsive approach
Chairs: Becker L, Tugwell P
Panelists: Oliver S, Hyde C, Thompson Coon J, Whear R, Allen C, Clarke
M, Moher D, Nasser M, Welch V, Li T, Crowe S
The Cochrane Collaboration aims to help health care providers, policy
makers, patients, their advocates and carers make well-informed
decisions about health care, by preparing, updating and promoting
the accessibility of Cochrane Reviews. The principles underpinning
this work focus on how review teams and groups organise themselves
to produce and promote systematic reviews. These do not include
being responsive to important or urgentuncertainties that stakeholders
face. Being responsive includes updating Cochrane reviews on
topical issues, adopting methodologiesthat provide better insightsinto
the questions stakeholders face or packaging reviews in a more
accessible way. We have attempted to address these issues by
looking at different aspects of our processes separately e.g. setting
priorities for reviews, involving consumers in developing reviews.
A more holistic approach would adopt a coherent structure for
developing evidence in response to our stakeholders’ uncertainties.
This session includes five presentations; the first three provide insight
on methods and processes that other organizations have developed
to be responsive to the needs of the stakeholders. The two lasts
presentations provide an overview how two initiatives in the Cochrane
Collaboration attempting to fill this gap: Cochrane Rapid Review
response and the Agenda and Priority setting Methods Group. (1)
Responsive Evidence Development: a Methodological Approach:
Sandy Oliver—EPPI Centre (2) Responsive Evidence Development:
a local approach: Chris Hyde, Joanna Thompson Coon, Rebecca
Whear—PenCLAHRC (3) Responsive Evidence Development: a global
approach: Claire Allen, Mike Clarke—Evidence Aid (4) Cochrane Rapid
Reviews: David Moher—Cochrane Bias Methods Group/Cochrane
Rapid Reviews workshop group (5) Prioritisation of topics in the
Cochrane Collaboration: at the micro, meso and macro level: Mona
Nasser, Vivian Welch, Tianjing Li, Sally Crowe–Cochrane Agenda and
Priority Setting Methods Group (6) Discussion–‘‘How we can use our
existing structures in the Cochrane Collaboration to build up a more
responsive approach to evidence development?’’: Chair: David Tovey,
Mona Nasser.
Target audience and level of expertise: Members of the Cochrane
Collaboration with any level of expertise.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Research issues in the evaluation and design of
interventions to improve outcomes for patients
with multimorbidity
Translation of Cochrane summaries: a realistic
and timely goal for the collaboration?
Chair: Ravaud P
Panelists: Boyd C, Smith S, Fortin M
Multimorbidity is defined as the co-existence of two or more chronic
conditions in the same individual and is also sometimes referred
to using the term ‘multiple medical conditions’ and includes both
physical and mental health conditions. The term co-morbidity
is sometimes used as well but implies an index conditions with
associated and related other conditions. There is a growing literature
on the epidemiology of multimorbidity and its impact on patients
and healthcare systems. However, a recently published Cochrane
review highlighted the lack of evidence regarding the effectiveness of
interventions designed to improve outcomes in such patients. Prior
work has shown that many reviews and guidelines focused on index
conditions also inadequately address comorbidity and multimorbidity.
Multimorbidity is rising in prevalence across all ages and will need to
be considered by any researchers conducting systematic reviews on
interventions for chronic conditions or on interventions designed to alter
care delivery. It is therefore of relevance to many authors across the
Cochrane Collaboration and it is important that both multimorbidity and
co-morbidity are considered and addressed appropriately in ongoing
reviews and review updates. This special session will discuss the issues
related to multimorbidity and comorbidity for researchers and authors
of Cochrane reviews.
This will be an interactive session that will start with brief presentations
and be followed by an interactive panel discussion. The presentations
will focus on four key areas: a) What is multimorbidity and how do we
measure it? b) Potential interventions for patients with multimorbidity?
c) How do we select appropriate outcomes in multimorbidity research?
d) How can multimorbidity impact on the effectiveness of any
intervention for chronic conditions and how reviewers of existing
reviews could consider incorporating multimorbidity/comorbidity and
its impact within their reviews?
The session will be led by Prof Susan Smith, Prof Martin Fortin and
Prof Cynthia Boyd Each will give a 10 minute presentation to start the
session and we will then move to the panel discussion. Participants
will be encouraged to record one observation or question on paper
provided, that will be presented by a nominated chairperson to the
panel for the interactive discussion.
Target audience and level of expertise: The session will be
designed for researchers new to the concept of mutimorbidity and
related research.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Panelists: Ravaud P, Yvon F, Rada G
From a linguistic point of view, the world is very diverse. The largest
languages by native speakers are Mandarin (14%), Spanish (6%),
and English (5%). Although in many countries most educated health
professionals can read texts in English, many others are not capable
of doing so. If we consider the general population as potential
consumer of Cochrane materials, then the proportion of people who
can be reached and influenced at the moment is actually surprisingly
small. Furthermore, evidence from the usage statistics of the Biblioteca
Cochrane Plus (the Spanish version of The Cochrane Library) has
repeatedly demonstrated that universal access to content in the local
language increases usage substantially, in this case reaching more than
four million users every year. Lately, the addition of French content on
Cochrane Summaries has showed this effect as well: Access to Cochrane
Summaries by French-speaking users has tripled from September 2012
to February 2013, and France is now ranking third among the
countries most accessing Cochrane Summaries. A number of projects
translating Cochrane materials have been conducted, and several small
or bigger projects are currently on-going or planned. All of them
have been initiated, co-ordinated, funded and published by Cochrane
Centres, Review Groups or Cochrane external organisation based in
non-English speaking countries, without any resources, funding or
infrastructure provided by The Cochrane Collaboration centrally. The
results are spread over different platforms, many of them partially
outdated and difficult to track. The most comprehensive and sustained
project has been conducted by the Iberoamerican Cochrane Centre
over the past 15 years, but other initiatives have also been, or are
still, enabling access to Cochrane content in a variety of languages:
French, Japanese, Simplified and Traditional Chinese, German, and
Portuguese. This session will discuss this issue more deeply and debate
different mechanisms to enhance translation support in Cochrane.
Topics covered include: Translation of Cochrane summaries: necessary
or accessory for users from developed countries, the Canadian view;
Standardization of abstracts and Conclusions: Potential Benefits for
English-native and non-native authors and readers of Cochrane reviews;
Is Automatic translation of Cochrane summaries an achievable goal?;
and, Translation using networks of volunteer translators.
Target audience and level of expertise: Centre Directors, Co Eds,
Centres staff members, stakeholders with an interest in translation.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Oral Presentations
Oral Session O1.01: Online tools for
dissemination and communication
The Cochrane Library for iPad—a new platform
for dissemination
Stewart G
Wiley, UK
Background: The Cochrane Library iPad edition was launched in
December 2012. Each issue contains an editorial and up to 12
specially abridged and enhanced Cochrane Reviews chosen by the
Editor-in-Chief. The app was devised to provide a new platform for the
dissemination of Cochrane Systematic Reviews and is free to download
via the Apple iTunes Store. Objectives: Prior to launch, the primary
aim was to offer an attractive new platform for reading Cochrane
Reviews to existing users of The Cochrane Library and to entice a
new audience to Cochrane Reviews. It was hoped that users of the
app would ‘click through’ to access the full text Cochrane Reviews on
www.thecochranelibrary.com. Methods: iTunes Connect and Google
Analytics have been used to collect data on visitors to the app since
launch. A short online survey of users will also be conducted. Results:
In the first 4 months of release the app was installed 11 967 times.
Is the iPad app proving to be popular with both new and existing
users of The Cochrane Library? Are users visiting from the iPad app
the full text versions of the Cochrane Reviews? The user survey will
be analysed and presented together with usage data from the first six
months following release of the app. Conclusions: As the app has
been downloaded nearly 12 000 times since launch it is clear that it
is appealing to a wide audience. Conclusions will be drawn from the
analysis once the data is available.
Engaging with the next generation
of ‘Cochranites’ through an international
web-based community
Millward H, Burton M
UK Cochrane Centre, UK
Background: The UKCC seeks to improve health by promoting the
production, understanding and use of high quality research evidence
by patients, healthcare professionals and those who organise and fund
our healthcare services. Students in all healthcare disciplines are the
practitioners of tomorrow and, potentially, the Cochrane contributors
of tomorrow. Objectives: To promote the understanding of healthcare
research amongst students in all health-related fields and amongst any
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
students in any discipline, with an interest in health care. To do this on
a global basis, inviting participation from any students in any country.
Methods: Working with evidence-based design agency Minervation
we have created an online community called ‘Students 4 Best Evidence’
(S4BE). This community is aimed at students from school to university
age from any part of the world. It brings together relevant, useful
resources about all aspects of evidence-based health care. Students
can, for example, find out how to practice EBM and how to critically
appraise a paper. The site signposts existing resources rather than
creating new ones. It provides a space for students to interact with each
other and discuss all aspects of EBM. Students are able to comment on
the quality of resources and post links to material they have identified.
Results: The site has been developed by 15 students from 7 different
countries, based on a community first developed using Facebook.
Phase I of the website goes live in late April 2013 and Phase II in
September 2013. Our presentation demonstrates the features of the
site and the lessons learnt in developing and refining it. Opportunity:
Students for Best Evidence is supported and promoted by the UKCC but
is not specifically or solely a Cochrane project. However, we invite any
interested Cochrane groups or individuals to support the endeavour by
encouraging students they know to engage and participate.
Using the Cochrane community site to support
Cochrane work
Mavergames C1 , Owens N2
Cochrane Collaboration Web Team, Germany; 2 Cochrane Collaboration
Web Team, Australia
Background: The Cochrane Community site, established as a
knowledge-sharing platform for Archie-registered Cochrane
contributors, provides a useful collaborative and informational resource
that can be a great asset for improving the quality of work and
communication. However, potential users may be daunted by the
volume of information and resources available, and may be unsure
of the practical application of such information to daily routines of
managing tasks. Objectives: (1) Familiarise participants with the
organisation and contents of the Cochrane Community site, and how
these relate to work functions. (2). Provide information on how the
Community site was developed and plans for the future. (3) Provide
practical information on how to use Community site to improve
quality of contributors’ work and communication. This presentation
will focus on exploring the Cochrane Community site: how it was
developed; how it is organised; what it includes; and how to use it,
including features such as discussion forums, role-based portals, and
organisational resources. The presentation will include a demonstration
of how contributors can use the Community site, and apply features to
everyday tasks of communication and information management. It will
also include a discussion of plans for future development of the site
and its resources to support knowledge management in Cochrane and
an opportunity for feedback from the audience.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Translating Cochrane Reviews to lay people
through the web: the IN-DEEP project
Oral Session O1.02: Publication/
Reporting Bias
Colombo C1 , Hill S2 , Filippini G3 , Mosconi P1 , Synnot A4 , Summers M5 ,
Osborne R6 , Hawkins M7 , Shapland S8 , Confalonieri P9 , Traversa S10 ,
Baroni I10
1 IRCCS -Istituto di Ricerche Farmacologiche Mario Negri, Italy; 2 Consumers
and Communication Review Group, Centre for Health Communication and
Participation, Australian Institute for Primary Care and Ageing, La Trobe
University, Melbourne, Australia; 3 Cochrane Multiple Sclerosis and Rare
Diseases of the Central NervousUnit of Neuroepidemiology, Fondazione
IRCCS Istituto Neurologico, C. Besta, Milano, Italy; 4 Centre for Health
Communication and Participation, Australian Institute for Primary Care
and Ageing, La Trobe University, Melbourne, Australia; 5 Centre for Health
Communication and Participation, Australian Institute for Primary Care
and Ageing, La Trobe University; The Nerve Centre, Melbourne, Australia;
Public Health Innovation, Population Health Strategic Research Centre,
School of Health and Social Development, Deakin University, Melbourne,
Australia; 7 Public Health Innovation, Population Health Strategic Research
Centre, School of Health and Social Development, Deakin University,
Melbourne, Australia; 8 MS Australia, Perth, Australia; 9 U.O. Neurologia IV
- Centro Sclerosi Multipla, Fondazione Istituto Neurologico ‘Carlo Besta’,
Milano; 10 Italian MS Society, Genova, Italy
Epidemiology and publication of
discontinued randomized trials—the DISCO
Background: The IN-DEEP project, Integrating and deriving evidence,
experiences and preferences: Developing research-based health
information applicable to decision making and self-management by
people with multiple sclerosis (PwMS), is a collaboration between
research teams in Australia and Italy, undertaking two parallel
projects. The aim is to make high-quality evidence accessible and
meaningful to PwMS and their families. Objectives: To discuss the
implications of our project findings for the provision of evidence-based
information to consumers. Methods: The Australian and Italian
teams each conducted a mixed-method study; drawing upon the
information needs of PwMS to create a website that presented
Cochrane Reviews (CR) of MS treatments. Extensive formal and
informal user testing with consumers and other stakeholders was
undertaken during development. The websites went live in 2012
with an online evaluation survey. Results: Due the iterative nature
of the projects and differing information needs, the Australian and
Italian websites took different approaches, but both were strongly
endorsed by consumers. The Italian website as a first topic covered a
CR on the effects of recombinant interferons for MS with additional
methodological information. The Australian website included a number
of different CRs. Lessons learnt include the importance of understanding
consumer needs, the complexity of being faithful to the volume/quality
of the evidence and to say it clearly, and effective strategies to involve
lay people in the selection of treatment topics and in the production and
dissemination of evidence-based information. Conclusions: Preparing
accessible summaries of evidence for consumers identifies potential
improvements for Cochrane Reviews, eg the importance of Summary
of Findings tables, but also challenges of providing the full range
of information which people need to manage their health. Working
in partnership with consumer organisations will aid this process.
Funding: Fondazione Italiana Sclerosi Multipla (Italian arm); Multiple
Sclerosis Research Australia, Multiple Sclerosis Australia ACT/NSW/VIC
(Australian arm).
Attachments: the IN-DEEP project abs 2013.pdf
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Kasenda B1 , von Elm E2 , You J3 , Blümle A4 , Tomonaga Y5 , Saccilotto R1 ,
Amstutz A1 , Bengough T2 , Meerpohl JJ4 , Stegert M1 , Briel M1
Basel Institute for Clinical Epidemiology and Biostatistics, University
Hospital Basel, Switzerland; 2 Cochrane Switzerland, CHUV and University
of Lausanne, Switzerland; 3 Department of Clinical Epidemiology &
Biostatistics, McMaster University, Canada; 4 German Cochrane Center,
Freiburg, Germany; 5 Institute of Social and Preventive Medicine, Zurich,
Background: Discontinuation of randomized clinical trials (RCTs) has
ethical implications: Participants consent on the premise of contributing
to new medical knowledge, non-publication of discontinued RCTs
compromises systematic reviews, and precious resources are wasted.
Little is known about the epidemiology and publication history
of discontinued RCTs, especially those discontinued due to poor
recruitment. Objectives: To (i) estimate the risk of trial discontinuation, (ii) identify risk factors for discontinuation due to poor recruitment,
and (iii) identify risk factors for non-publication in journals. Methods:
We established a multicentre cohort of RCTs based on protocols
approved by six research ethics committees (REC) from 2000 to
2003 in Switzerland, Germany, and Canada. From included RCT
protocols we extracted data on study design and planned recruitment.
We determined completion status of RCTs using REC files, identified
publications, and surveys of trialists. We investigated factors associated
with discontinuation due to poor recruitment and full publication using
logistic regression. Results: We included 1080 RCT protocols; 956
(88.5%) enrolled patients or participants at risk, and 124 (11.5%)
included healthy volunteers only. The latter were excluded from the
present analysis. 52 RCTs (5.4%) were never started, 10 (1.0%) are still
ongoing. Of the remaining 894 RCTs, 248 (27.7%) were discontinued;
reasons thereof are summarized in the table. In multivariable analysis,
industry-initiation was the strongest factor preventing discontinuation
due to poor recruitment (adjusted odds ratio [OR] 0.24, 95% CI
0.14–0.40; p < 0.001). 532 (59.5%) RCTs were published in journals
including 115 discontinued RCTs (46% of 248). Trial discontinuation
was strongly associated with non-publication (adjusted OR 2.94,
95% CI, 2.12–4.10; p < 0.001). Conclusions: Discontinued RCTs
are common, in particular if they are investigator-initiated. Data
from discontinued RCTs are frequently not published and therefore
compromise systematic reviews and meta-analyses.
Attachments: TABLE DISCO.pdf
Understanding the process and impact
of within-study selective reporting bias for harm
outcomes (ORBIT II—outcome reporting bias in
Saini P1 , Gamble C1 , Loke Y2 , Altman DG3 , Williamson P1 , Kirkham JJ1
1 University of Liverpool; 2 University of East Anglia; 3 University of Oxford
Cochrane Database Syst Rev Suppl 1–212 (2013)
Background: The prevalence and impact of outcome reporting bias
(ORB), whereby outcomes are selected for publication on the basis
of the result, has previously been quantified for benefit outcomes in
randomised controlled trials (RCTs) on a cohort of Cochrane systematic
reviews. Important harm outcomes may also be subject to ORB where
trialists prefer to focus on the positive benefits of an intervention.
Empirical evidence suggests that the reporting of harms data is likely
to be less complete than that of efficacy measures. Objectives:
• To estimate the prevalence of selective outcome reporting of harm
outcomes in a cohort of both Cochrane and non-Cochrane Reviews
• To consider the assessment of selective reporting of harm outcomes
in both RCTs and non-randomised studies (NRSs) • To investigate
the impact of ORB on the benefit-harm ratio • To understand the
mechanisms that may lead to incomplete reporting of harms data.
Methods: A classification system for detecting ORB for harm outcomes
in RCTs and NRSs was developed and applied to both a cohort of
Cochrane systematic reviews and reviews identified via the Cochrane
Database of Systematic Reviews (CDSR) and Database of Abstracts
of Reviews (DARE). In a subset of reviews where ORB is identified,
benefit-harm ratios will be calculated based on (i) the original analyses
reported in the review (ii) the adjusted estimates once ORB has
been accounted for using a suitable sensitivity adjustment method.
Results: From 2007 onwards a total of 234 reviews were identified
from the CDSR and DARE databases in which approximately three
quarters showed evidence of ORB. Full study findings from the study
will be presented at the conference. Conclusions: Making informed
decisions that consider both benefits and harms of an intervention in
an unbiased way is essential in order to make reliable benefit-harm
A selection model to explore whether
publication bias is more likely in two-arm
and placebo-controlled trials rather than
in multi-arm and head-to-head studies
Mavridis D1 , Welton NJ2 , Sutton AJ3 , Salanti G1
Department of Hygiene and Epidemiology, University of Ioannina School
of Medicine, Ioannina, Greece; 2 School of Social and Community Medicine,
University of Bristol, UK; 3 Department of Health Sciences, University of
Leicester, UK
Background: Selection models are used to explore the potential
impact of publication bias (PB) via sensitivity analysis by making
assumptions for the probability of publication of trials conditional on
their precision. Selection models have been previously extended for
a star-shaped network where several treatments are compared to a
common comparator but not between themselves. Objectives: (a) to
suggest a selection model for PB in a full Network Meta-Analysis
(NMA) (b) to explore whether different trial designs (number of arms
and nature of comparison) pertain to different levels of PB. More
specifically, we explore whether multi-arm and head-to-head trials
are less prone to PB than two-arm and placebo-controlled trials.
Methods: We developed a design-by-PB interaction model to describe
the mechanism by which studies with different designs and precision
are selected for publication. We measure the extent of PB by the
correlation coefficient between propensity for publication and study
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
results. We illustrate the methodology in a network including two-arm
and three-arm trials that compare Placebo, Aspirin and Aspirin plus
Dypiridamole for the failure of vascular graft or arterial patency.
Results: The correlation between probability of publication and effect
size for the comparison Aspirin versus Placebo is larger in two-arm
studies compared to three-arm studies. In our example, publication of
a three-arm study is not dependent on the estimated relative treatment
effects, unlike placebo-controlled trials for which publication is highly
associated with the magnitude of the treatment effect. Conclusion:
The suggested selection model accounts for the fact that larger studies,
studies with more than two arms and head-to head studies might
have larger chances for publication independently of their findings. We
suggest employing this sensitivity analysis across various scenarios for
PB to infer about the robustness of the summary treatment effects and
the ranking of the competing treatments.
Extent of publication bias in cohorts of studies
approved by research ethics committees and
included in trial registries
Schmucker C1 , von Elm E2 , Schwarzer G3 , Schell L1 , Bluemle A1 ,
Meerpohl JJ1
1 German Cochrane Centre, Germany; 2 University Hospital Lausanne,
Switzerland; 3 Institute of Medical Biometry and Medical Informatics,
Background: The synthesis of published research in systematic reviews
is increasingly important in providing evidence to inform clinical and
health policy decision making. However, its validity is threatened
if publications represent a biased selection of all studies that have
been conducted (publication bias). Objectives: To investigate the
extent of publication bias we conducted two systematic reviews of
methodological research projects that determined publication rates
and investigated factors associated with full publication of studies
approved by (i) research ethics committees (RECs) or (ii) included in
trial registries. Methods: We conducted electronic literature searches
without language restriction to February 2012. Data were extracted
for methodological research projects that reported the publication rate
of studies approved by RECs or studies included in trial registries with
a minimum follow-up of 24 months. For both reviews separately,
we calculated weighted estimates of publication rates (random effects
model). Pooled odds ratios (OR) were used to express associations
between study characteristics and journal publication. Results: Fifteen
methodological research projects following studies approved by RECs
and 11 following studies included in trial registries were identified.
After REC approval, the weighted publication rate was 45.0% (95%CI
36.7–53.6) and after inclusion in trial registries it was 49.5% (95%CI
35.8–63.2). REC-approved studies with significant results (compared
to those without) were more likely to be published (pooled OR
2.8; 95%CI 2.0–3.9). In the cohort of studies followed after trial
registration phase-III trials were more likely to be published than
early-phase trials (pooled OR 1.9; 95%CI 1.6–2.3). Conclusions:
Many studies approved by RECs or included in trial registries remain
unpublished. As non-publication is not a random process, our findings
support the notion that the dissemination of research findings is
Cochrane Database Syst Rev Suppl 1–212 (2013)
Oral Session O1.03: Statistical
The impact of modified intention-to-treat
reporting randomised trials in meta-analyses
Montedori A1 , Schünemann HJ2 , Cozzolino F1 , Orso M1 , Luchetta L3 ,
Germani A4 , Amici S5 , Folletti I6 , Menculini G6 , De Florio R7 , Abraha I1
1 Regional Health Authority of Umbria, Perugia, Italy; 2 McMaster University,
Canada; 3 Local Health Unit 2, Foligno, Italy; 4 Azienda Ospedaliera di
Perugia, Perugia, Italy; 5 Local Health Unit 1, Perugia, Italy; 6 University of
Perugia, Perugia, Italy; 7 Local Health Unit 1, Perugia, Italy
Background: A modified intention-to-treat (mITT) analysis with
multiple and inconsistent descriptions is increasingly being used in
randomized clinical trials (RCTs). However, little is known about the
impact of mITT reporting trials included in meta-analyses. In addition,
mITT reporting RCTs are likely to be associated with post-randomization
exclusions and funding. However, this evidence comes from trials
published in few journals. Objectives: (1) To estimate the prevalence
of the modified intention-to-treat reporting trials in meta-analyses;
(2) to determine differences in terms of post-randomised exclusions
among the types of intention-to-treat reporting; (3) to confirm whether
mITT is associated with funding. Methods: We searched Pubmed
for systematic reviews with at least one intervention RCT from
2006 to 2011. Trials were classified according to the type of
intention-to-treat reporting as follows: (1) ITT, trials reporting the
use of standard ITT analyses; (2) mITT, trials reporting the use of
‘modified intention-to-treat’ analyses; or (3) ‘no ITT’ trials not reporting
the use of any intention-to-treat analyses. Trials reporting the use
of ITT with descriptions or conditions different from the standard
intention-to-treat definition were classified as mITT. Results: The
prevalence of meta-analyses that included trials with mITT reporting
ranged from 19 to 39%. Compared to ITT trials, the mITT trials were
more likely to report post-randomization exclusions (OR 6.48 [95%CI,
4.11–10.21]). Moreover, there was a strong association between
trials classified as mITT and for-profit agency sponsorship (OR 7.08
[95%CI, 3.70–13.56] ) as well as the presence of authors’ conflicts
of interest (OR 3.65 [95%CI, 2.1–7.89]). Trials classified as ‘no ITT’
were also associated with funding (OR 1.39 [95%CI, 1.07–1.82];
p = 0.016). Conclusions: The reporting of mITT is systematically
present in meta-analyses. Trials reporting mITT are strongly associated
with post-randomization exclusions, for profit funding and presence of
conflict of interest.
Ethics of randomised controlled trials
challenged: the selective cross-over in trials
assessing efficacy of therapies for breast cancer
Balduzzi S1 , Miglio R2 , Petracci E2 , Guarneri V3 , Moja L4 , D’Amico R1
1 Italian Cochrane Centre, University of Modena and Reggio Emilia, Italy;
Department of Statistics, University of Bologna, Italy; 3 Department
of Medicine, University of Padova, Italy; 4 University of Milan, IRCCS
Orthopedic Institute Galeazzi
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: Selective cross-over (SCO), defined as the opportunity
given to patients in a randomised controlled trial (RCT) to switch
to the experimental arm, is an increasingly common phenomenon.
Although there are various reasons justifying it, the equipoise principle
is challenged and problems in the data analysis and interpretation may
arise. Objectives: (i) To assess the prevalence of SCO in scientific
literature concerning the efficacy of biological and hormonal therapies
for breast cancer (BC); (ii) To identify the statistical methods used to
manage it. Methods: RCTs assessing the efficacy of biological and
hormonal therapies in both early and metastatic BC patients published
between January 2000 and July 2012 were searched. For trials in which
SCO has occurred, the following characteristics were recorded: primary
end point, reason justifying the cross-over (i.e. interim analysis),
total randomised patients, fraction of patients switching, statistical
methods used. Results: Figure 1 shows the flow diagram of studies.
Seventy-two RCTs were identified. Cross-over occurred in 14 RCTs
(19.4%) (Table 1). When SCO occurred, the methods mostly used to
analyse data were: (1) Intention To Treat (ITT) analysis (2) Censored
analysis (3) Inverse Probability of Censoring Weighting (IPCW) analysis
All the studies in the early setting presented ITT analyses; two studies
(BIG 1-98, HERA) conducted censored analysis; two studies (BIG 1-98,
MA17) conducted IPCW analysis. All the studies in the metastatic
setting reported the ITT analysis and two (EGF104900, Mouridsen
2003) conducted censored analysis. Censored and IPCW analyses led
to results favouring the experimental drug compared to ITT (Table 2).
Conclusions: SCO entails ethical and methodological issues: since
different methods lead to different results, further research on the
impact of the various strategies is needed. It is important to keep the
phenomenon monitored—not just in BC.
Attachments: Figure 1.jpg, Table 1.jpg, Table 2.jpg
Treatment effects from the patient
perspective: understanding the alternatives
to intention-to-treat analyses
Shrier I
McGill University, Canada
Background: A regulatory agency or clinician is interested in the total
causal effects of recommending an intervention, which is provided by
the intention-to-treat (ITT) analysis. Differing adherence rates will create
heterogeneous results in a meta-analysis, which may be considered
part of the treatment effect. Alternatively, the individual patient is only
interested in the total causal effect of taking versus not taking treatment
(complier average causal effect)—how the average population causal
effect changes when others decide not to adhere to treatment is of
little interest. As these analyses become more frequent, meta-analyses
of these patient-focused estimates will become more common. It is
essential that meta-analysts understand the fundamental assumptions
and limitations of these approaches. Objectives: To explain why
and how non-ITT, patient-oriented treatment causal effects (complier
average causal effects), and their underlying assumptions. This
presentation will review and explain the different analytical methods
currently being used to determine these causal effects with respect to
(1) the different questions being addressed by different methods, and
2) underlying assumptions of each method. The results of the different
Cochrane Database Syst Rev Suppl 1–212 (2013)
analyses will be compared across two published RCTs to illustrate the
strengths and weaknesses of different approaches.
Oral Session O1.04: Conflicts of
Association between personal financial conflicts
of interest and recommendation of medical
interventions: systematic review
Lundh A1 , Jørgensen AW2 , Bero L3
1 The Nordic Cochrane Centre, Denmark; 2 Department of Otorhinolaryngology and Head & Neck Surgery, Aarhus University Hospital, Denmark;
Department of Clinical Pharmacy and Institute for Health Policy Studies,
University of California, San Francisco, California, USA
Background: Financial conflicts of interest may influence scientific
data presentation and therefore influence which treatments are
recommended in review articles and clinical guidelines. Objectives:
To determine whether authors of scientific opinion pieces or clinical
guidelines with personal financial conflicts of interest related to drug,
device or medical imaging companies were more likely to recommend
the companies’ products. Methods: We searched The Cochrane
Methodology Register, MEDLINE and EMBASE for eligible studies. In
addition we searched similar systematic reviews, reference lists of
included studies, Web of Science for studies citing the included studies
and contacted experts for additional relevant studies. Two assessors
independently included studies, extracted data, and assessed studies
for risk of bias. We calculated pooled risk ratios (RR) for dichotomous
data (with 95% confidence intervals). Results: Based on a preliminary
search we included three studies (303 journal articles about drug
treatments). Articles written by authors with any financial conflicts
of interest were more likely to recommend a company’s drug than
articles by authors without conflicts of interest, risk ratio: 6.31 (95%
confidence interval: 1.66–23.92). Despite the inclusion of only three
studies the heterogeneity was substantial (I2: 66%). Full data analysis
and further exploration of data will be presented at the conference.
Conclusions: Our preliminary findings suggest that recommendations
to use a particular drug are associated with financial conflicts of interest
of the authors of the recommendation.
Identifying and managing nonfinancial conflicts
of interest for systematic reviews
Viswanathan M1 , Carey T2 , Belinson S3 , Chang S4 , Graham E4 , Guise J5 ,
Ip S6 , Maglione M7 , McCrory D8 , McPheeters M9 , Newberry SJ7 , Sista P2 ,
White M10
1 RTI International, USA; 2 University of North Carolina at Chapel Hill,
USA; 3 Blue Cross Blue Shield Association, USA; 4 Agency for Healthcare
Research and Quality, USA; 5 Oregon Health Sciences University, USA; 6 Tufts
University, USA; 7 RAND Health, USA; 8 Duke University, USA; 9 Vanderbilt
University, USA; 10 University of Connecticut, USA
Background: Systematic reviews are increasing in number, and
groups including the Institute of Medicine (IOM) emphasize the
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
importance of attention to financial conflicts of interest. Little guidance
exists, however, on how to manage the risk of bias for systematic
reviews (SRs) from nonfinancial conflicts of interest (NFCOI) such as
strongly held beliefs, personal relationships, and desire for career
advancement. Objectives: To provide practical guidance on ensuring
adequate clinical or content expertise while maintaining independence
of judgment on SR teams by (1) defining NFCOI as it applies to SR teams,
(2) developing guidance and an instrument to identify, characterize, and
manage NFCOI, and (3) improve transparency of judgment regarding
NFCOI for users of reviews. Methods: Fourteen workgroup members
reviewed existing international guidance on managing conflicts, built
on these approaches to define NFCOI, and developed practical guidance
in the form of an instrument and examples for each potential source
of conflict. Results: Our definition of NFCOI in the context of
systematic reviews builds on the broader IOM definition of conflict of
interest. In our instrument, we propose questions for funders and SR
principal investigators to evaluate whether the SR topic is subject to
intense advocacy, active policy debate, large interspecialty variations,
and limited availability of clinical or content expertise. Responses to
these contextual questions can serve as a guide to creating an SR
team that appropriately balances critical clinical and content expertise
with independence of judgment. Once the team is assembled, we
suggest additional questions on personal beliefs, previously published
opinions, institutional relationships, and career advancement. We
also propose a range of approaches to managing identified conflicts.
Conclusions: This work is a consensus effort attempting to achieve
a balance between supplying needed expertise and minimizing NFCOI.
However, the utility of this approach and barriers to implementation
must be investigated.
Considering intellectual, in addition to financial,
conflicts of interest proved important in a clinical
practice guideline
Akl EA1 , El-Hachem P2 , Abou-Haidar H3 , Neumann I4 , Schünemann HJ4 ,
Guyatt GH4
1 American University of Beirut, Lebanon; 2 Mount Sinai School of Medicine,
USA ; 3 McGill University, Canada; 4 McMaster University, Canada
Background: The conflict of interest (COI) policy of the American
College of Chest Physicians 9th iteration of the Antithrombotic
Guidelines (AT9) restricted panelists from discussing recommendations
on which they disclosed a primary COI. To what extent, beyond
assessing financial COI, assessing intellectual COI affected management
of COI is uncertain. Objectives: To describe financial and intellectual
COI among AT9 panelists and assess how frequently intellectual COI
would have, in the absence of financial COI, resulted in restrictions on
participation in decision-making. Methods: We classified financial and
intellectual COI into primary (leads to voting restriction) and secondary
(no restrictions). We analyzed COI disclosures of panelists and in
recommendations as units of analysis. Results: Of 104 panelists, 102
made 4030 disclosures for 431 recommendations. The median number
(and range) of recommendations for which the panelists disclosed
COI was: 0 (0–33) for secondary financial COI, 0 (0–21) for primary
financial COI, 1 (0–63) for secondary intellectual COI, and 0 (0–32)
for primary intellectual COI. Of the 102 panelists, 37 (36%) disclosed
a primary intellectual but no primary financial COI for at least one
Cochrane Database Syst Rev Suppl 1–212 (2013)
recommendation. Among 431 recommendations, the median number
(and range) of panelists per recommendation who disclosed COI was:
0 (0–4) for secondary financial COI, 0 (0–5) for primary financial
COI, 1 (0–6) for secondary intellectual COI, and 0 (0–7) for primary
intellectual COI. Of the 431 recommendations, 63 (14.6%) had at least
one panelist with a primary intellectual COI but no primary financial
COI. Conclusions: There was relatively low prevalence of COI in
AT9. The distribution of COI was skewed (many with none, some
with many). In the absence of financial COI, a substantial number
of disclosures would have resulted in restrictions based on intellectual
COI. The Cochrane Collaboration should ask systematic review authors
to disclose both their financial and intellectual COI.
The influence of pharmaceutical companies
on guidelines—two examples from Germany
Schott G1 , Dünnweber C2 , Mühlbauer B3 , Niebling W4 , Pachl H1 ,
Ludwig W5
1 Arzneimittelkommission der deutschen Ärzteschaft, Berlin, Germany;
Berlin School of Public Health, Charité, Berlin, Germany; 3 Institut für
Pharmakologie, Klinikum Bremen-Mitte gGmbH, Germany; 4 Lehrbereich
Allgemeinmedizin, Albert-Ludwigs-Universität Freiburg i. Breisgau,
Germany; 5 Klinik für Hämatologie, Onkologie und Tumorimmunologie,
HELIOS Klinikum Berlin buch, Germany
Background: Recommendations in clinical guidelines are based on
study results and the opinion of experts. Objectives: The influence of
pharmaceutical companies on these two factors will be examined using
two examples from Germany. Methods: Court records have shown
that the marketing authorization holder of gabapentin manipulated
the publicly available data. Therefore, gabapentin was chosen as
an example to examine if German guideline recommendations are
based on manipulated data. The guidelines published by the German
Association of Scientific Medical Societies (Arbeitsgemeinschaft der
Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) were
searched for demonstrably false publications about gabapentin. The
potential impact of financial connections between guideline authors
and pharmaceutical companies was investigated by comparing the
recommendations of the German S3 guideline for the treatment of
psoriasis using efalizumab with guideline recommendations created
by authors without conflicts of interest. This example was chosen
because one of the authors noticed a difference in the prescribing
practice of dermatologists, with prescribers of efalizumab referring to
the S3 guideline. Results: Recommendations for the prescription of
gabapentin in guidelines published by the AWMF were based on data
manipulated by the marketing authorization holder. Compared to the
NICE-Guideline, efalizumab and its application were favorably assessed
in the S3 guideline, i.e. the quality of the evidence was considered
to be good, the use of efalizumab for induction and combination
therapy in psoriasis vulgaris was advocated and the improvements in
health-related quality of life were highlighted. Conclusions: Public
access to all trial data must be ensured. Responsibility for the
development of guidelines should lie with authors and organizations
that are free from conflicts of interest. This requires more public
funding, as does the implementation of industry-independent drug
research. The research will be published in detail: Schott G et al.: Dtsch
Arztebl Int 2013; 110: in print.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Oral Session O1.05: Searching and
information retrieval—Session 1
Effective searching of LILACS database
for systematic reviews
Glujovsky D1 , Ciapponi A2
Institute for Clinical Effectiveness and Health Policy (IECS), Argentina;
2 Argentine Cochrane Center IECS, Argentina
Background: Information retrieval for systematic reviews needs to
be comprehensive in order to identify those studies which will provide
a reliable result. The range of databases used to identify those
studies, and particularly the inclusion of regional databases such as
LILACS—the Latin American and Caribbean Health Sciences database,
varies across organisations. Information specialists and others involved
in searching for studies for evidence syntheses such as systematic
reviews need to be aware of regional databases such as LILACS and
how best to search them to identify studies not included in other major
bibliographic databases such as MEDLINE and EMBASE. Objectives:
To enable participants to operate an effective searching on the LILACS
database in order to retrieve relevant information to improve the
conduct of Systematic Reviews. The presentation will include an
overview of the LILACS database and will focus on issues such as
journal coverage, multilingual searching (to identify records in English,
Portuguese and Spanish), advantages of searching these resources in
addition to other databases, search features, downloading records,
any current limitations to the search interface and plans for future
Data cleaning in the Cochrane Register of Studies
Foxlee R1 , Noel-Storr A2 , Dooley G3 , Littlewood A4 , Salzwedel D5
1 Cochrane Wounds Group/Cochrane Editorial Unit, UK; 2 Cochrane
Dementia Group, University of Oxford, UK; 3 Metaxis Ltd, UK; 4 Cochrane
Oral Health Group, UK; 5 Cochrane Hypertension Group, Canada
Background: The Cochrane Register of Studies (CRS) contains over
2 million records, and represents a vital data repository for Cochrane. It
is also the mandatory mechanism for submitting records to CENTRAL.
Objectives: To give an overview of the role of the Cochrane Register of
Studies (CRS) in cleaning and enriching the Cochrane Central Register
of Controlled Trials (CENTRAL). The presentation examines how the
CRS can help ‘clean up’ Specialised Registers from Cochrane groups
and therefore CENTRAL. The elements of CRS functionality that will
help facilitate data cleaning will be outlined. The audience will be
encouraged to share their experiences and ideas, with the aim of
developing more harmonised, uniform practices that will improve the
quality of our global data set and ultimately drive, and improve the
quality of Cochrane products. This oral session is aimed at users of the
CRS and users of CENTRAL.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Peer review of literature search strategies: does
it make a difference?
Spry C1 , Mierzwinski-Urban M1 , Rabb D1
Canadian Agency for Drugs and Technologies in Health Canada (CADTH),
Background: Peer review is an integral part of scientific research.
For Information Specialists, peer review feedback is used to validate
the quality of search strategies. Objectives: To determine whether
the peer review of literature search strategies has an effect on the
number and quality of articles included in Canadian Agency for Drugs
and Technologies in Health (CADTH) rapid review reports. Methods:
A total of 150 pairs of pre-peer-reviewed and peer-reviewed search
strategies for CADTH rapid review reports related to health devices
medical procedures, and pharmaceuticals were randomly selected and
screened. For search strategies meeting specified selection criteria,
pre-peer-reviewed and their corresponding peer-reviewed searches
were run and the search results were compared. Unique articles
retrieved solely by peer-reviewed searches and included in the final
reports were identified and categorized according to publication type.
Results: Of the 150 pairs of pre-peer-reviewed and peer-reviewed
searches screened, 47 met the selection criteria. Of these 47 pairs of
searches, 43% (20/47) of the peer-reviewed searches retrieved a total
of 81 unique articles that were included in rapid review reports. The
81 articles consisted of 5 systematic reviews, 3 randomized controlled
trials, 52 non-randomized studies, 1 guideline, 18 review articles and
2 other. Conclusions: The results of this study suggest that the peer
review of literature search strategies can improve both the number and
quality of relevant articles retrieved.
Attachments: Cochrane abstract revised June 2013.pdf
Development of high-performing population
search filters is feasible and their use warranted
in systematic reviews and clinical practice
Iansavichus A1 , Hildebrand A1 , Haynes B2 , Garg A1
1 London Kidney Clinical Research Unit, London Health Sciences Centre,
Canada; 2 Health Information Research Unit, McMaster University,
Background: Many clinical and research questions relate to the same
patient population (e.g. people receiving dialysis). Developers of
guidelines and systematic reviews require efficient and reproducible
search strategies for studies of a given population, but even strategies
developed by expert searchers have unknown performance.
Objectives: To assess the consistency and performance of populationspecific search strategy segments used in clinical practice guidelines
and Cochrane Reviews, with renal populations as proof-of-concept.
Methods: We collected population-specific segments of search
strategies published in Cochrane Reviews and clinical guidelines
pertaining to patients with glomerular disease, chronic kidney disease,
acute kidney injury, kidney transplantation, and dialysis. Our group
developed and validated search strategies for studies relevant to these
five patient populations. We tested search performance in a database
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
established by manual review of 22 992 full text articles (from 39
journals) tagged by nephrologists as relevant or not relevant to each
population. Results: While aimed at the same population, search
strategies varied in content and performance across guidelines and
Cochrane Reviews. Our new strategies demonstrated high sensitivities
and specificities (90–99%+) in Pubmed, Ovid Medline, and EMBASE.
For example, our high sensitivity acute kidney injury strategy for
Ovid Medline achieved 97.62% sensitivity, 96.49% specificity, and
38.78% precision. Our high specificity strategy achieved 90.51%,
99.45%, and 80.11%, respectively. The search strategy used in the
most authoritative acute kidney injury guideline (KDIGO) achieved
68.71%, 98.79%, and 56.27%. Three randomly selected Cochrane
Reviews averaged 58.73%, 99.83%, and 88.29. Conclusions: We
demonstrated that bibliographic databases can be reliably filtered for
population of interest using validated search strategies. Our preliminary
results show that, across guidelines and Cochrane Reviews, search
strategies for retrieving studies of the same renal population use
different terms and have inconsistent retrieval performance. Validated
strategies improve performance. Full results will be available for the
Oral Session O1.06: Investigating
bias—Session 1
Addressing missing participant data for
continuous outcomes assessed with different
instruments: a guide for systematic review
Ebrahim S1 , Johnston B2 , Akl EA3 , Mustafa RA4 , Sun X5 , Walter SD1 ,
Heels-Ansdell D1 , Alonso-Coello P6 , Guyatt GH1
1 Department of Clinical Epidemiology & Biostatistics, McMaster University,
Canada; 2 Department of Anesthesia and Pain Medicine, The Hospital For
Sick Children, Canada; 3 Department of Internal Medicine, American
University of Beirut, Lebanon; 4 Department of Medicine, University
of Missouri-Kansas City, USA; 5 Center for Clinical Epidemiology and
Evidence-based Medicine, Xinqiao Hospital, China; 6 Iberoamerican
Cochrane Centre, CIBERESP-IIB Sant Pau, Spain
Background: We previously developed an approach to address
the impact of missing participant data for continuous outcomes in
meta-analyses of trials that used the same measurement instrument.
Objectives: To extend our approach to meta-analyses including
trials that use different instruments to measure the same construct.
Methods: We reviewed the available literature, and conducted an
iterative consultative process with nine methodologists. We applied our
approach to an example systematic review of respiratory rehabilitation
for chronic obstructive pulmonary disease. Results: Our approach
involves first choosing a reference instrument, typically the one that is
most familiar to the target audience and/or has the best measurement
properties. Second, we convert scores from different instruments to
the units of the reference instrument. Third, we impute the means
for participants with missing data using five sources of data that
reflect observed outcomes from the trials in the systematic review.
These range from the best mean score among the intervention arms
Cochrane Database Syst Rev Suppl 1–212 (2013)
of included trials to the worst mean score among the control arms of
included trials. Fourth, we apply four increasingly stringent imputation
strategies for addressing missing participant data (Table 1). To
impute standard deviation (SD), we used the median SD from the
control arms of all included trials. Finally, we calculate a pooled
mean difference for the complete case analysis and each of the
four imputation strategies. In the example review, pooled effect
estimates diminished but lost significance only with the most stringent
strategy (Strategy 4, Fig. 1). When judging the risk of bias as
a result of missing participant data, one should consider both the
plausibility of the more stringent strategies, and the importance of the
apparent intervention effects. Conclusions: Our extended approach
provides guidance for addressing missing participant data in systematic
reviews of trials using different instruments to measure the same
Attachments: Table 1.pdf, Figure 1.pdf
Prediction study risk of bias assessment tool
Wolff R1 , Whiting P1 , Mallett S2 , Riley R3 , Westwood M1 , Kleijnen J4 ,
Moons KGM5
Kleijnen Systematic Reviews Ltd, UK; 2 Department of Primary Care Health
Sciences, University of Oxford, UK; 3 School of Health and Population
Sciences, and School of Mathematics, University of Birmingham, UK;
Kleijnen Systematic Reviews Ltd, UK; Care and Public Health Research
Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands;
Julius Center for Health Sciences and Primary Care, UMC Utrecht, The
Background: Quality assessment of included studies is a crucial step
in any systematic review. Review and synthesis of prediction modelling
studies is a relatively new and evolving area. The QUIPS tool for
prediction finding studies has been recently updated. However, a tool
facilitating quality assessment for prognostic and diagnostic prediction
modelling studies is needed. Objectives: To develop PROBAST,
a tool for assessing the risk of bias and applicability of prediction
modelling studies. Methods: Risk of bias addresses the extent
to which reported estimates of the predictive performance/accuracy
(e.g. discrimination, calibration and (re)classification estimates) of the
prediction model are potentially biased. Applicability refers to the
extent to which the reported prediction model and the population
used to measure model performance matches the review question
and intended use of the model. For PROBAST, we have adopted a
domain-based structure supported by signalling questions similar to
QUADAS-2, which assesses risk of bias in diagnostic studies. We
are using a Delphi process to develop PROBAST. Existing initiatives
in the field of prediction research such as the REMARK (Reporting
Recommendations for Tumor Marker Prognostic Studies) guidelines
and the TRIPOD prediction model reporting guidelines formed part of
the evidence base for the tool development. The scope of PROBAST
was determined with consideration of existing tools, such as QUIPS.
Forty experts and review authors in the field of prediction research are
taking part in the Delphi process. We anticipate about five rounds
of this process will be needed until agreement on the content of the
final tool. Results and Conclusions: The first rounds developing
domains are now completed. The presentation will give an overview
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
of the process, the current version of the tool (including the addressed
domains and signalling questions) as well as an insight into underlying
Attachments: PROBAST references.pdf
Exploring mechanisms of publication bias in
systematic reviews of diagnostic test accuracy
van Enst WA1 , Naaktgeboren C2 , Ochodo EA3 , Leeflang MM3 , Reitsma
JB2 , de Groot JA2 , Bossuyt PM3 , Moons CGM2 , Scholten RJPM1 , Hooft L1
1 Dutch Cochrane Centre, Academic Medical Center, Amsterdam, The
Netherlands; 2 Julius Center, University Medical Center, Utrecht, The
Netherlands; 3 Department of Clinical Epidemiology, Biostatistics and
Bioinformatics, Academic Medical Center, The Netherlands
Background: Selective publication can seriously threaten the validity
of the results of a systematic review. For intervention studies
various mechanisms of selective publication have been identified. The
mechanisms underlying selective publication of studies on diagnostic
test accuracy (DTA), however, are not well understood. There might be
some analogies with intervention studies: small sample sizes tend to
have a larger and more positive effect compared to studies with larger
sample sizes. In addition, the first studies reporting results of a novel
intervention, tend to have more positive findings, though subsequent
publications commonly show less optimistic results. Objectives: To
explore whether sample size or time of publication affects the results of
DTA reviews. Methods: We have searched MEDLINE and EMBASE to
identify DTA reviews with a meta-analysis published between May and
September 2012. From the largest meta-analysis of every review we
have extracted characteristics of the primary studies: total sample size,
year of publication, and two-by-two tables. The existence of sample
size effect or time effect will be investigated by meta-regression for
each meta-analysis by the use of the bivariate model. The resulting
regression coefficients and corresponding variances will be combined in
a random effects model to investigate the overall association. Results:
We have included 53 DTA reviews. So far, we have done data extraction
for 28 reviews. The meta-analyses contained a median of 12 primary
studies (IQR = 7–17) and a median sample size of 81 participants
(IQR = 42–153). Median difference in publication year since first
publication was 7 years (IQR = 4–11). Data collection is currently
ongoing and results of the meta-regression will be presented at the
Colloquium. Conclusions: This study aims to investigate sample size
and time of publication as possible mechanisms of selective publication
in the DTA setting. We will provide authors of DTA reviews with
guidance regarding the investigation of publication bias.
What is the probability of discovering
breakthrough interventions in industry versus
publicly sponsored randomized controlled trials
Kumar A, Miladinovic B, Reljic T, Mhaskar R, Wao H, Djulbegovic B
University of South Florida, Center for Evidence-based Medicine, USA
Background: Research efforts tested in randomized controlled trials
(RCTs) have played a vital role in the development of new treatments in
Cochrane Database Syst Rev Suppl 1–212 (2013)
medicine. Treatment research in medicine is primarily performed
by publicly funded entities or privately funded drug companies.
Objectives: To study whether new interventions tested in publicly
versus industry funded RCTs are highly successful or ‘breakthrough’.
Methods: All completed phase 3 RCTs conducted by 5 publicly
funded groups (820 trials, 1064 comparisons, 331 004 patients) and
GlaxoSmithKline (40 trials, 55 comparisons, 19 889 patients) were
reviewed. Published and unpublished data were used. Breakthroughs
were defined two ways: semi-quantitatively (score 1–6): the intervention was so successful according to the original researchers that it should
be adopted immediately as a new therapeutic standard (= 6), and
quantitatively: the intervention effect resulted in a log odds ratio < -0.5
for the primary outcome. Results: Quantitatively, 14% (n = 149) of
comparisons resulted in breakthrough interventions in publicly funded
studies versus 34% (n = 19) in industry sponsored RCTs. According to
the original investigators, 15% (n = 124) of experimental testing were
breakthrough in the cohort of publicly funded versus 35% (n = 14)
in industry sponsored studies. Semi-quantitatively 12% (n = 15)
of breakthroughs were for breast cancer in publicly funded studies
versus 78% (n = 11) in privately funded studies for chemo/radiation
induced emesis. Induction and curative therapies jointly resulted in
62% and 73% of breakthroughs by quantitative and semi-quantitative
assessment, in publicly funded RCTs versus 2% quantitatively and 0%
semi-qualitatively in industry sponsored RCTs. Conclusions: This is
the first comprehensive assessment of success of innovative therapies
in medicine tested in a cohort of public versus industry sponsored RCTs.
Majority of breakthroughs by publicly funded RCTs addressed curative
therapy strategies compared with supportive care in industry funded
RCTs. All stakeholders should understand what it takes to produce a
successful breakthrough intervention in medicine.
Oral Session O1.07: Accessing and
disseminating Cochrane evidence
Impact of translations on access to Cochrane
Stewart G1 , Ried J2 , Hives D1 , Janczyk M3 , Becker L4
The Cochrane Library, John Wiley & Sons, UK; 2 Cochrane Innovations,
Germany; 3 Cochrane Web Team, Germany; 4 Cochrane Innovations, USA
Background: Translations of Cochrane abstracts and plain language
summaries have been published centrally via Archie since September
2012 on www.thecochranelibrary.com and http://summaries.cochrane.
org/. Croatian, French, Portuguese, Simplified Chinese, Spanish and
Traditional Chinese translations are currently available online or will be
made available in the coming months. Objectives: To measure the
impact of translations on access to and usage of Cochrane Reviews.
Methods: Data acquired from Google Analytics will be analysed
to determine the usage of translated abstracts and plain language
summaries via the Cochrane Summaries website; data acquired from
the Wiley Usage Data Warehouse will be analysed to measure usage
on The Cochrane Library website. A strategic approach to promoting
the available translations via Cochrane communication channels and
involving Centres and others in regional promotion in the respective
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
languages is planned. Usage statistics for the different languages
will be compared on both websites over a period of 4–5 months.
Results: Analysis of usage statistics from Cochrane Summaries has
demonstrated a tremendous increase in access from French-speaking
countries since the regular addition of French translations, including a
French interface, search and browse from September 2012. Similarly,
recent analysis of a sample of Simplified Chinese translations has
shown an increase in access to Cochrane Reviews on The Cochrane
Library by Chinese users. Strategic promotion as indicated above
and continued usage analysis will aim at answering the following
questions: Are the translations reaching their intended audience?
What effect do translations have on the overall usage of Cochrane
Reviews? How do people go to translations, and is that different to
English reviews? Have some languages proved more popular than
others? Conclusions: Based on the initial analysis of French and
Chinese translations, strategic promotion and further data analysis
should highlight the important usage of Cochrane translations and
their impact on the overall usage of Cochrane Reviews.
Issues in developing and disseminating
summaries of Cochrane Reviews for specific
external audiences
Mahan KM1 , Pearson A2
1 Neurological Field, Italy; 2 Nursing Care Field, Australia
Background: The role of Cochrane Fields is to provide links
between the Cochrane Collaboration and the stakeholders (clinicians,
researchers, and consumers) in the Field’s area of interest. Developing
and disseminating summaries of Cochrane Reviews is one way in which
Fields link between Cochrane and specific external audiences of Field
stakeholders. Objectives: To share two models of Cochrane Review
summary development and dissemination to specific stakeholder
groups. Methods: Examples of summaries of Cochrane Reviews
produced by two Cochrane Fields will be presented and analysed to
exemplify different successful models of summary development and
dissemination. The methods used by each Field, and the lessons
learned, will be described in detail. Issues addressed will include:
working with authors and Cochrane Review Groups, methods to
identify and work with collaborators in developing the summaries,
successful strategies for positioning Cochrane Review summaries in a
range of media, and evidence of impact of summaries upon targeted
groups. Results: Examples include summaries of Cochrane Reviews
published in topic specific international journals; journal commentaries
upon reviews; a handbook of summaries of Cochrane Reviews; and
bulletins with translated plain language summaries. Conclusions:
Cochrane Fields have considerable expertise in knowledge translation
activities related to Cochrane, including producing and disseminating
summaries of Cochrane Reviews. The variety of approaches leading to
successful knowledge translation for Field audiences, and the lessons
learned along the way, may serve as models for others wishing
to develop and disseminate Cochrane Review summaries and other
derivative products.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Cochrane goes green and gold: overview and
impact of open access options for Cochrane
Pentesco-Gilbert D1 , Maclehose H2 , Urquhart B1
John Wiley & Sons Ltd., UK; 2 Cochrane Editorial Unit, UK
Background: ‘Gold’ open access—known as ‘green’ open access.
Secondly, authors can choose to make their Cochrane Review freely
available immediately upon payment of an article processing charge—
The Cochrane Collaboration aspires to prepare and publish high-quality
research aimed at informing decision-making globally and to make this
available via one-click access at the point of use. On February 1, 2013,
two open access options were introduced for all Cochrane Reviews
for the first time. Firstly, all new and updated Cochrane Reviews will
be made freely available 12 months after publication. Objectives:
To summarise the new open access options and provide analytics on
their uptake and impact on usage and access, evaluate how ‘open’
the Cochrane Database of Systematic Reviews (CDSR) is according
to the ‘How open is it?’ guide (www.plos.org/about/open-access/
howopenisit/), and describe how this relates to funder mandates.
Results: The open access options and the analytics will be described.
Figure 1 (modified from HowOpenIsIt? Open Access spectrum’, c
2013 SPARC and PLOS, licensed under CC-BY) shows where the CDSR
currently fits onto the open-access spectrum. Conclusions: Open
access is here to stay and the CDSR is responding to requirements of
funders and authors to provide different options for making Cochrane
Reviews open access. However, the open access landscape is still
evolving and so it is important that anyone involved in producing
Cochrane Reviews is aware of their funder’s particular requirements,
and the publishing options available to them. Figure 1. How open is
it? Gold and green access in the CDSR
Attachments: figure 1.png
Why should we translate Cochrane Reviews into
Mbuagbaw L, Ongolo-Zogo P
Centre for Development of Best Practices in Health
Background: The efforts of the Cochrane Collaboration to produce
up-to-date high quality health evidence are undermined by language
barriers. People in many regions of the world where disease and
poverty are rife do not speak English and therefore are unable to
benefit from many Cochrane products. A number of translation efforts
are underway but there are still many challenges to be overcome. What
is the argument for translating reviews into French? The first reason
is equity. It is unfair that something as surmountable as language
should limit access and utilization of a resource as important as the
Cochrane Library. The second is that if we hope to alleviate the
burden of disease we must target the regions of the world where it
is highest. This region is arguably Africa where the highest numbers
of French speakers reside. Thirdly, French public health publications
do not respond to the needs of French-speaking developing countries.
What are the challenges in developing useful French translations for
developing countries? The most important challenge is dedicated
man-power for French translations. The second involves setting up a
mechanism for establishing priorities, such that the translations are
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
relevant to the people who need them the most. The third challenge is
creating dissemination mechanisms that correspond to the users. The
fourth challenge is collaboration between all the entities involved in
translations such that efforts are not duplicated. The fifth is engaging
more French-speaking researchers in the production of Cochrane
Reviews so that the first four obstacles are less onerous. Conclusion:
Despite current efforts, we can do more to reach non-English speakers,
by enhancing and streamlining our efforts, and establishing priority
topics for translation and dissemination.
Oral Session O1.08: International
Policy buddies: baseline assessment of the
institutional capacity for evidence informed
decisions in provincial health departments
in South Africa
Young T1 , Zani B2 , Dudley L3 , Ongolo-Zogo P4 , Naude CE1 , Garner P5
Centre for Evidence-based Health Care, Faculty of Medicine and Health
Sciences, Stellenbosch University, South Africa; 2 South African Cochrane
Centre, South African Medical Research Council, Cape Town, South Africa;
Division of Community Health, Faculty of Medicine and Health Sciences,
Stellenbosch University, South Africa; 4 Centre for the Development of
Best Practices in Health, Yaoundé, Cameroon; 5 Effective Health Care
Research Consortium, International Health Group, Liverpool School of
Tropical Medicine, Liverpool, UK
Background: Robust evidence helps policy-makers shape effective
and efficient health services, including what services to provide, how
to deliver them, and how to shape the service. Helping policymakers
understand what research can help with, and helping researchers
understand what might be useful to policy makers, is central to
effective research-user dialogue. We report on the initial analysis
from the Policy BUDDIES—Building Demand for evidence in Decision
making through Interaction and Enhancing Skills of policymakers
funded by the World Health Organization. Aim: To understand
policymakers’ capacity, as well as enablers and constraints related to
demanding evidence during policy formulation and implementation,
and map existing communication between policymakers, research
intermediaries and researchers. Methods: We carried out key
informant interviews of managers of health programmes related to
delivery of Millennium Development Goals 4 (reducing child mortality),
5 (improving maternal health) and 6 (combating HIV/AIDS, malaria
and other diseases). We recorded, transcribed and analysed the
interviews formally, using framework analysis. Results: We will
present the provincial policymakers’ priorities, and their knowledge
and attitude to evidence informed decision-making. This will include
an assessment of the contexts in which policies are formulated,
enabling and constraining factors related to demanding evidence;
roles, skills, and resources that provincial policymakers’ have towards
evidence-informed decision-making; and priority areas for research
and policy-making in provincial health departments; existing links
between decision-makers, research intermediaries and researchers for
obtaining research evidence; and policymakers’ opinions on existing
knowledge translation tools. Conclusion: A thorough understanding
of how policy process operates and policymaker priorities is essential
Cochrane Database Syst Rev Suppl 1–212 (2013)
to effective evidence to policy and practice, and these data will help
effective dialogue between researchers, people engaged in systematic
reviews and those responsible for making decisions in the health
services. It will also help inform question formulation and prioritisation
to inform policymaking.
Translating Cochrane abstracts and plain
language summaries from traditional to
simplified Chinese: feasibility assessment
and user survey
Wang Y, Tang X, Jiang Y, Zeng H, Lei X
Chongqing Medical University, China
Background: Awareness of Cochrane Systematic Reviews is increasing
in mainland China. To date, there has been no systematic effort to
translate a substantive number of Cochrane abstracts into Simplified
Chinese for mainland China. Objectives: To examine the feasibility of
translating Cochrane abstracts and plain language summaries (PLSs)
from traditional into simplified Chinese and to assess the work and
resources involved in creating good quality translations. Methods: One
hundred Cochrane abstracts and PLSs on a range of topics were selected
to be translated into Simplified Chinese based on a pre-designed
Standard Operating Procedure (SOP)(Annex 1). Resources including
personnel, expertise, time, and financial cost were assessed during the
translation process. User views on the translations were explored by
qualitative interview with key informants using semi-structured topic
guide (Annex 2). All the interviews were transcribed verbatim in
Chinese characters and appropriately analysed using a simple thematic
analysis approach. Results: We did the translation mainly based
on the pre-designed SOP and made some adjustments according to
the practical situation. The detailed resources we used included
personnel, expertise, time, and financial cost see Annex 3. User views
on the following three aspects were summarized: (a) the quality of
translated abstracts and PLS; (b) whether investing in these translations
is worthwhile; (c) whether it helps to disseminate Cochrane Review
evidence in China. Conclusions: The translations are good quality
and easy to read. The SOP played an important role in the whole
process of translation. The idea of converting from Traditional Chinese
version into Simplified Chinese version needs to be reconsidered as it
created reading and understanding problems and did not save our time
and resources. For scale up of the project, we may firstly translate a
selection of reviews and then formally evaluate on user views after the
translations have been put on The Cochrane Library.
Attachments: Annex 1.pdf, Annex 2.pdf, Annex 3.pdf
Development of user-friendly evidence
summaries for the rational use of essential
medicines and other complex drugs in the
Solà I1 , Rigau D1 , Selva A2 , Osorio D2 , Posso M2 , Pardo H1 , Sanabria AJ1 ,
Roqué M1 , Porrás A3 , Bonfill X1
1 Iberoamerican Cochrane Centre; 2 Epidemiology and Public Health
Department, Hospital de la Santa Creu i Sant Pau, Barcelona; 3 Health
Systems Based on Primary Health Care Office, Pan American Health
Organization (PAHO)
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: The Pan American Health Organization (PAHO) is
promoting user-friendly summaries based on the best available evidence
to inform policymakers on the use of essential medicines, drugs with
high costs or under conditional approval by regulatory agencies.
Objectives: To describe the methodology to develop evidence
syntheses that integrates evidence on benefits and harms and aspects
related to the use of resource use, to support policymaking. Methods:
PAHO created the Regional Platform on Access and Innovation for
Health Technologies (PRAIS) with the aim to improve access and rational
use of essential medicines and other complex drugs. PAHO formulates
specific clinical questions on relevant drugs for their use in the Americas.
Each clinical question generates a search of a systematic review in
the CDSR, DARE or PubMed. The review results on effectiveness and
safety are summarised, classifying the quality of evidence according
GRADE system. The summaries incorporate comments on economic
studies retrieved from the NHS Economic Evaluation Database and a
contextualisation about the applicability of the evidence. The evidence
summaries are then included in the ‘Annotated medicines list’ section
of the PRAIS as a support tool to decision making. Results and
Conclusions: We have developed 65 evidence summaries about
antibacterial agents, antineoplastics and cytotoxics, antiprotozoal,
antiparasitic, antivirals, antiretrovirals, antituberculosis medicines,
contraceptives, and vaccines. These summarises are produced following
a pragmatic and simplified methodology that provides technical support
to policymakers in the decision making process. The integration of
these summaries into PRAIS facilitates access to reliable knowledge and
promotes rational use of drugs and governance of health technologies
from a public health perspective. We plan to discuss how the Summary
of Findings tables could ease the process of evidence synthesis
by identifying patient important outcomes and the presentation of
systematic reviews results.
IRIS—a tool for prioritising guidance
development at the European Centre for Disease
Prevention and Control (ECDC)
de Carvalho Gomes H, Jansen A, Kramarz P, Giesecke J
European Centre for Disease Prevention and Control, Sweden
Background: ECDC provides independent scientific expertise to
EU bodies and Member States (MS) in the field of communicable
diseases. Identifying topics of relevance for the European community
in order to use the available limited resources in an efficient and
equitable way becomes even more important in view of economic
constraints. Objectives: The aim was to develop a priority setting
framework that ensures transparency throughout the whole process
and the involvement of stakeholders. Methods: A literature review
was performed to identify examples of prioritisation exercises and
guidelines. 155 publications were assessed in view of pre-defined
objectives and 27 were used to inform the ECDC prioritisation
framework IRIS. A matrix including four priority categories and three
indicators each was created in collaboration with ECDC’s Advisory
Forum (AF) (Tables). A commercially available survey tool was
adapted to IRIS, piloted and revised, and firstly fully applied within
the planning process for the work plan 2014. In a first step, each
indicator was weighted. Project proposals provided by the Centre’s
disease programmes were then ranked against the indicators by
Cochrane Database Syst Rev Suppl 1–212 (2013)
the AF members. Results: 16/35 AF members participated in the
weighting exercise, and 27/35 in the prioritisation of project proposals.
However, the variation obtained in the weighting exercise was very
wide with only a small preference given to ‘Saves MS resources when
coordinated/performed at EU level’. 27 project proposals were then
ranked against the weighted indicators. Within the possible range from
−12 (no priority) to +12 (highest priority), the seven highest ranked
projects were between 6 and 7. Only one project was ranked below
zero. Conclusions: The wide variation of results obtained during
the weighting of the indicators most probably reflects the diversity of
interests and needs in the different MS, although the low participation
does not allow final conclusions. The participation in the prioritisation
of project proposals was higher and the feedback received with regard
to usefulness and feasibility generally positive. The objectives of
developing an easy-to-use and transparent tool were met, although
the right balance between individual MS and European level needs
remains a challenge.
Attachments: IRIS - attachment (2 tables).pdf
Oral Session O1.09: Knowledge
Translation and Communicating the
Evidence—Session 1
Workforce training in evidence-informed
decision making
Waters E, Armstrong R, Pettman T, Doyle J, Burford B
Cochrane Public Health Group, Australia
Background: Whilst public health practitioners and policymakers
ideally should be using evidence to inform their decision-making, a
range of barriers exist in practice, including time to access evidence,
skills, and organisational culture. The Cochrane Public Health Group
(CPHG) has instigated a range of knowledge translation (KT) strategies,
including workforce development (training), to encourage utilisation of
its reviews in public health decision-making. The CPHG has delivered
tailored short-courses in evidence-informed public health (EIPH) since
2005 in collaboration with others. Whilst training programs that aim to
increase knowledge and skills for evidence-informed decision-making
show promise, few rigorous evaluations are available to determine
their effectiveness. Objectives: To describe the methods and results
of an ongoing evaluation to understand short-term and longer-term
impacts of workforce EIPH training. Methods: Traditionally CPHG have
evaluated participants’ experiences directly following each EIPH course.
A more comprehensive pre-post evaluation to assess knowledge,
confidence and attitudes was undertaken in 2012. Survey instruments
were developed to suit the EIPH teaching process. Participants
were invited to complete a pre and post impact evaluation survey
within a week prior and immediately after each course was delivered.
Participants were also invited to respond to a longitudinal assessment
after 6 months to assess sustainability of training outcomes. Results:
In addition to consistently high ratings of the course relevance, ease
of understanding content, and facilitators’ performance, improvements
across five core domains of evidence-informed practice have been
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
observed from evaluation data collected pre and post training courses
delivered in 2012. Data analysis is underway and longitudinal
assessment is ongoing. This presentation will report results on
participant experiences, and changes in confidence and attitudes
to finding and utilising evidence to inform programs and policies.
Conclusions: Evaluation of EIPH training will build knowledge about
whether this strategy is effective for enhancing the use of evidence in
public health decision-making.
Dietitian’s perspectives of systematically
reviewed interventions enhancing adherence to
dietary advice for preventing and managing
chronic diseases in adults: a Delphi study
Desroches S1 , Bissonnette-Maheux V2 , Lapointe A2 , Deschênes S2 ,
Légaré F3 , Gravel K2 , Thirsk J4
Institute of Nutrition and Functional Foods, Laval University, Quebec
City, Quebec, Canada;CHU Research Center, Quebec University Hospital
Center–Hospital St-François d’Assise, Quebec City, Quebec, Canada;
Institute of Nutrition and Functional Foods, Laval University, Quebec
City, Quebec, Canada; 3 Department of Family and Emergency Medicine,
Laval University, Quebec City, Quebec, Canada; CHU Research Center,
Quebec University Hospital Center–Hospital St-François d’Assise, Quebec
City, Quebec, Canada; 4 Practice Based Evidence in Nutrition, Dietitians of
Canada, Canada
Background: Adoption of a healthy diet has been identified
as the cornerstone for preventing and managing several chronic
diseases. However, adherence to dietary advice is suboptimal,
thus potentially hampering the effectiveness of dietary interventions.
Objectives: To assess dietitians’ perspectives on the importance
and applicability of interventions enhancing adherence to dietary
advice for preventing and managing chronic diseases in adults in the
Canadian context. Methods: By conducting a Cochrane systematic
review, we identified eight promising interventions for enhancing
adherence to dietary advice: telephone follow-up, feedback based
on self-monitoring, portion sizes, exchange lists, individualized menu
suggestions, behavioural contract, watching a video, and multiple
interventions. Expert dietitians were recruited to participate to a
Delphi study through an invitation email sent to various chronic
diseases-related networks from Dietitians of Canada. They were
invited to participate by completing an electronic questionnaire asking
them to rate the importance and applicability on a seven-point Likert
scale of each of these eight specific interventions in their practice.
Results: Among the 32 dietitians who completed the three-round
Delphi study, four interventions showed a strong consensus using
a ≥ 75% level of agreement. Among those, feedback based on
self-monitoring (6.97 ± 0.18 and 6.72 ± 0.46; means ± SD
for importance and applicability respectively), multiple interventions
(6.94 ± 0.25 and 6.81 ± 0.40), and portion sizes (6.69 ± 0.54
and 6.75 ± 0.51) were found important and applicable, while video
(4.75 ± 0.67 and 4.84 ± 0.72) was found neither important nor
unimportant and neither applicable nor inapplicable. Conclusions:
These findings could guide the development of educational training
sessions for dietitians to help them provide interventions that are
likely to be adhered to by their patients but also that are applicable
to their practice. Further studies should validate these findings with
Cochrane Database Syst Rev Suppl 1–212 (2013)
patients to assess whether these interventions are also relevant to their
reality. (Supported by a Knowledge synthesis grant from the Canadian
Institutes of Health Research.)
Communicating Cochrane Reviews: experiences
with a review specific dissemination strategy
Jones B, Stephani A, Hinds P, Smith H, Garner P
Cochrane Infectious Diseases Group Editorial Base, Liverpool School of
Tropical Medicine, UK
Background: Effective communication of Cochrane Reviews helps
people use our reviews to identify research priorities, to teach, to help
clinical decision making, and to contribute to policy. What is more, if
academics find the reviews helpful, they may cite them. The Cochrane
Infectious Diseases Group (CIDG) has developed a Review Specific
Dissemination Strategy that targets stakeholders on a case by case
basis. Objectives: To report on our Review Specific Dissemination
Strategy, and reflect on lessons learnt. Methods: The Editorial Team
assess each review at the time of submission against a checklist of
stakeholder categories such as ‘multilateral organizations’, ‘clinical
specialists’, or ‘the general public’. Within each we might identify
specific categories, organizations, and individuals, and decide on our
dissemination strategy for each. In addition, we identify the lead
authors of included trials published in the last 10 years and let them
know the review has been published. For reviews that have high
potential for impact, we may seek ways to ensure pickup by blogs or
in editorials. Results: We have been applying this approach for the
last 8 years. We will present case studies of review specific strategies,
an analysis of the various strategies used across reviews, and report
on the experiences emailing individual trial authors. We will also
provide examples of particular impact with the public, medical press
and other stakeholders. Conclusions: Cochrane Review Groups,
with their knowledge of stakeholders in their topic areas, can develop
and implement systematic, thoughtful review specific dissemination
strategies. These could potentially increase the impact of Cochrane
Hitting the right target—disseminating
Cochrane Review findings for greatest impact
Jones K, Doyle J, Pettman T, Armstrong R, Waters E
Cochrane Public Health Group, Australia
Background: Knowledge translation and exchange (KTE) strategies
aim to support evidence informed decision-making. Such strategies
look to bridge the gap between research producers and end-users of
research, building interactive communicative relationships between the
two groups. The Cochrane Public Health Group (CPHG) produces
reviews of a range of interventions focused on the social and
structural determinants of health at population-levels. CPHG has
used a variety of KT strategies, including stakeholder identification
and engagement, knowledge brokering, targeted dissemination and
workforce development to ensure that CPHG reviews are useful and
utilised in public health decision-making. As new Cochrane Reviews
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
are published, KTE strategies are required to ensure findings and
recommendations from each review reach the people who need
to act upon them. One such strategy focuses on dissemination
through strategic communication. Objectives: CPHG has sought to
understand how review groups can support authors develop and deliver
dissemination strategies; ensuring findings and recommendations of
reviews are targeted towards appropriate audiences and messages
are tailored accordingly. Methods: Working with review authors,
CPHG developed dissemination strategies addressing communication
objectives. Extensive stakeholder lists were developed to determine key
individuals and organisations that each review and its recommendations
were relevant to. A variety of communication tools were developed to
engage with these audiences. Results: Using case studies of recently
published CPHG reviews; the process of developing and implementing a
dissemination strategy will be discussed. Experiences will be described
highlighting how review groups can support authors. Observations
of the value of targeting dissemination to relevant stakeholders
will also be reported. Conclusions: Dissemination strategies for
Cochrane Reviews require time, resources and appropriate skillsets. By
delivering well-considered strategies, the reach of review findings can
be expanded and authors can develop communicative relationships
with key stakeholders. These relationships can promote ongoing KTE,
including the identification and funding of priority reviews.
Oral Session O1.10: Outcomes
Searching for black swans: critically assessing
surrogate markers in Cochrane Reviews
Tejani AM1 , Wright JM1 , Musini V1 , Bassett K1 , Perry T1 , Mintzes B1 ,
Jauca C1 , Hinch M2
Therapeutics Initiative, University of British Columbia, Canada; 2 Faculty
of Pharmaceutical Sciences , University of British Columbia, Canada
Background: The US Food and Drug Administration defines a
surrogate as ‘a laboratory measurement or physical sign that is used
in therapeutic trials as a substitute for a clinically meaningful end
point that is a direct measure of how a patient feels, functions,
or survives. Surrogate markers are expected to predict the effect
of therapy’. Examples of surrogate markers are LDL cholesterol,
glycated hemoglobin, and blood pressure. Despite their frequent use
in healthcare intervention research, surrogate markers are not always
useful as efficacy measures and can be misleading. Surrogate marker
evidence appears in many Cochrane Reviews but is not always critically
assessed. Objectives: To provide an understanding of the logic and
systematic framework that is required to critically assess surrogate
markers when used as measures of efficacy in healthcare intervention
reviews. Methods: This presentation will introduce the concept of
falsifiability (i.e. looking for ‘black swans’) and the logic required
to assess the relationship between surrogate markers and the risk
of morbidity and/or mortality as it relates to healthcare intervention
efficacy. Participants will be given practical exercises to help answer
the following questions when faced with surrogate marker evidence
in the process of conducting a Cochrane Review: does a ‘worsening’
surrogate marker (e.g increasing LDL cholesterol) indicate an increased
risk of morbidity and mortality?; is it universally true that ‘improving’
Cochrane Database Syst Rev Suppl 1–212 (2013)
the surrogate marker (e.g. lowering LDL) with a intervention leads to
an improvement in a clinical condition or a decreased risk of M/M?; can
we use surrogate markers to monitor the effect of interventions (i.e.
if a surrogate marker is ‘improving’, does that mean the medication
is working)? Participants will then be given guidance on including
critical assessments of all surrogate marker evidence in their Cochrane
Reviews. For readers of reviews, guidance will be given on interpreting
this type of assessment.
Variation in outcome measure usage across
Cochrane Systematic Reviews related to three
common eye conditions
Saldanha I, Wang X, Li T, Dickersin K
Cochrane Eyes and Vision Group, USA
Background: For meaningful comparisons of interventions across
systematic reviews (SRs), including network meta-analyses, outcome
measures in SRs should be consistently and clearly specified. Previous
research has demonstrated substantial variation in specification of
outcome measures across SRs addressing glaucoma. Objectives: To
assess variation in outcome measure specification across Cochrane
SRs addressing three common eye conditions: age-related macular
degeneration (AMD), cataract, and diabetic retinopathy (DR).
Methods: We first determined all outcomes assessed across the SRs
addressing these conditions, and ranked the outcomes by frequency.
Two abstractors independently extracted information from the methods
sections of these SRs about the three most frequently assessed
outcomes. For each outcome, we extracted the measure(s) used in the
analysis, whether continuous (e.g., mean visual acuity at a follow-up
time point) or discrete (e.g., percent of participants falling into a
pre-specified category). Results: We identified 36 completed Cochrane
SRs and protocols addressing AMD (n = 16), cataract (n = 16), and
DR (n = 4). The most frequent outcomes were visual acuity (n = 35),
quality-of-life (n = 32), and contrast sensitivity (n = 13). A variety
of outcome measures were specified (Table). For example, for AMD,
8/16 SRs assessing visual acuity used mean visual acuity at a follow-up
time point, 4/16 used mean change in visual acuity from baseline to a
follow-up time point, 5/16 used number/percent of participants falling
into pre-specified categories, and 6/16 reported that they would analyze
visual acuity as provided in included studies (Box). Outcome measures
were often not specified, for example, in 6/9 SRs on AMD assessing
contrast sensitivity and in all 4 SRs on DR assessing quality-of-life.
Conclusions: While certain outcomes (e.g., visual acuity) were
assessed frequently in SRs, specific outcome measures were used in
various ways and were often not specified. SR authors should be aided
by review group editors to be more consistent and explicit in outcome
measures used.
Attachments: Outcomes Abstract-Consistency 2013 Tables.pdf
Effect sizes in child health and association with
unreported outcomes
Hartling L, Fernandes R, Dryden D, Vandermeer B
University of Alberta, Canada
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Background: Research has shown that half of randomized controlled
trials (RCTs) included in Cochrane systematic reviews do not contribute
to the meta-analysis of patient-important outcomes. Further, previous
research showed an inverse relationship with effect size and the
proportion of RCTs contributing to the meta-analysis. One potential
explanation for this finding is selective outcome reporting. Objectives:
To describe effect sizes in pediatric RCTs and the association between
the proportion of relevant RCTs contributing to a meta-analysis and
the magnitude of effect. Methods: Using the Cochrane Database
of Systematic Reviews we identified systematic reviews relevant to
child health. We identified the primary outcome for each systematic
review and extracted data when a meta-analysis had been conducted
(n = 432). We calculated an overall effect size for meta-analyses
based on the proportion of relevant RCTs included using categories
from previous research: < 20, 20 to < 40, 40 to < 60, 60 to < 80,
≥ 80%. Results: The median effect size across all meta-analyses was
0.35 (IQR 0.15,0.59) which is considered small to moderate. The mean
proportion of relevant studies contributing to a meta-analysis was 0.49
(95%CI 0.47, 0.52). There was no association between effect sizes and
the proportion of RCTs contributing to a meta-analysis. However, effect
sizes were associated with the size of the meta-analysis with smaller
effect sizes seen with larger meta-analyses (i.e., smaller confidence
intervals). Conclusions: We found an association between effect sizes
and the size of meta-analysis. This effect is similar to that seen for
publication bias at the individual study level. Caution should be taken
when interpreting meta-analyses based on small numbers of studies
and patients, which is consistent with the GRADE recommendations for
considering imprecision. Effect sizes were small to moderate overall.
These data may provide a guide for sample size calculations in future
pediatric trials.
Making results of patient-reported outcomes
Guyatt GH1 , Patrick D2
McMaster University, Canada; 2 University of Washington, USA
Background: Patient-reported outcomes include reports of symptoms,
health-related quality of life, and patient satisfaction. In some areas,
patient-reported outcomes are typically primary outcomes; in others,
they complement measures of morbidity and mortality. Patient-reported
outcomes often present unique challenges in interpretation faced to
a considerably lesser extent by other outcomes. Many of those who
use Cochrane Reviews will be unfamiliar with the instruments used
to measure patient experience, and they will find the significance
of the differences expressed in natural units (the pooled differences
between intervention and control was five units on instrument x)
obscure. The challenge is compounded when several instruments using
different units measure the same construct requiring standardized units
for aggregation across studies. Objectives: The presentation will
describe the tools to make patient-reported outcomes interpretable
to the audiences of their Cochrane Reviews. This presentation
will address the methods available for making patient-reported
outcomes readily understandable to the audience of Cochrane Reviews.
Concepts that will be introduced include the minimal important
difference (the smallest difference that would motivate a patient
to use an intervention), the dichotomization of outcomes (e.g.
Cochrane Database Syst Rev Suppl 1–212 (2013)
proportion of patients who achieve a minimal important difference),
and alternatives to the standardized mean difference as an approach
to aggregating across different instruments measuring the same
Oral Session O1.11: Qualitative
Integrating findings from a Cochrane Systematic
Review of effectiveness and a Cochrane
qualitative evidence synthesis: methods
and lessons learnt
Glenton C1 , Lewin S2 , Colvin C3 , Carlsen B4 , Noyes J5 , Swartz A6 ,
Rashidian A7
Norwegian Branch of the Nordic Cochrane Centre, Norwegian Knowledge
Centre for the Health Services, Norway; 2 Norwegian Satellite of the
Cochrane EPOC Group, Norwegian Knowledge Centre for the Health
Services and MRC South Africa, Norway; 3 Centre for Infectious Disease
Epidemiology and Research (CIDER), University of Cape Town, South Africa;
Uni Rokkan Centre, Norway; 5 University of Bangor, UK; 6 University
of Cape Town, South Africa; 7 National Institute of Health Research
and School of Public Health, Tehran University of Medical Sciences,
Background: There is a growing interest globally and within the
Cochrane Collaboration in conducting qualitative evidence syntheses
to complement reviews of intervention effectiveness. Qualitative data
synthesis can be used, for instance, to explore diversity in populations
and interventions included in reviews of effectiveness and to shed light
on processes behind the results of these reviews. However, there is
very little knowledge or experience on how to integrate these two
sources of evidence. Objectives: To describe an approach used
to integrate evidence from a Cochrane Review of the effectiveness
of lay health worker programmes with evidence from a Cochrane
qualitative evidence synthesis exploring barriers and facilitators to the
implementation of these programmes. Methods: Based on the draft
qualitative evidence synthesis, we produced a summary of qualitative
findings table of factors that appear to affect lay health worker
programme implementation. We are currently using this summary of
findings to build a logic model that indicates how these factors might
relate to each other and how they might lead to specific lay health
worker programme outcomes, such as changes in health care utilization
or health outcomes. Our next step is to examine the effectiveness
review to see whether this includes outcomes that correspond to the
various stages of the model, and to identify where we have gaps in
both outcome assessment and evidence regarding specific explanatory
pathways within the model. Results: In our presentation we will
describe our experiences when moving from the summary of qualitative
findings table to the logic model, including the challenges encountered
in linking together specific qualitative findings in a relational model; in
the development of methods for indicating the certainty of each finding
or factor, as well as the certainty of the relationship between each
factor; and in bringing together the logic model and the effectiveness
review data.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Assessing how much certainty to place
in findings from qualitative evidence syntheses:
the CerQual approach
Lewin S1 , Glenton C2 , Munthe-Kaas H3 , Carlsen B4 , Colvin C5 , Noyes J6 ,
Rashidian A7
1 Norwegian Knowledge Centre for the Health Services and MRC South
Africa, Norway; 2 Norwegian Branch of the Nordic Cochrane Centre,
Norwegian Knowledge Centre for the Health Services, Norway; 3 Norwegian
Knowledge Centre for the Health Services, Norway; 4 Uni Rokkan Centre,
Norway; 5 Centre for Infectious Disease Epidemiology and Research (CIDER),
University of Cape Town, South Africa; 6 Centre for Health-Related Research,
Bangor University, UK; 7 National Institute of Health Research and School
of Public Health, Tehran University of Medical Sciences, Iran
Background: Qualitative evidence syntheses are increasingly used
to bring together findings from qualitative studies. However, it is
difficult to use these findings alongside Cochrane effects reviews, or
to inform policy development, because methods to assess how much
certainty to place in these synthesis findings are poorly developed.
Objectives: To describe a novel approach for assessing how much
certainty (or confidence) to place in the findings of qualitative evidence
syntheses. Methods: The certainty of the qualitative evidence
(CerQual) approach was developed through review of existing tools in
this area; discussions within a working group; and piloting of the tool on
three qualitative evidence syntheses. Results: The CerQual approach
bases assessments of certainty on two factors: the methodological
limitations of the individual studies contributing to a review finding
and the coherence of each review finding. Methodological limitations
are assessed using a quality-assessment tool for qualitative studies.
Coherence is assessed by looking at the extent to which it is possible
to identify a clear pattern across the individual study data. Coherence
may be further strengthened if the individual studies contributing
to the finding are drawn from a wide range of settings. We
propose three levels of certainty: high, moderate and low. Findings
drawn from generally well-conducted studies with few methodological
limitations—and showing high levels of coherence—are rated as ‘high’
certainty. Findings are assessed as ‘moderate’ certainty where there
are concerns regarding either the methodological limitations of the
studies or the coherence of the review finding. Where the studies have
important methodological limitations and there are concerns regarding
the coherence of the review finding, the certainty is assessed as ‘low’.
Conclusions: The CerQual approach provides a transparent method
for assessing the certainty of evidence from qualitative syntheses and
may facilitate the use of these findings alongside Cochrane Reviews of
Using qualitative research to explore
heterogeneity in a Cochrane Review
Glenton C1 , Carlsen B2 , Flottorp S3 , Jamtvedt G3
1 Norwegian branch of the Nordic Cochrane Centre, Norway; 2 Uni
Rokkan Centre, Norway; 3 Norwegian Knowledge Centre for the Health
Services, Norway
Background: The Cochrane Handbook suggests several ways in
which qualitative research can contribute to Cochrane Reviews.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Supplemental guidance to the Handbook suggests that one way
of doing this is by providing information, for instance on diversity in
population characteristics, that can contribute to decision making about
subgroup analyses, and thereby offer explanations for heterogeneity
on study findings. Objectives: To describe how a systematic
review of qualitative research was used to explore heterogeneity
in a Cochrane Review. Methods: The Cochrane Review on the
effects of audit and feedback on professional practice and healthcare
outcomes offers a large body of evidence. However, the included
studies showed large variation in effectiveness. When updating the
review, the authors therefore explored factors that might explain
this heterogeneity and provide a basis for exploratory analysis. A
systematic review of qualitative research exploring GPs’ attitudes
to clinical practice guidelines concluded that GPs’ reasons for not
following guidelines differed according to whether the guideline in
question was prescriptive, in that it encouraged a certain type of
behaviour or treatment, or proscriptive, in that it discouraged certain
treatments or behaviours. These findings were used as a basis for
exploratory analysis in the Cochrane Review. The authors examined
the direction of change required in each trial, i.e. whether feedback
aimed to increase or decrease current behaviour. In addition, four other
intervention characteristics (format, source, frequency and instruction
for improvement/action plan) were identified through an additional
meta-analysis and qualitative research, from theories for change
(Control Theory, Feedback Intervention Theory) and common sense.
Results: The direction of change required, along with the other four
characteristics of the intervention, helped explain variation in effects
(expected difference in adjusted RD = 6%). Conclusions: This
experience supports the suggestion that qualitative data may provide
a useful source of information when preparing systematic reviews of
Enhancing transparency in reporting the
synthesis of qualitative research: the ENTREQ
statement—discussion and debate
McInnes E1 , Tong A2 , Flemming K3 , Oliver S4 , Craig J2
1 Australian Catholic University, Australia; 2 University of Sydney, Australia;
The University of York, UK; 4 University of London, UK
Oral Session O1.12: Diagnostic Test
Accuracy Review Methods
Estimating a test’s accuracy using tailored
meta-analysis—the potential of setting-specific
data in aiding study selection
Willis B1 , Hyde C2
1 University of Birmingham, UK; 2 University of Exeter, UK
Background: The decision on whether a diagnostic test accuracy study
is applicable to practice is largely a qualitative process. Consequently,
the summary estimates provided by meta-analysis may be, in some
cases, completely inaccurate for a particular setting. Objectives: To
develop a new method in which the selection of applicable studies is
based on more quantitative criteria. Methods: It is shown how routine
data collected on the test positive rate and prevalence from the setting
of interest may be used to define an ‘applicable region’ for studies
in ROC space. Studies are selected based on both qualitative criteria
and the probability that their study estimate for the false positive
rate and sensitivity arose from their parameters lying in the applicable
region. Three methods for calculating these probabilities are developed
and used to tailor the selection of studies for meta-analysis. The
Pap test applied to the NHS cervical screening programme provides
a case example. Results: The original meta-analysis included 68
studies. In contrast, tailoring the selection using NHS data resulted
in at most 17 studies being considered plausible for the NHS. From
conventional meta-analysis the sensitivity and specificity for the Pap
test were estimated to be 72.8% (95% CI:65.8–78.8) and 75.4%
(95% CI:68.1–81.5) compared with 50.9% (35.8–66.0) and 98.0%
(95% CI: 95.4–99.1) from tailored meta-analysis using a binomial
method for selection. The positive likelihood ratio increased from 3.0
(95% CI:2.4–3.7) to 25.6 (95%:10.1–65.0) between the conventional
and tailored meta-analysis. Thus, for a background prevalence for CIN
1 of 2.2%, the post-test probability for CIN 1 increases from 6.2 to
36.6%. Conclusions: Tailored meta-analysis provides a method for
augmenting study selection based on their applicability to a setting. As
such the summary estimate is more likely to be plausible for a setting
and could improve diagnostic prediction in practice.
Attachments: Figure 1.pdf, AR2.pdf
Background: The ENTREQ statement was developed to assist
reviewers report the stages most commonly associated with the
synthesis of qualitative health research. It consists of 21 items, has
undergone some pilot testing, been published in a peer-reviewed
journal and posted on the EQUATOR web-site. Objectives: (i) To
obtain feedback on the ENTREQ statement (Enhancing Transparency
in REporting the synthesis of Qualitative research; (ii) To explore and
debate issues related to the 21 items in the statement; (iii) To obtain
general consensus on the included items. Description: However,
the synthesis of qualitative research is an evolving methodological area
and some steps in qualitative synthesis such as quality appraisal have
been contested. This presentation will present the development of
ENTREQ to an audience with an interest in qualitative synthesis, and
discuss and debate these issues. The obtained feedback will inform the
next phase of development of the ENTREQ statement.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Reporting and methods in systematic reviews
of comparative accuracy
Takwoingi Y, Riley R, Deeks J
University of Birmingham, UK
Background: Systematic reviews in which the accuracy of two or
more tests are compared can provide evidence to support the clinical
validity of each test and aid test selection. Because test evaluation
is often limited to the assessment of test accuracy, it is vital that in
the rapidly expanding evidence base, reviews and meta-analyses that
compare the accuracy of multiple tests are conducted and reported
appropriately to avoid misleading conclusions and recommendations.
Objectives: To provide a descriptive survey of current practice
Cochrane Database Syst Rev Suppl 1–212 (2013)
with a view to identifying good practice and problems, and to
make suggestions for the improvement of future reviews. Methods:
Systematic reviews of test accuracy in the Database of Abstracts of
Reviews of Effects published between 1994 and October 2012 were
identified. We placed no restrictions on language of publication, test
type, purpose of the test (screening, staging, diagnostic, etc), setting,
or disease area. We extracted information on the target condition,
patient population, tests evaluated, purpose of the tests, analysis
methods and reporting characteristics of each review. Descriptive
statistics were computed. We also compared reporting characteristics
with the most relevant reporting guideline—the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.
Results: We included 248 reviews that evaluated the accuracy of
two or more tests. The reviews contained 6915 studies (studies
may appear in more than one meta-analysis). Initial results indicate
that tests are not often formally compared in the same meta-analysis
but instead a separate meta-analysis is performed for each test and
comparisons are made informally by comparing summary estimates
between meta-analyses. Data analysis is still ongoing and results will
be available for presentation at the colloquium. Conclusions: Initial
findings highlight the need for better understanding of methods and
strategies for comparing tests in meta-analysis and specific guidance
for reporting reviews of comparative accuracy.
Why do diagnostic tests differ in performance
between different settings?
Willis B1 , Hyde C2
University of Birmingham, UK; 2 University of Exeter, UK
Background: Whether the findings from a diagnostic test accuracy
(DTA) study may be applied to another setting is important to
evidence-based practice. First, the study should have internal validity:
the results are a true representation of the test’s performance within
the study setting. However, internal validity does not beget external
validity, where the results may be generalised to other clinical settings.
Further, we know from meta-analyses that widespread variation in DTA
studies is commonplace. Objectives: To identify the different sources
of variation between DTA studies before considering the implications
for diagnostic research. Methodology: The literature was searched for
methodological and primary studies that evaluated a test’s performance
over different settings. Results: DTA studies are affected by both
artefactual and real variation. Predominantly, in artefactual variation,
the design differs between studies and this affects the internal validity
of results. However, even ‘internally valid’ studies evaluating the same
test and target disorder may report different test accuracies due to
there being real variation. This has three sources.The test’s execution
may vary between studies due to poor reliability, cognitive errors by the
operators and changes in prevalence. Similarly, cognitive biases and the
disease prevalence may affect the test’s threshold. Patient spectrum,
which reflects the mix of patients with and without disease, may
also change between studies. Conclusion: A number of conditions
need to be met if the results of a DTA study are to be applicable in
practice. Although it is unclear to what extent these conditions vary in
practice, there is an obvious difficulty in ensuring they are similar to
the reported study. This has implications for the concept of external
validity. If test settings, test execution, and thresholds do vary in
practice then designing a study to be applicable in multiple settings
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
may be unattainable in large number of cases.
Attachments: Figure 1.pdf
Enhancing the acceptance and implementation
of GRADE summary of findings tables
for evidence about diagnostic tests
Mustafa RA1 , Wiercioch W2 , Brozek JL3 , Lelgemann M4 , Buehler D5 , Garg
AX6 , Bossuyt PM7 , Schünemann HJ8
1 McMaster University, Canada, University of Missouri-Kansas City, USA;
McMaster University, Canada; 3 McMaster University, Canada; 4 Medical
Service of the Central Federal Association of Health Insurance Funds,
Germany; 5 GKV-Spitzenverband, Germany; 6 University of Western Ontario
and McMaster University, Canada; 7 Amesterdam Medical Center, The
Netherlands; 8 McMaster University, Canada
Background: The Grading of Recommendations Assessment,
Development and Evaluation (GRADE) Working Group developed
Summary tables adapted to summarise and present evidence from
diagnostic test accuracy (DTA) systematic reviews. Objective: To
develop guidance on what information to include in these summary
tables and to determine the best method(s) for presentation for different
end users, including healthcare providers, systematic reviewers and
guideline developers. Methods: We presented a number of alternative
summary tables to different users of the Cochrane library including
authors of diagnostic systematic reviews, physicians and guideline
developers. We conducted questionnaires and one-on-one user
testing interviews with target end users. We presented printed
copies of summary tables and asked open-ended and seven-point
Likert-scale questions to obtain information about users’ understanding
and preferences. Results: All participants (n = 60) agreed that
using summary tables to present results of DTA reviews is helpful.
Presentation of several disease prevalence values was identified as a
source of confusion. There was an overall preference for placement
of sensitivity and specificity values inside summary tables to allow
making a link to individual test results (TP, FN, TN, FP). A third of
the participants read explanatory content in table footnotes. Two
thirds of the participants noted that additional data, including adverse
effects, costs, and treatment consequences, would be helpful for
making appropriate conclusions and decisions about diagnostic tests.
Conclusion: As results of DTA reviews are conceptually complicated,
presenting the data in a clear, comprehensive, comprehensible way
that is tailored to different end users is critical. To respond to different
end users needs, we are developing a 3-layer approach, with varied
content in summary tables.
Oral Session O1.13: Evidence
Evidence packaging to support public
Lavis JN1 , Abelson J2
1 McMaster Health Forum, Canada; 2 McMaster University, Canada
Cochrane Database Syst Rev Suppl 1–212 (2013)
Background: The use of deliberative dialogues to address pressing
health challenges has generated a lot of interest in recent years as
a promising way to engage citizens and stakeholders. Deliberative
dialogues are usually informed by a pre-circulated evidence brief
that mobilizes relevant research evidence in order to spur discussion
among participants about problems, policy options and implementation
considerations. While there is an increasing body of evidence regarding
policymakers’ preferences regarding the formats used for evidence
packaging, little is known about how to effectively package research
evidence to support deliberations with the public. Objectives: Drawing
from the McMaster Health Forum’s experiences with stakeholder
dialogues and citizen panels, this presentation aims to: (1) introduce
the evaluation platform that will be launched to assess citizens’ views
and experiences about evidence packaging as part of the Forum’s citizen
panel program; (2) identify criteria to guide the preparation of briefs to
support public deliberation; and (3) compare features of briefs targeted
to policymakers and the public. Methods: The evaluation platform was
developed, and a preliminary list of normative criteria identified, based
on a review of the public literature on citizen engagement evaluation
research (both empirical and non-empirical) and following consultation
with selected organizations that have long-standing experience with
citizen engagement. These criteria will be compared with those used to
appraise the effective packaging of research evidence for policymakers.
Results: The current state of the citizen engagement evaluation
research reveals that a key challenge is to provide the right balance
of research evidence to support the creation of an ‘expertise space’
for citizens. Conclusions: Cochrane Reviews constitute an invaluable
source of research evidence on pressing health challenges. This project
offers a natural laboratory to learn about the citizens’ views about the
most effective way to package research evidence in order to support
and nurture public deliberation.
Comparison of alternative evidence summary
and presentation formats in clinical guideline
development: a mixed-method study
Opiyo N1 , Shepperd S2 , Musila N1 , Allen E3 , Nyamai R4 , Fretheim A5 ,
English M1
Health Services Research Group, KEMRI-Wellcome Trust Research
Programme, Kenya; 2 Department of Public Health, University of Oxford, UK;
3 Department of Medical Statistics, London School of Hygiene and Tropical
Medicine, UK; 4 Division of Paediatrics, Ministry of Medical Services, Kenya;
International Health Care Unit, Norwegian Knowledge Centre for Health
Services, Norway
Background: Best formats for summarising and presenting evidence
for use in clinical guideline development remain less well defined.
Objectives: We aimed to assess the effectiveness of different
evidence summary formats for use in clinical guideline development.
Methods: Healthcare professionals attending a one-week Kenyan,
national guideline development workshop were randomly allocated to
receive evidence packaged in three different formats: systematic reviews
(SRs) alone, systematic reviews with summary-of-findings tables (SR
with SoF tables), and ‘graded-entry’ formats (a ‘front-end’ summary
and a contextually framed narrative report plus the SR). The influence of
format on the proportion of correct responses to key clinical questions,
the primary outcome, was assessed using a written test. The secondary
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
outcome was a composite endpoint, measured on a five-point scale,
of the clarity of presentation and ease of locating the quality of
evidence for critical neonatal outcomes. Interviews conducted within
2 months following completion of trial data collection explored panel
members’ views on the evidence summary formats and experiences
with appraisal and use of research information. Results: 65 (93%)
of 70 participants completed questions on the pre-specified outcome
measures. There were no differences between groups in the odds
of correct responses to key clinical questions. ‘Graded-entry’ formats
were associated with a higher mean composite score for clarity and
accessibility of information about the quality of evidence for critical
neonatal outcomes compared to systematic reviews alone (adjusted
mean difference 0.52, 95% CI 0.06–0.99). There was no difference
in the mean composite score between SR with SoF tables and SR
alone. Findings from interviews with 16 panelists indicated that short
narrative evidence reports were preferred for the improved clarity
of information presentation and ease of use. Conclusions: Our
findings suggest that ‘graded-entry’ evidence summary formats may
improve clarity and accessibility of research evidence in clinical guideline
A systematic review of the use of narrative
storytelling and visual arts-based approaches as
knowledge translation tools in healthcare
Scott SD, Brett-MacLean P, Archibald M, Albrecht L, Flynn R, Hartling L
University of Alberta, Canada
Background: The arts are powerful, accessible forms of communication that have the potential to impart knowledge by attracting interest
and developing meaningful connections. Knowledge translation aims
to reduce the ‘evidence-practice’ gap by developing, implementing and
evaluating strategies designed to enhance awareness and promote
behaviour change congruent with research evidence. Increasingly,
innovative tools such as narrative storytelling and other arts-based
interventions are being investigated to bridge the research-practice
gap. This study is the first to systematically identify and synthesize
current research on narrative storytelling and visual art to translate
and disseminate health research. Methods: A health research
librarian developed and implemented search strategies designed to
identify relevant evidence. Studies were included if they were
primary research employing narrative storytelling and/or visual art
as a knowledge translation strategy in healthcare. Two reviewers
independently performed study selection, quality assessment, and
data extraction using standard forms. Disagreements were resolved
through discussion or third party adjudication. Data was grouped and
analyzed by research design, type of knowledge translation strategy
(i.e., narrative storytelling or visual arts-based approach), and target
audience. Currently, an overall synthesis across all included studies is
ongoing to determine the success of narrative storytelling and visual arts
as translation and dissemination tools in health research. Discussion:
Narrative and arts-based approaches are innovative tools that have
the potential to faciliate dissemination and stakeholder involvement,
while simultaneously crossing boundaries of literacy and language.
The findings from this research project will describe the ‘state of the
science’ regarding the use of narrative storytelling and visual art as
tools to translate and disseminate health research. We intend to share
Cochrane Database Syst Rev Suppl 1–212 (2013)
results of this review and reflect on the potential for these tools to
bridge the research-practice gap.
Cochrane vignettes: use of Cochrane Reviews in
a Cochrane learning continuing medical
education program
Moja L1 , Becker L2 , Bjerre LM3 , Chande N4 , Grad R5 , Kwag K6 , Leontiadis
GI7 , Lewin G8 , Moayyedi P7 , Ni Ogain O9 , Pentesco-Gilbert D10 , Pussegoda
K11 , Sapko MT12 , Schaafsma ME11 , Tugwell P13 , Ueffing E11 , Urquhart
B14 , Tovey D9 , Grimshaw JM11
University of Milan, IRCCS Orthopedic Institute Galeazzi; 2 Department
of Family Medicine, SUNY Upstate Medical University; 3 Department of
Family Medicine, University of Ottawa; Department of Epidemiology and
Community Medicine, University of Ottawa; Bruyere Research Institute;
4 Division of Gastroenterlogy, Western University; 5 Department of Family
Medicine, University of McGill; Herzl Family Practice Centre; 6 University of
Milan, Mario Negri Institute for Pharmacological Research; 7 Department of
Medicine, McMaster University; 8 Department of Family Medicine, University
of Ottawa; 9 Cochrane Editorial Unit; 10 Wiley-Blackwell; 11 Canadian
Cochrane Centre, Ottawa Hospital Research Institute; 12 Sapko Medical
Writing; 13 University of Ottawa, Department of Medicine, Faculty of
Medicine; Ottawa Hospital Research Institute, Clinical Epidemiology
Program; University of Ottawa, Department of Epidemiology and
Community Medicine, Faculty of Medicine; Institute of Population Health,
University of Ottawa; 14 Wiley-Blackwell
Background: One of missions of the Cochrane Collaboration is
to promote access to its outputs. Although the Collaboration has
emphasised the role of online continuing medical education (CME)
in the dissemination of systematic review (SR) findings, it has not
proposed specific strategies for the incorporation of SR contents into
CME programs. Objectives: We developed a suite of online CME
modules targeting Canadian family physicians based upon Cochrane
SRs. Methods: The CME modules are based upon published
Cochrane SRs addressing gastrointestinal, back, inflammatory bowel,
and musculoskeletal conditions. Each module includes five multiple
choice questions plus a fictional and memorable vignette featuring
‘Dr. Cochrane’. Vignettes are produced through a multi-step editorial
process to ensure scientific, editorial, and educational rigour. This
process conforms to the requirements of several CME accreditation
authorities in North America. We reviewed the experience of the
editorial unit who completed the program. Results: To date, 64
Cochrane vignettes have been developed. Abstracts, Summary of
Findings Tables, and primary results were the sections of Cochrane
SRs most useful for developing CME activities; methods and secondary
results sections were rarely used. The relevance of certain reviews for
primary care and educational purposes was challenged during peer
review, and a few vignettes raised questions of the social, cultural, and
clinical suitability of interventions and patient-physician interactions.
We also encountered tensions between the accreditation requirements
and the design of the Dr Cochrane programme, most of which were
solved to meet the accreditation criteria. Conclusions: CME programs
represent an opportunity to improve the relevance and accessibility of
Cochrane SRs to health professionals. Progress in the development
and dissemination of Cochrane-based CME programs will require
innovation leadership, sufficient resources to maintain top scientific
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
and editorial standards and the expansion to other countries and
health professionals. Funding Sources: A CIHR Knowledge Translation
Supplement Grant provided funding.
Oral Session O1.14: Cochrane structure
and processes
Starting a new review group: tribulations
without trials
Grant R1 , Hart M1 , Quinn G2 , Jess C2
Cochrane Neuro-Oncology Group, UK; 2 Cochrane Gynaecology Cancer
Group, UK
Background: Neuro-Oncology is the multi-disciplinary subspecialty
dealing with the effect of cancer or cancer treatments on the nervous
system. To date, these reviews have been published through the
Cochrane Gynaecological Cancer Group (CGCG) under its ‘orphan’
cancer remit. With the retirement of the CGCG Co-coordinating Editor
and increasing numbers of trials, a Cochrane Neuro-Oncology Group
(CNOG) was formed in mid 2012. Here we discuss the development
of the new group. Objectives: Develop a responsive, outward facing
group, integrated into existing professional and Cochrane networks, to
provide a high quality review process and encourage new reviews in
Neuro-Oncology. Methods: To establish an expert group of evidence
based contact editors we approached members of the European and
North American Neuro-Oncology groups with particular expertise in
the breadth of neuro-oncology fields and the International patient
organisations. Meetings were held with Executive Board members
of these organisations to promote Cochrane links at Board level and
through their membership. Relationship building with CRGs where
there is overlap. Involve contact editors and interested staff in local
Cochrane training. Trial cross-continent collaboration on reviews and
new potential review topics. Results: 12 contact editors who have
either undertaken a Cochrane Review or have established evidence
based interest were enrolled. CNOG articles were published in the
professional organisations websites and newsletters, including patient
organisations, to publicise CNOG. A Neuro-Oncology webpage has
been established. Meetings have ben held to explore links and training
in US/Canadian Cochrane Centers. There is a four fold increase in new
titles and a hit list of potential review topics scored by Contact Editors.
Neuro-Oncology James Lind Alliance Partnership in planning stages
to identify unanswered questions. Conclusions: Small subspecialty
CRGs may benefit from linkages with ‘overlap’ Cochrane CRGs and
‘it’s a small world’ international contacts to promote Cochrane.
The Cochrane collaboration ’in the making’:
an actor-network perspective
Hannes K1 , Decuypere M2
1 KU Leuven - Methodology of Educational Sciences Research Group; 2 KU
Leuven - Education, Culture and Society Research Group
Cochrane Database Syst Rev Suppl 1–212 (2013)
Background: Drawing on the Actor-Network Theory (ANT), we
will explore the dynamics of the Cochrane Collaboration (CC); how
different agencies and mechanisms have translated CC from a bunch
of 80 likeminded people from around the world that attended the
first Cochrane meeting in Oxford (October 1993) in what CC is today.
Objectives: To visually map the development process of CC, with a
particular focus on some of the ‘ancient’ and ‘recent’ methodological
developments. To critically explore the role of non-human agencies
such as methodological standards, systematic reviews, computer
software, impact factors and libraries in shaping CC. Methods:
Our methodological stance towards exploring CC’s development is
an Actor-Network perspective. Actor-Network Theory (ANT) aims to
explore how particular practices are being fabricated by means of
actors populating these practices and more precisely by means of the
interactions and relations between all these actors. ANT is then used
as both a conceptual and a methodological lens in order to describe
the concrete assemblage of CC. Results: A visual map of the CC
that emphasizes its role as both an actant and a network is displayed.
Attention will be focused on the initial interessement phase initiated
by Iain Chalmers, the enrolment and mobilisation process of different
human and non-human actors into the collaboration. We particularly
focus on the standardisation of methodological procedures for reviews
and assisting software, which we consider the policy vehicles that
highly influence the further (non)enrolment of particular agencies.
Conclusions: The insights of ANT are used to place the ‘successful
story’ of the Cochrane Actant-Network into a more realistic perspective,
visually emphasizing the many agencies that did not (yet) fully make it
into the CC actor network and as such affecting its stabilisation process
(visual mapping work currently in progress—small fragment included
for review purposes).
The complex and challenging role of Cochrane
fields: moving Cochrane evidence into practice
Thomson D1 , Pearson A2 , Mahan KM3 , Wieland LS4 , Gallagher C5 ,
McIlwain C6
1 Child Health Field, Canada; 2 Nursing Care Field, Australia; 3 Neurological
Field, Italy; 4 Complementary Medicine Field, USA; 5 Justice Health Field,
USA; 6 Consumer Network, UK
Background: As the Cochrane Collaboration celebrates its 20th
anniversary, this is an opportunity to reflect on the many innovative
parts of its mission. The establishment of Cochrane Fields early in
the Collaboration’s history was an acknowledgement of the crucial
importance of moving evidence into practice—taking the findings of
Cochrane Reviews and connecting them with those making practice
and policy decisions. Fields have played a crucial bridging role in
moving Cochrane evidence out into the world. Objectives: To
review the development and contribution of Fields to the Cochrane
Collaboration. Geographic and disciplinary spread of Fields: Fields
focus on a dimension of health care other than a specific healthcare
problem—such as the setting of care, the type of consumer, the
type of provider, the type of intervention, or a major division of
health care which embraces an area too large to be covered by a
single Review Group——and represents its interests (Cochrane Policy
Manual). The current geographic and disciplinary spread of Fields
is displayed in Table 1. Ongoing activities: Cochrane Fields take
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
the evidence produced by Cochrane Review Groups and connect it
with the practitioners and policy makers who need it. We engage
in a range of knowledge translation activities, including: podcasts;
overviews of reviews; briefings to legislators and policy makers;
summaries; commentaries; reformatting reviews; training; journals and
journal supplements; etc. All of these activities are customized to the
individual Field’s audience and area of focus. Conclusions: Fields
are Cochrane’s resident experts in moving knowledge into practice, in
identifying gaps in information, and advocating for evidence in health
care research and practice. As such, Fields represent a vital part of
the Collaboration and their activities may serve as guides for others
wishing to bridge gaps between Cochrane evidence and the needs of
consumers, clinicians and policy-makers.
Attachments: Table 1.pdf
Improving the efficiency of updating Cochrane
Reviews: a joint pilot project of the McMaster
PLUS database team and the musculoskeletal
review group
Pardo J1 , Lawson J2 , Rader T1 , Parrish R2 , Cotoi C2 , Tugwell P1 , Haynes
B2 , Iorio A2
Cochrane Musculoskeletal Group, Canada; 2 Health Information Research
Unit, McMaster University, Canada
Background: Reviews updating is a primary goal for the Collaboration,
yet a common challenge for most Groups due to the workload
associated with identifying new relevant content. There is currently
no systematic mechanism for efficiently managing the update process
without periodically repeating a full-gauge literature search.
Objectives: To create a service that detects clinically relevant new
studies likely to prompt review updates and that includes features to
assist editors and authors with the task of organizing those references
to streamline the update process. Methods: We used the continuously
updated McMaster Plus database to feed a service aimed at efficient
and timely management of new trials published in top journals topical
to the Cochrane Musculoskeletal Review Group (CMSG). The studies
are indexed according to clinical topics, and made available to the
editorial team on a dedicated software platform for manual assignment
to individual reviews. The assignment in turn triggers automatic alerts
to the reviews’ corresponding authors. Authors are offered a simple
management tool to help decide on subsequent actions regarding the
alerted study, e.g. filing for inclusion in the update, linking it with
the review until incorporated into the update, as well as providing
feed-back regarding any article’s non-appropriateness. Results: The
system has been piloted with CMSG. Between 7 and 15 new studies
per topic were identified on a weekly basis, half of which were assigned
to reviews. Analysis of whether matched studies trigger an update is
underway. As well, highly relevant articles not filed to existing reviews
are being logged and may serve to suggest new titles for the CMSG
group. Conclusions: Ease of use and efficiency are being tested in the
pilot toward the timely identification of reviews in need of an update,
as well as the prompting of topics not covered by the current CRG
knowledge base.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Oral Session O1.15: Tools for Review
Superfilters website: a searching tool for review
Wilczynski N, Cotoi C, Haynes R
McMaster University Canada
Background: Reviewers could benefit from more efficient study
retrieval tools than currently exist. Having an online, ‘1-stop’
federated search facility providing empirically derived and validated
search filters and filtering aids to retrieve and collate all pertinent
studies would help. Objectives: To develop a ‘superfilters’ website
that provides review authors with the opportunity to search across
several electronic databases simultaneously with empirically derived,
high performance, search filters. To add ‘capture-mark-recapture’
(CMR) statistical modeling to this superfilters site to help those
searching for all available evidence to determine whether to continue
or stop searching, for example, when conducting systematic reviews.
Methods and Results: We designed a website that has federated
search capabilities, enabling users to select from a host of search filters
and search in large, bibliographic databases including PubMed, Ovid
Medline, Ovid Embase, EBSCO CINAHL, Ovid PsycINFO and MacPLUS.
These filters retrieve articles of higher methodological rigor from various
disciplines of medicine, and do so according to the research methods
used. The user can turn the search filters on or off when performing a
single search across multiple bibliographic databases simultaneously.
Searches can be limited by type of article (e.g., treatment, diagnosis),
age of study participants (e.g., adult, geriatric), and date of publication.
Searches include options for breadth: broad (highly sensitive), balanced
or narrow (highly specific). The retrieved set of citations is collated with
duplicate citations removed. In the process of identifying duplicate
citations, CMR statistical modeling is performed and an estimate of
the total theoretical size of a collection of literature is provided. This
automated statistical technique can provide searchers with evidence
that their searching can stop or should continue. Conclusions:
A superfilters website has been developed that can aid researchers
when conducting comprehensive and targeted searches of the medical
Epistemonikos: a comprehensive, systematic,
collaborative and multilingual database for
evidence-based health care
Rada G1 , Capurro D1 , Rivera S1 , Peña J1 , Claro JC1 , Soto M1 , Neumann
I1 , Pérez D2
Epistemonikos. Evidence Based Health Care Program, Pontificia
Universidad Católica de Chile; 2 Epistemonikos Foundation
Epistemonikos (www.epistemonikos.org) is a
user-friendly, multilingual, collaborative database of evidence. One
unique feature of this database is that connects different types of
evidence and allows to compare different systematic reviews addressing
a similar question. Methods: Systematic reviews (SR), overviews and
structured summaries of reviews are searched for in over 20 databases,
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
and information is uploaded into a single database. Primary studies
included in SR are also uploaded, independent of the publication or
language status. All information is collaboratively classified and a
direct connection between systematic reviews, overviews of reviews
and their included studies is added, making it easy to get an overview
of the evidence and find what is being looked for. A tool for comparing
reviews that share primary studies and to mantain an updated body of
evidence for a specific question has been recently released. Results:
The database contains over 160 000 records, including 29 000
systematic reviews and more than 100 000 primary studies. Using
software and a network of collaborators, titles and abstracts are
translated into nine languages. More than 20 000 official translations
to Spanish, French, Chinese, German, Dutch, Arabic, Portuguese and
Italian have been compiled from the internet. Over 1000 translations
to Spanish have been generated by collaborators of Epistemonikos. It
is possible to search in those nine languages, using both intuitive (i.e
google-like) and traditional (i.e. boolean) strategies. More than 150
000 connections between related articles are available which makes
possible to navigate between different types of evidence (e.g. from
primary studies to systematic reviews) and to compare different reviews
that share primary studies. Conclusion: Epistemonikos allows user to
obtain relevant evidence in an easy way, and can also help Cochrane
reviewers and CRGs to search for studies, decide upon updating reviews
or prioritising new reviews. The tool to compare reviews has potential
to improve Cochrane Reviews.
Shortening the pipeline: the use of data mining
to link new trials to Cochrane Reviews
McDonald S1 , Thomas J2 , Wallace S3 , Elliott J4
1 Australasian Cochrane Centre,
Monash University, Australia;
EPPI-Centre, University of London, UK; 3 Cochrane Incontinence Group,
University of Aberdeen, UK; 4 Monash University, Australia
Background: It’s estimated that at least 500 reports of trials are
published every week. The pipeline by which these trials find their way
into existing Cochrane Reviews (often via the Cochrane Central Register
of Controlled Trials and the specialised registers of Cochrane Review
Groups (CRGs)) can be lengthy and inefficient. Data mining offers the
prospect of the automated distribution of trials upon publication in
major databases (e.g. PubMed). The advent of the Central Register
of Studies makes it possible to test the feasibility of data mining
approaches. Objectives: To test the feasibility and accuracy of
introducing an automated process for assigning newly published trials
to (1) the relevant Cochrane Review Group, and (2) the relevant
Cochrane Review(s) using data mining approaches. Methods: Using
the Central Register of Studies, we created a dataset consisting of
the titles, abstracts and keywords (where available) of reports of all
included studies in all Cochrane Reviews. We then trained a classifier
using the LibSVM Support Vector Machine based on the included
studies of reviews from the Cochrane Incontinence Group. Over a
3 month period we automatically identified potentially relevant studies
for that Group that had been published on PubMed. Results: The
studies identified using the datamining system were compared with
those which the Group identified using its standard practices. Metrics
of sensitivity and precision were calculated, as well as yield and
burden of the datamining system. Conclusions: The usefulness of
Cochrane Database Syst Rev Suppl 1–212 (2013)
Cochrane Reviews and the efficiency of the review process would
be improved if relevant reports of trials could be identified and
linked to reviews on a prospective basis using automated approaches,
such as data mining. This system demonstrates the potential of such
technologies, though further work will be needed in order to optimise its
Oral Session O1.16: New tools
of dissemination
Surveillance system assessing the need for
updating systematic reviews
Dobbins M
National Collaborating Centre for Methods and Tools, Canada
Ahmadzai N1 , Newberry SJ2 , Maglione M2 , Tsertsvadze A1 , Ansari MT1 ,
Hempel S2 , Motala A2 , Tsouros S1 , Garritty C1 , Schneider Chafen J3 ,
Shanman R2 , Skidmore B1 , Moher D1 , Shekelle PG4
Knowledge Synthesis Group, Clinical Epidemiology Program, Ottawa
Hospital Research Institute, Centre for Practice-Changing Research, 501
Smyth Rd, Ottawa, ON, K1H 8L6, Canada; 2 Southern California
Evidence-based Practice Center (SCEPC), The RAND Corporation, 1776
Main Street, PO Box 2138, Santa Monica, CA 90401, USA; 3 Stanford
University, Stanford University 117 Encina Commons, Stanford, CA
94305-6019, USA; 4 Southern California Evidence-based Practice Center
(SCEPC), The RAND Corporation, 1776 Main Street, PO Box 2138, Santa
Monica, CA 90401, USA; Veterans Affairs Greater Los Angeles Healthcare
System, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA
Background: Developed by the National Collaborating Centre for
Methods and Tools (NCCMT), the Registry of Methods and Tools is a
searchable, online database of knowledge translation (KT) resources
for public health. The Registry of Methods and Tools contains
summary statements of KT resources, in French and English, which
address at least one KT activity (synthesis, dissemination, exchange
and application). Knowledge translation methods and tools provide
a systematic approach to using research evidence, along with other
forms of evidence, in program and policy decisions. Objectives: This
presentation will provide an overview of the Registry and how it can
be used by public health practitioners to identify relevant KT resources.
This interactive session will employ a mix of large group didactic
and problem-based learning in small groups. Workshop participants
will work in small groups to explore the database online and conduct
searches to retrieve relevant KT resources using case-based scenarios. In
small groups, participants will interact with the database online to learn
what knowledge translation resources are available, how resources
are organized to increase ease of use, and develop search strategies
to access methods and tools. Features and additional supplemental
resources included in summary statements of KT resources will also be
Background: Systematic reviews (SRs) go out of date as new
evidence emerges. Instead of fixed periodic updating, an efficient
SR currency surveillance program could be less resource intensive.
Objectives: Based on methods we developed previously, three
Evidence-based Practice Centers were tasked to establish and execute
a surveillance program to identify the need for updating a cohort of
Comparative Effectiveness Reviews (CERs) commissioned by the Agency
for Healthcare Research and Quality. Methods: We incorporated two
existing methods of updating signal detection into a step-by-step
surveillance approach and assessed the currency of 24 CERs. New
evidence was identified from: (a) literature searches, (b) expert opinion,
and (c) safety alerts. We determined the currency of conclusions in
the reviews, and, based on their potential impact on decision-making,
the updating priority (low, medium, or high) of CERs. Low or medium
priority CERs were reassessed every 6 months (Fig. 1). We did not
update the reviews. Results: The CERs mainly compared effectiveness
and safety of pharmaceuticals and surgical procedures for various
health conditions (Table 1). The median number of studies in the
original SRs was 104 (range, 8–436), new studies were 15 (range,
0–35), and the expert response rate was 35% (71% for re-assessed
CERs). Of the nine identified safety alerts only one influenced the
updating priority of one CER. Of the 24 CERs, 2 were classified as
high (8%), 5 as medium (21%), and 17 as low (71%) priority for
updating from 11 to 62 months after their last search date. Of the 10
re-assessed CERs reassessed after 6 months, updating priority changed
for only 1 CER. Conclusions: We established a surveillance program
and evaluated 24 CERs. The application of the program is practical and
efficient for assessing the need for updating SRs across a wide range
of health interventions.
Attachments: Figure 1.jpg, Table 1.pdf
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Searching a database of knowledge translation
resources for public health: The Registry of
Methods and Tools
DynaMed summaries and Cochrane Reviews: a
dynamic collaboration!
Alper B1 , Fedorowicz Z2 , van Zuuren E3
EBSCO Publishing, USA; 2 Bahrain Branch (UKCC) The Cochrane
Collaboration, Kingdom of Bahrain; 3 Editor Cochrane Skin Group.
Department of Dermatology, Leiden University Medical Centre, Leiden,
Background: Providing better knowledge for better health requires
collaboration and rapid responsiveness to changing evidence. The
Cochrane Collaboration has established internal collaborative networks
and external partnerships, but none that systematically contribute to
review updating. An innovative and dynamic collaboration is developing
between DynaMed and the Cochrane Collaboration, blending expertise
in evidence analysis and just–in–time updating to improve the quality
(comprehensive, accuracy, and clarity) of Cochrane Reviews (CRs)
and point-of-care summaries. Objectives: To explore and develop
the use of a balanced, bidirectional and mutually beneficial feedback
mechanism to improve both products in terms of their currency,
accuracy, and overall quality. Methods: Unrestricted DynaMed
access was given to a CR team who provided feedback on DynaMed
summaries relevant to their ongoing review. Selection of clinically
important outcomes for the review, methodologic issues relating to the
Cochrane Database Syst Rev Suppl 1–212 (2013)
identification of missing studies, and quality assessment of included
studies were discussed and shared through the process. Results:
The CR was improved by refined selection and definition of outcomes
of interest, and corresponding improvements in the reporting of
included trials. The DynaMed summary was improved by greater
specification of risk of bias assessments of specific trials. For example,
DynaMed content revisions included ‘DynaMed commentary—this trial
was determined to be quasi-randomized by contact with principal
investigator during Cochrane Review development’. Conclusions:
The interaction between CR authors and DynaMed editors improved
the content of both the CR and DynaMed to bring more relevant
and valid information to health care professionals at the point of
care. CR authors also benefit by additional acknowledgements in
the DynaMed community and early notification of new evidence as it
becomes available. We will present our experience on facilitating this
and strategies for making this opportunity available to all CR authors.
Making Cochrane Reviews more clinically
accessible: the new Cochrane clinical answers
derivative product
Pettersen K
Wiley, UK
Background: One of the Collaboration’s strategic goals is ‘to promote
access to Cochrane Reviews and other products of The Cochrane
Collaboration’. Cochrane Clinical Answers (CCAs) http://cochrane
clinicalanswers.com/aims to provide an entry point to Cochrane Reviews
that supports decision-making at the point of care. Objectives: To
develop a new format that brings to the forefront the Population,
Intervention, Comparison, and Outcome (PICO) data that allow results
of a review to be individualized to the patient. Methods: Detailed PICO
data are extracted from Cochrane Reviews: in terms of population: age,
co-morbid conditions; intervention: drug dose, intensity and duration
of intervention (walking or kick-boxing?); comparison: with alternative
treatment options or with placebo; and outcome—if weight was
reduced, how much by, and how long did weight loss take? Finally,
can clinicians have confidence that the trial evidence mirrors what will
happen in practice? Results: A key challenge of translating Cochrane
Reviews into CCAs relates to the lack of standardized presentation of
PICO data. Summary of findings tables greatly facilitate the creation
of CCAs and there are many small changes that could be made that
would both enhance the user experience of Cochrane Reviews and
facilitate usage of Cochrane content in derivative products.
Development and evaluation of a point-of-care
tool for providers based on a meta-analysis and
clinical practice guideline
Furlan A, Flannery J
Toronto Rehabilitation Institute, UHN, Canada
Background: Our group recently updated a meta-analysis of opioids
for chronic pain. Based on our review, a national group developed
a clinical practice guideline for safe and effective use of opioids for
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
chronic non-cancer pain, which was released in 2010. However, the
guideline is long and not practical to be used at the point of care by
busy physicians, nurses or pharmacists. Our group decided to develop,
evaluate, translate and adapt a tool which condenses the key elements
from the guideline that could be used as a chart insert. Objectives: To
present the steps used to develop, evaluate, translate and adapt the
Opioid ManagerTM, a two-page, colour document that was developed
based on the opioid guideline. Methods: We obtained funds from the
Ministry of Health. In 2010, we developed a ‘draft Opioid Manager’
that was pilot tested over 9 months. We received feedback from
70 users. The final Opioid ManagerTM was released in February 2011.
We integrated the Opioid Manager to various Electronic Medical Record
(EMR) platforms. We used quantitative and qualitative methods to
survey and interview users of the Opioid Manager. Results: The Opioid
Manager is free of charge and can be downloaded from the guideline’s
website. (See Fig. 1) As of April 2013, there are 4957 registered users
who downloaded the tool. The Opioid Manager is integrated to six
EMR platforms. It is translated to five languages (French, Spanish,
Portuguese, Farsi and Italian). The Opioid Manager is available as an
App for iOS and is Trade-Marked in Canada. See Figure 2 for the most
common use by family physicians. Conclusions: The development of
a point of care tool is time and resource consuming. It is essential to
develop tools to assist practitioners to apply the recommendations from
clinical practice guidelines that are based on evidence from systematic
Attachments: Opioid Manager Feb 2011.pdf, Figure 2 - How the
Opioid Manager is Used.pdf
The Healthcare Knowledge Integrity Framework:
a conceptual map of the synergy, mediators,
and threats to integrity within the healthcare
research/practice continuum
Galipeau J1 , Shamseer L1 , Moher D2
1 Ottawa Hospital Research Institute, Canada; 2 Ottawa Hospital Research
Institute, University of Ottawa Faculty of Medicine, Canada
Background: The quality of health services delivery and patient care
depend heavily on the integrity of the research process, the complete
and transparent reporting of research findings, and the effective
translation of research knowledge into evidence-based practices.
However, few educational resources exist that take into account the
entire research/practice cycle. In addition, there is little documentation
of the interrelated factors that may influence the integrity of healthcare
knowledge throughout its life cycle, from the conception of a research
idea to the outcome(s) of patient care. Objectives: The objective of
the Healthcare Knowledge Integrity Framework (HKIF) is to provide a
conceptual map for understanding and discussing different factors that
may impact the integrity of the research/practice cycle of healthcare
knowledge. Methods: The HKIF outlines optimal factors and training
that promote a synergistic relationship between healthcare research
and practice while also highlighting potential internal (personal) and
external threats to integrity that can lead to wasteful practices and other
negative downstream effects. Results: In this presentation, specific
attention will be focused on the areas of knowledge dissemination
and knowledge translation, highlighting best practices, training, and
Cochrane Database Syst Rev Suppl 1–212 (2013)
threats to integrity at these particular points in the research/practice
cycle. In addition, the course of events related to well-known cases of
misconduct and poor research practices will mapped onto the HKIF to
demonstrate its utility as a teaching and learning tool. Conclusions:
The HKIF may help researchers, practitioners, and decision-makers
to take into account the multitude of factors that may influence the
integrity of knowledge creation, reporting, translation, and utilization
within the healthcare field. It is hoped that the framework will
act as a tool for these groups to analyze systemic weaknesses in
current practices and engage in a collaborative dialogue on how to
improve the integrity of healthcare knowledge, and ultimately the care
of patients.
Oral Session O1.17: Methods for
improving review efficiency
Systematic Review Data Repository (SRDR):
beyond old school data abstraction
Hadar N
Brown University, USA
Background: The Systematic Review Data Repository (SRDR) is a
Web-based open-access tool that supports electronic data abstraction
and entry by multiple users, data comparison and exporting, progress
monitoring, and data archiving and sharing. SRDR has a great
potential to reduce the burden of conducting systematic reviews (SRs),
while improving data quality and transparency of the process. The
development of SRDR is funded by the AHRQ and is being maintained
by the team at Brown University. Objective: To introduce the audience
to SRDR and its tools, share user experience, and invite feedback and
discussion. Methods: The steps to initiate a systematic review project
in SRDR include creating the project and abstraction forms, adding
users to the project, and assigning roles. The systematic reviewers then
extract and enter data directly from study reports into SRDR for seamless
data storage and processing. The Data Comparison and Adjudication
tool allows identification and adjudication of discrepancies between
data abstractors. The Data Exporting tool enables users to export
data from SRDR into an analyzable format for further processing. The
Summary Table Creation tool can also be used to generate reports and
descriptive information about data collected in SRDR. Results: SRDR
was launched in June 2012, and since then over 50 SR projects have
been initiated with over 200 users (from EPCs, Cochrane, and other
organizations) entering over 2000 study records. The creation of a
central database of SR data enables data sharing among organizations
and individuals producing SRs worldwide. The Cochrane Eyes and Vision
Group will present their experience using SRDR for their large network
meta-analysis of over 500 studies and other projects. Conclusions:
SRDR can facilitate efficient data collection, adjudication, preparation
of a dataset for analysis, and archiving. Future efforts must focus
on linking SRDR to RevMan and further testing by multiple Cochrane
groups conducting systematic reviews in diverse topics.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Enhancing the efficiency of the systematic review
process for evidence-based medicine
Crawford C, Jonas W
Samueli Institute, USA
Background: Systematic reviews are widely recognized as the best
means of synthesizing clinical research; however traditional approaches
can be costly and time-consuming and are often subject to selection and
judgment bias. It can be difficult to interpret the results of a systematic
review in a meaningful way in order to make research recommendations
or clinical decisions about implementation. Objectives: In order to
maximize efficiency in the execution and dissemination of synthesized
literature, there is a need for a streamlined, coordinated international
effort among researchers and healthcare professionals to provide
regular, up to date, objective, high quality information on healthcare
practices, interventions and treatments. Methods: Samueli Institute
has developed a systematic review process known as the Rapid
Evidence Assessment of the Literature (REAL c) that not only makes
the systematic review process more reliable and objective but also
streamlines the process without compromising quality. Results: The
REAL uses a clearly described and reliably applied set of steps embedded
in standard rule books and customized, automated software for efficient
evaluation and remote subject matter expert input. Conclusions:
The efficiency of the REAL process is such that it can facilitate
the conduct of rigorous, high quality, transparent evidence-based
systematic reviews more rapidly (approximately half the time) and at
lower cost (approximately 30–50% less) than other standard methods.
In addition to increased efficiency, the REAL process incorporates an
assessment of the overall literature pool and its current implications for
research and practice. Thus, a REAL provides a basis allowing subject
matter experts to determine the quality of the research as a whole,
gaps in the literature, effectiveness of the intervention, the confidence
in that effectiveness estimate, and the appropriateness of clinical use of
the intervention. Using this process enables researchers, clinicians and
patients to be better informed as to the current state-of-the-science for
any intervention.
Many hands make light work—or do they?
Results of two pilot studies looking at the effects
of crowdsourcing
Noel-Storr A1 , Struthers C2 , Cullum S3 , McShane R1 , Creavin S4 , Davis D5 ,
Huckvale K6
1 Cochrane Dementia and Cognitive Improvement Group; 2 Cochrane
Training; 3 University of Bristol; 4 North Bristol NHS Trust; 5 Cambridge
University; 6 Imperial College London
Background: The production and maintenance of Cochrane systematic
reviews is no small undertaking. It is a process made up of many
steps and frequently author teams stall or lose momentum. These two
studies sought to assess whether it is feasible to recruit individuals
to perform one task necessary to Cochrane Reviews and CENTRAL
in a way that would enable the task to be performed successfully,
in a timely way and with no compromise to the methodological
rigours required for Cochrane Reviews. Methods: Two studies were
Cochrane Database Syst Rev Suppl 1–212 (2013)
conducted. Each looked at using ‘a crowd’ for the completion of a
task vital to the maintenance of Cochrane Reviews and CENTRAL. Trial
Blazers gave participants 200 citations to screen for potential inclusion
in CENTRAL. The gold standard: whether those citations selected were
indeed reports of randomised or controlled trials (thereby suitable
for inclusion in CENTRAL); the second study gave a different cohort
of subject 250 citations to screen for potential inclusion within a
Cochrane diagnostic test accuracy (DTA) review. Gold standard: those
studies that went on for inclusion within the review as selected by
the expert author team. Outcomes: efficacy—were randomised trials
and DTAs correctly identified and were those which were not trials
or diagnostic test accuracy studies, correctly discarded? Participant
motivation to take part; participant perceptions of the task in terms
of difficulty or perceived skills required, and an assessment of ease of
performing the task using the technology provided (a mobile screening
tool for one, tradition PC based bibliographic software for the other
study). Results: Sensitivity and specificity of both studies was very
good for those who completed the task. However, drop-out was
high raising questions around participant incentive and motivation to
perform the task, the importance of accessible support and guidance
provided and the vital need to provide a smooth and user-intuitive
pathway regarding the use of mobile technologies to perform the task.
Conclusions: Non-traditional contributors can be recruited and can
successfully perform this task which is vital for both Cochrane Reviews
and for CENTRAL. However, crowdsourcing is not an easy option. High
drop-out is to be expected but chance of success on a large scale will
rely heavily on reliable technologies, accessible guidance and ultimately
an excellent understanding of user incentives and motivations.
A cloud computing database for data extraction
in a Cochrane Review
Stordal B1 , Kapros E2 , Busschots S1 , Lawlor D1 , Doherty B1 , Smith L3 ,
Hennessy B4 , O’Mathúna D5
1 Department of Histopathology, St James’ Hospital and Trinity College
Dublin, Dublin 8, Ireland; 2 Department of Computer Science, Trinity
College Dublin, Dublin 2, Ireland; 3 Department of Social Work and Public
Health, Brookes University Oxford, UK; 4 Department of Medical Oncology,
Beaumont Hospital, Dublin 9, Ireland; 5 School of Nursing & Human
Sciences, Dublin City University, Dublin 9, Ireland
Background: An online database was needed for the Cochrane
Review ‘Taxanes for the treatment of platinum pre-treated epithelial
ovarian cancer’ for several reasons. Firstly, a large amount of clinical
parameters were to be extracted from 68 identified studies and the
data was to be subdivided into 16 different subgroups. Secondly,
there were six authors performing data extraction for this Cochrane
Review, working at four different institutions. Therefore data could
not be entered and stored centrally at one institution. Objectives:
Development of a cloud computing database accessible online for all
authors performing data extraction. Methods: The database utilises
cloud computing, such that the information is stored online and can
be accessed from anywhere and is populated through a web-based
user interface. Results: Using an online database-as-a-service and
cloud computing to query and compare data allows the elimination
of transaction concurrency conflicts. That is, the two authors can
simultaneously review the same study without breaking the database.
In the data extraction phase the cloud computing model allows authors
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
to all work remotely. Each study in our review must have the
data extracted by two review authors. The database will crosscheck
information entered by two authors and flag discrepancies that need
to be resolved by discussion. In the analysis phase the database
allows each relevant paper containing data for each subgroup to be
easily identified amongst the identified studies. Data to be presented
will include a demonstration of functionality of the database and
excerpts of results highlighting the usefulness of the database in
complex subgroup categorisation. Conclusions: The cloud computing
database was invaluable for performing this Cochrane Review as the
subgroups overlapped in many publications. Many complex Cochrane
Reviews could benefit from this approach to data extraction which
facilitates collaboration across multiple institutions.
Oral Session O1.18: Complexity
Methods for configurational synthesis:
extensions to traditional meta-analysis for
addressing intervention complexity and
contextual variation in reviews
O’Mara-Eves A, Thomas J
EPPI-Centre, Institute of Education
Background: One of the underlying principles of meta-analysis
is that sufficiently similar trials are aggregated in order to gain
greater precision of effect size estimate and confidence around that
estimate. This assumption breaks down outside clinical settings where
interventions tend to be complicated and complex; they are also rarely
replicated. In order to identify what works for whom in what situation,
we need methods that ‘aggregate’ findings statistically and ‘configure’
(i.e. arrange, or compare and contrast) findings from different contexts.
Objectives: To investigate the utility of a range of methods that
might be useful for complex topics that lie on different points of
the ‘aggregate—configure continuum’. Methods: We consider four
methods that use quantitative or semi-quantitative approaches to
synthesising quantitative data for different types of research questions:
a) Multivariate meta-analysis; b) Path analysis, including structural
equation modelling; c) Qualitative comparative analysis; and d) Factor
analysis, including principal components analysis. We discuss the
conceptual basis and potential limitations of each. Examples are
provided from a recent systematic review on a complex public health
topic. Results: In addition to aggregation to determine a point
estimate, we identified the following types of analytical questions that
might be considered by systematic reviewers as relates to the synthesis
of quantitative data: a) Identifying confounding variables; b) The
personality of studies (i.e., profiles of interventions); c) Defining
theoretical constructs using indicator variables; and d) Construct
validation. The four methods discussed show promise in addressing
these different research questions, which lie on different points of the
aggregate-configure continuum. In our example systematic review,
we were able to address a broader range of research questions.
Conclusions: Meta-analysis alone is insufficient in some situations
when variation is encountered—and is indeed part of the purpose of
the analysis. While there are alternatives, they each have particular
limitations, and further methodological development is required.
Cochrane Database Syst Rev Suppl 1–212 (2013)
Key domains of context and implementation
and their assessment in systematic reviews of
complex health interventions
Pfadenhauer LM, Rehfuess EA
Institute for Medical Informatics, Biometry and Epidemiology, University of
Munich (LMU), Germany
Background: The effectiveness of complex interventions is critically
influenced by implementation and context. To date, limited information
on implementation and contextual factors is included in primary studies
and, consequently, in systematic reviews. This constitutes a major
barrier to the appraisal of the generalizability of the findings of a
systematic review and their applicability in a specific setting and
context. To our knowledge, no framework exists that describes key
domains of context and implementation comprehensively. Objectives:
To review concepts of setting, context and implementation, to
propose a comprehensive framework, and to operationalize this in
an assessment template for systematic reviews. Methods: We
conducted literature reviews on terminology, concepts and frameworks
of context and implementation, their constituent components and
the use thereof in primary research and systematic reviews. In
a first step, constituent components recurring under various labels
across different frameworks were collected and reviewed. In a
second step, existing components were selected for inclusion and
supplemented with additional components, and structured under clearly
defined key domains and integrated in a consolidated, comprehensive
framework. Results: We propose a multi-layered framework
comprising implementation and context—with setting being one
domain of context—as distinct dimensions. Implementation embraces
the key domains programming and delivery; context includes setting,
community and key domains related to social, cultural, political and
other aspects. Based on this framework, we developed a matrix to
assess generalizability and applicability, which allows the assessment
of each of these domains for systematic review authors. Conclusions:
This guidance is designed to complement existing reporting and
evaluation guidelines on context and implementation in primary as
well as in synthesis research of complex interventions. The guidance
will be tested in several systematic reviews of complex interventions
and revised as needed.
Systematic reviews on multimorbidity:
methodological challenges
Menear M, Fournier L
University of Montreal, Canada
Background: Health care systems are undergoing dramatic
transformations in response to the rise of chronic diseases in
populations. In most cases, such system transformations have been
driven by single-disease approaches to chronic care management and
improvement. A wave of evidence in the past decade has shown
however that a significant proportion of the population lives with
multiple chronic diseases, i.e. multimorbidity. Given this reality, it is
important that high-quality evidence related to services or interventions
for people with multimorbidity be available to decision-makers.
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
Systematic reviews examining populations with multimorbidity have
the potential to inform current quality improvement efforts, yet such
reviews are challenging to conduct on a number of levels. Objectives:
To present several methodological challenges related to the conduct
of systematic reviews on the topic of multimorbidity. Approach:
The challenges encountered at each stage of the review process will
be presented. First, defining review questions and inclusion criteria
can be difficult, as review authors must weigh the relevance of
the concepts of multimorbidity versus comorbidity, identify a clear
population of interest among many possibilities, and decide on an
appropriate scope for the review. This is a highly iterative process that
occurs while attempting to search for studies. Searches are time- and
resource-intensive given the importance in this case of searching
multiple databases and using multiple data sources. Designing
effective search strategies is complicated by the relative novelty of the
multimorbidity concept. Study selection and data analysis is challenged
by a lack of consistency in multimorbidity definitions and measures, and
heterogeneity between studies makes data comparisons and quality
assessment difficult. Conclusions: There is a rapidly growing literature
related to services and interventions for people with multimorbidity.
Reviews of this literature can be challenging, but are urgently needed to
inform efforts to improve care and outcomes for this large, vulnerable
Oral Session O1.19: Investigating
bias—Session 2
Incorporation of assessments of risk of bias
of primary studies in systematic reviews of
randomized trials: a cross-sectional review
Hopewell S1 , Boutron I2 , Altman DG3 , Ravaud P2
French Cochrane Centre, France; Centre for Statistics in Medicine,
University of Oxford, UK; INSERM, U738, Paris, France; AP-HP (Assistance
Publique des Hôpitaux de Paris), Hôpital Hôtel Dieu, Centre d’Epidémiologie
Clinique, Paris, France; Univ. Paris Descartes, Sorbonne Paris Cité, Faculté
de Médecine, Paris, France.; 2 French Cochrane Centre, France; INSERM,
U738, Paris, France; AP-HP (Assistance Publique des Hôpitaux de Paris),
Hôpital Hôtel Dieu, Centre d’Epidémiologie Clinique, Paris, France; Univ.
Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France.;
3 Centre for Statistics in Medicine, University of Oxford, UK; Statistics
Methods Group, UK.
Background: Assessment of the validity of individual studies included
in a systematic review, and the risk that they might overestimate
the true intervention effect, is a critical part of the systematic review
process. Objective: We examined how assessments of risk of
bias (RoB) of primary studies are carried out and incorporated into
the statistical analysis and overall findings of a systematic review.
Methods: We assessed 200 systematic reviews of randomized trials
published 2012; Cochrane (n = 100), non Cochrane (n = 100). Our
primary outcome was a descriptive analysis of how assessments of
RoB are carried out, methods used, and the extent to which such
assessments were incorporated into the statistical analysis and review
findings. We also evaluated differences between Cochrane and non
Cochrane Database Syst Rev Suppl 1–212 (2013)
Cochrane Reviews. Results: Most Cochrane Reviews (90%) assessed
individual methodological components using the Cochrane RoB tool
whereas non Cochrane Reviews (38%) were more likely to use a quality
assessment scale; 20% of non Cochrane Reviews did not report the
method used. Based on the assessment carried out by the authors of
the systematic review, 58% (n = 116) of reviews had ≥ 1 trial at high
RoB; median proportion of trials per review at high RoB was 50% (IQR
31–89%). Despite this only 56% (n = 65/116) incorporated the RoB
assessment into the interpretation of the results in the abstract and
49% (n = 40/81) of Cochrane and 20% (n = 7/35) of non Cochrane
Reviews incorporated the RoB assessment into the interpretation of the
conclusions. Of the 166 (83%) systematic reviews which included a
meta-analysis only 19 (11%) incorporated the RoB assessment into the
statistical analysis. Conclusion: Cochrane Reviews were more likely
than non Cochrane Reviews to report how RoB assessments of primary
studies were carried out, however both frequently failed to take such
assessments into account in the statistical analysis and conclusions of
the systematic review.
Reporting, dealing with, and judging risk of
bias associated with missing participant data in
systematic reviews: a methodological survey
Akl EA1 , Johnston B2 , Carrasco A3 , Brignardello Petersen R3 , Neumann I3 ,
Sun X3 , Briel M4 , Busse J3 , Granados C3 , Iorio A3 , Irfan A5 , Martinez L6 ,
Mustafa RA3 , Ramı́rez A7 , Solà I6 , Martı́nez Garcı́a L6 , Selva A6 , Sanabria
AJ6 , Zazueta OE6 , Vernooij R6 , Tikkinen KA8 , Ebrahim S9 , Vandvik PO10 ,
Guyatt GH3 , Alonso Coello P6
American University of Beirut, Lebanon; 2 SickKids Research Institute,
Canada; 3 McMaster University, Canada; 4 University Hospital Basel,
Switzerland; 5 University of Illinois at Urbana-Champaign, USA;
Iberoamerican Cochrane Centre, Spain; 7 Central America Cochrane, Costa
Rica; 8 Tampere University Hospital, Finland; 9 [email protected];
10 Norwegian Knowledge Centre for the Health Services, Norway
Background: When conducting a meta-analysis, systematic review
authors need to deal with trials reporting missing participant data
including an assessment of the risk of bias associated with missing
participant data in the body of evidence. Objectives: To describe
how authors of systematic reviews are reporting, dealing with, and
judging the risk of bias associated with missing data for dichotomous
outcome. Methods: We searched Medline and the Cochrane Database
of Systematic Reviews for systematic reviews of randomized controlled
trials published in 2010 and reporting a meta-analysis of dichotomous
outcome. We randomly selected 101 Cochrane systematic reviews and
101 non-Cochrane systematic reviews. Teams of two reviewers selected
eligible studies studies and abstracted data independently and in
duplicate using standardized, piloted forms with accompanying written
instructions. The Cochrane Collaboration Methods Innovation Fund
funded this study. Results: Of the 202 systematic reviews, 187 (93%)
reported a standard meta-analysis, 166 (82%) addressed a medical
topic, 130 (64%) assessed pharmacological interventions; they included
a median of 5 trials (IQR 2–8). The table shows the percentage of
systematic reviews that reported, dealt with, and judged the risk of bias
associated with participant with missing data for dichotomous outcome.
In general, Cochrane Reviews performed poorly (approximately 50%
or less for all key criteria other than judging the risk of bias associated
with missing participant data) and non-Cochrane Reviews very poorly
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
(20% or less for all key criteria with the exception of 52% for judging
risk of bias associated with missing participant data). Conclusions:
Both Cochrane and—particularly—non-Cochrane Reviews need to do
far better in attending to issues of reporting and handling missing
participant data.
Attachments: Table.pdf
Do prominent biomedical journals have methods
for detecting outcome reporting bias? (survey
of the top 30 journals by impact factor)
Huan N1 , Tejani AM2 , Egan G1 , Chua S3
1 Faculty of Pharmaceutical Sciences, University of British Columbia,
Canada; 2 Therapeutics Initiative, University of British Columbia, Canada;
Faculty of Science, University of British Columbia, Canada
Background: Outcome reporting bias (ORB) is an increasingly
recognized source of bias within primary research with the potential
to negatively influence systematic reviews and healthcare in general.
Literature is arising regarding outcome reporting bias’ effect on research
but no studies have been conducted to determine if biomedical journals
have processes to minimize the impact of ORB. Objectives: To
investigate the top 30 biomedical journals ranked by impact factor
for their methods, if any, on the detection and management of
outcome reporting bias. Methods: For each journal who agreed to
participate, we administered a standardized set of survey questions via
e-mail or telephone. Results: 24 (83%) journals responded to our
initial inquiry of which 14 (58%) responded to our questions and 10
(42%) declined participation. 5 (36%) journals indicated they had a
specific method to detect ORB whereas 9 (64%) journals did not. 6
(43%) journals delegated this responsibility to both peer reviewers and
editors, while 4 (28.5%) relied solely on peer reviewers. The remaining
4 (28.5%) journals did not indicate either peer reviewers or editors as
responsible for detecting ORB. 4 (29%) journals indicated ORB was
found commonly in the review process whereas 7 (50%) indicated
ORB was uncommon or never detected by their journal previously.
Conclusions: Many prominent medical journals lack a method with
which to detect outcome reporting bias. Improvements at the medical
journal level for detecting outcome reporting bias are needed. We
recommend that journals mandate the submission of the original trial
protocol by researchers. In addition, diligent cross-referencing of the
manuscript and data set to the protocol by editorial staff and peer
reviewers should be routinely performed to minimize the influence of
ORB on both primary research and systematic reviews.
Reporting of industry-funded trial outcome
data: a comparison of journal publications with
confidential individual patient data and clinical
study reports
Rodgers M1 , Brown J1 , Heirs M1 , Higgins J1 , Mannion R2 , Simmonds M1 ,
Stewart L1
1 Centre for Reviews and Dissemination, University of York, UK;
2 Addenbrookes Hospital, Cambridge, UK
Cochrane Database Syst Rev Suppl 1–212 (2013)
Background: There is increasing concern about selective nonreporting of outcome data, particularly from industry funded clinical
trials. Controversy around the use of recombinant human bonemorphogenetic protein-2 (rhBMP-2) for spinal fusion has stemmed
from this issue. Objectives: To investigate whether published
results of industry-funded trials of rhBMP-2 in spinal fusion accurately
reflect the underlying trial data. Methods: We compared three
different data sources: (1) publicly available journal publications
and conference abstracts; (2) confidential individual participant data
(IPD); (3) confidential clinical study reports (CSRs). The manufacturer
of rhBMP-2 products (Medtronic Inc.) provided complete IPD and
CSRs for all their trials of rhMBP-2 in spinal fusion. We identified
publications and conference abstracts through comprehensive literature
searches. Across the three data sources we compared meta-analyses of
effectiveness outcomes and the number and type of reported adverse
events. Results: Eleven of 17 manufacturer-funded studies were
published; between 56 and 88% of collected effectiveness outcomes
were reported in these publications. Despite some missing data from
publications, meta-analyses of primary pain outcomes were almost
identical across the three data sources. Only 23% of the total adverse
events collected in published RCTs were reported in the published
literature. RCTs evaluating the licensed preparation of rhBMP-2
(INFUSE) reported just 11% of their collected adverse events. Several
journal articles reported only ‘serious’, ‘related’, or ‘unanticipated’
adverse events, without defining these terms. Confidential CSRs
presented considerably more adverse event data than did publications.
Conclusions: The published literature only partially represents the
total data known to have been collected on the effects of rhBMP-2.
While this did not substantially influence meta-analyses of primary
effectiveness outcomes, reporting of adverse event data was inadequate
and inconsistent. In the absence of IPD, access to full CSRs can produce
more accurate, reliable and robust findings with less time and effort
than relying on incomplete published data.
Oral Session O1.20: Using Cochrane
Systematic Reviews
Towards an optimal use of the Cochrane
Systematic Review to support decision making
in a hospital setting
Rhainds M
CHU de Québec, Canada
Objectives: • Exchange of experience in the hospital environment
by Health Technology Assessment Units (UETMIS) in Québec, grouped
into a Community of Practice (CoP), regarding the use of evidence
generated through the Cochrane Collaboration; • Initiation of a
discussion on the use of this data by hospital UETMIS through the
perspective of local decision making. Results: This presentation
will present a synthesis of the results of a survey of members of
the health technology assessment CoP in Québec, reflecting their use
of systematic reviews of health technology projects in care facilities
generated by the Cochrane Collaboration. It will also outline the
facilitating factors and barriers to the implementation of the conclusions
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
of these systematic reviews in clinical practice. The presentation
will present strategies that can be implemented to promote more
consultation of the systematic reviews generated by The Cochrane
Collaboration, supporting decision makers in health care facilities in
their choice of technologies and methods of intervention. Possible
solutions to facilitate uptake of information generated by the Cochrane
Collaboration among health care institutions, taking into account the
context, needs and expectations of the environment will be presented.
Using Cochrane Systematic Reviews in real
life—experiences from teaching health science
students and professionals to access and utilize
Cochrane Reviews
Kwok C, Lawrence K, Musini V, Perry T, Tejani AM
UBC Therapeutics Initiative, Canada
Background: Medical students, nursing students, pharmacy students
and other health professional students have heard of the Cochrane
Collaboration, but seldom access reviews to answer clinical questions.
We have tried to encourage our students to do so, but encountered
significant problems. Objectives: Encourage health professional
students to utilize the scientific knowledge available in Cochrane
systematic reviews and to understand both its strenghts and limitations.
Methods: Since 2005 we have routinely taught elective medical
students and other health professional or science students and
post-graduate trainees how to read and evaluate Cochrane systematic
reviews. At the same time, we have introduced them to critical
appraisal of the primary RCT reports, and encouraged students to
assess whether Cochrane systematic review authors have followed
standard Cochrane methodology so as to reach believable conclusions.
Over this interval, understanding of publication bias and other biases
has expanded, so we have placed increasing evidence on assessing
the quality of systematic reviews and of the authors’ critical appraisal
of the primary evidence. Results: Our experience has shown that
Cochrane systematic reviews vary in quality from very useful and
apparently reliable to virtually irrelevant to the apparent clinical issue
or clearly unreliable. We will show examples where students could
recognize flaws that apparently evaded the authors, peer reviewers,
and Cochrane editorial groups, as well as examples which encouraged
students to access Cochrane Reviews again to explore evidence as
opposed to ‘expert opinion’, ‘consensus’, or guidelines.. Conclusions:
Cochrane systematic reviews vary substantially in quality. While a high
quality review may encourage health professionals to utilize this unique
source of scientific information, low quality reviews can discourage
even a Cochrane enthusiast. Authors and editorial groups need to
listen the experience of systematic review users in order to ensure that
the Cochrane Collaboration meets its idealistic goals.
The use of Cochrane evidence and guidance
in World Health Organization guidelines
Hartling L1 , Thomson D1 , Sommerville M1 , Bero L2
1 Child Health Field, Canada; 2 US Cochrane Centre, USA
Cochrane Database Syst Rev Suppl 1–212 (2013)
Background: One of the key functions of the World Health
Organization (WHO) is the preparation of global guidelines to address
public health questions. Guidelines comprise recommendations that can
impact upon health policies or clinical interventions. As The Cochrane
Collaboration (Cochrane) is a leader in producing high-quality reviews
for policy and practice decisions, it is important to assess the degree
to which guidance and evidence from The Cochrane Collaboration are
used in the formulation of WHO guidelines. Objective: To assess
the extent to which Cochrane’s guidance and evidence is cited in
WHO guidelines. Methods: We identified all currently available WHO
guidelines (n = 76) and reviewed them for references to Cochrane
guidance (e.g. The Cochrane Handbook for Systematic Reviews of
Interventions, assistance from a particular Cochrane Review Group)
and evidence (Cochrane Reviews). We analyzed guidelines overall and
categorized topics as pertaining to children (n = 19), mixed adult
and child (n = 6), and adult-only (no specific reference to children)
(n = 51). Results: 53% of all WHO guidelines contain references to The
Cochrane Collaboration. 90% of these references are to one or more
Cochrane Review; 10% are to Cochrane guidance. Adult guidelines:
47% reference the Cochrane Collaboration. There is an increasing use
of Cochrane evidence from 2008 (20%) to 2012 (78%). Mixed adult
and child guidelines: 83% reference The Cochrane Collaboration. Child
guidelines: 58% reference the Cochrane Collaboration. More detail
about the citations in various disease and topic areas will be presented
at Colloquium. Conclusions: There is considerable use of Cochrane
evidence in WHO guidelines, and some use of the guidance provided
by the Collaboration. More research would be useful in detailing
how and why Cochrane Reviews are cited, the use of non-Cochrane
Reviews, and areas where systematic reviews are needed but are not
available. This could serve to identify and prioritize topics for future
Cochrane Reviews.
20 ways to move Cochrane evidence into
practice: a celebration of 20 years of
disseminating Cochrane’s research to the
world—and how you can use what we’ve done!
Thomson D1 , Mahan KM2 , Pearson A3 , Wieland LS4
1 Child Health Field, Canada; 2 Neurological Field, Italy; 3 Nursing Care Field,
Australia; 4 Complementary Medicine Field, USA
Background: Cochrane Fields are the Collaboration’s KT experts,
employing a range of strategies to get Cochrane evidence used in
practice and policy decisions. We customise our strategies based on
the patient population (e.g. children), type of health care professional
(e.g. nurses) and/or the type of intervention (e.g. complementary
medicine). Objectives: • To review examples of a wide range of
knowledge translation (KT) tools based on Cochrane evidence • To
develop, in the course of the workshop, a range of KT strategies for the
case studies that will be presented—or we will work with situations
raised by participants. Results: In this presentation, in honour of the
Collaboration’s 20th anniversary, we will first demonstrate 20 different
KT strategies that Fields have used, from summaries to podcasts
to Congressional briefings and beyond. Then we will draw on our
experience to work through three case studies—one addressing a
particular group of patients, a second tailored for a particular type
of health care professional, and the third targeted on a specific
Copyright c2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
intervention to narrow down their audience, develop strategies, and
address how to measure impact.
Oral Session O2.01: Review Methods
Talking to librarians: how to get the most out
of library staff and make your Cochrane Review
process easier and more successful
Witteman W
Centre Hospitalier Universitaire du Québec, Canada
Background: A successful Cochrane Review requires the participation
of someone who can be designated as a medical librarian. This often
this requires obtaining the services of a medical librarian who is not
part of your research team. Objectives: How to get the most of out of
a medical librarian. This presentation will be a guide to getting the best
help from a medical librarian. This includes: (1) How to request the
aid of a medical librarian (a) What to bring to a first meeting (b) What
questions to ask them (c) How to answer the questions that they will ask
you (d) How to overcome political/temporal barriers to the participation
of your librarian (2) How to assess the abilities and training of a medical
librarian (a) How to find out how much they know about systematic
reviews and Cochrane Reviews (b) How to help your medical librarian
provide the best service possible (training, materials, peer resources)
(3) What you want from a medical librarian’s contribution to your
Cochrane Review. (a) Reporting results (b) Screening administration
(c) Grey literature and hand-searching (d) Guidance on materials and
databases (e) Writing appendixes and the Methods section of the
Review (f) Tables and figures.
Documenting the search process: an update
of different methods?
Mann M1 , Rader T2 , Stansfield C3 , Cooper C4 , Sampson M5
Public Health Group, UK; 2 Cochrane Musculoskeletal Group, Canada;
3 Evidence for Policy and Practice Information and Coordinating (EPPI-)
Centre Social Science Research Unit, Institute of Education, University
of London, UK; 4 Peninsula Technology Assessment Group, University of
Exeter, UK; 5 Children’s Hospital of Eastern Ontario, Family Resource
Library, Canada
Background: In order to comply with the standards laid out
in Methodological Expectations of Cochrane Intervention Reviews
(MECIR) Cochrane authors are expected to provide detailed reporting
of the search process including search strategies for each database
searched. Objectives: To discuss methods to incorporate and
keep track of the literature search documentation during the search
process, and identify barriers to adhering to the MECIR standards.
Methods: To report an audit of search strategy reporting in
new and updated Cochrane Reviews in a recent issue of the
Cochrane Library. We will examine results from a survey conducted
amongst Trials Search Coordinators, Information Specialists and
review authors. We will highlight some of the challenges faced
such as incorporating search strategies from various databases.
Results: The survey revealed an inconsistency in information that
Cochrane Database Syst Rev Suppl 1–212 (2013)
was documented and reported by those responsible for search
documentation. The recent audit revealed that the MECIR standards
related to the search documentation are still presenting challenges
to some authors. This includes, incorporating search strategies from
bibliographic databases, websites, and documentation relating to
carrying out update searches. Conclusions: Keeping track of the
search documentation is applicable to any extensive search, including
Cochrane and non-Cochrane systematic reviews, health technology
and guidelines.
Incorporating the economic evidence in
systematic reviews of interventions: an example
from a systematic review in prophylaxis
of respiratory syncytial virus infection
Rojas MX1 , Rueda JD1 , Andabaka T2
Department of Clinical Epidemiology and Biostatistics. Pontificia
Universidad Javeriana, Colombia. Andean Branch of the Iberoamerican
Cochrane Centre.; 2 School of Medicine. University of Split, Croatia
Background: In order to address economic issues within a systematic
review (SR) of interventions, a SR of economic evaluation (EE) studies
focusing on the same interventions might be carried out. The value
of a SR of EEs is still open to debate. However, in some cases
undertaking a SR of EEs is fundamental due to the economic impact
that the new intervention could have, and the number of EE assessing
its cost-effectiveness that are published. In those cases the synthesis
of evidence will be more useful than that available from individual
studies. Objectives: To describe methodological challenges of
synthetizing the economic evidence, given the disparities across EEs,
while performing a SR of interventions. To illustrate a coherent
way of incorporating economic eviden