Cochrane Musculoskeletal Group

1
Cochrane Musculoskeletal Group Patient Decision
Aids

• Peter Tugwell

• May 25, 2013

2
Learning Objectives

• Update on the Cochrane Musculoskeletal Group
• Participants will learn different knowledge
  translation strategies to disseminate the results
  of systematic reviews.
• Participants will have an overview of 10
  different strategies and will be able to access
  them and/or get ideas to build their own

3
OUTLINE

1. Cochrane Collaboration
2. Cochrane Musculoskeletal Group
3. Knowledge Translation
4. 10 Ways of presenting Musculoskeletal Cochrane
   Reviews
5. More on Decision Aids

4
The Cochrane Library
5,131 completed reviews 2235 review
protocols 674,519 RCTs
5
Come to our party!

• 2013 is the 20th anniversary of the founding of
  the Cochrane Collaboration
• 21st global Cochrane Colloquium will be in Quebec
  City September 19th 23rd 2013

6
Cochrane Collaboration in 2013

• 40,000 contributors in 100 countries
• 25,000 authors
• 53 Cochrane Review Groups
• 13 Cochrane Centres

Please Join! Open to everyone who is committed
to the Cochrane Collaboration Principles
7
Global coverage of Cochrane Library ½ worlds
population now free one-click access
Green national license, Red free access, Blue
Institutions.
8
Impact factor of CDSR
5.963
top 10 highest General Medical journals
9
Impact factor of CDSR
Abstract downloadevery 2 seconds
5.963
Up from 5.653 in 2009
top 10 highest General Medical journals
Up from 14th in 2007
10
Impact factor of CDSR
Full text download3 seconds
5.963
Up from 5.653 in 2009
top 10 highest General Medical journals
Up from 14th in 2007
11
Impact Cochrane Inside
12
The Canadian Cochrane Network and Centre

• 2005-2010 Funded by
• CIHR
• CIHR Institutes
•  Institute of Gender and Health
•  Institute of Health Services and Policy Research
  
•  Institute of Human Development, Child and Youth
  Health
•  Institute of Infection and Immunity
•  Institute of Musculoskeletal Health and
  Arthritis
•  Institute of Nutrition, Metabolism and Diabetes
• CADTH (2005-2008)

13
Cochrane Musculoskeletal Group

• Registered in 1993 in Ottawa, Canada, the
  Cochrane Musculoskeletal Group
• 161 Cochrane Reviews in Cochrane Library
• 31 consumer representatives
• In 2005, a second editorial base was established
  at Cabrini Institute, University of Melbourne,
  Australia.
• Satellites in France, Scotland, Wales and USA.

14
May 2013 161 COCHRANE MUSCULOSKELETAL REVIEWS
15
Hot off the Press!

• Folic Acid with MTX in RA
• Shea et al

• Cochrane Musculoskeletal GroupIn press May 31,
  2013

16
Objectives
To perform a systematic review of the benefits
and harms of folic /folinic acid 1)in reducing
the mucosal, gastrointestinal, hepatic and
haematologic side effects of Methotrexate
(MTX). 2.) To assess whether or not
folic/folinic acid supplementation reduces MTX
benefit.
17
Flow chart
18
Results

• Best estimate of what happens to people who take
  folic acid or folinic acid while on MTX

19
(No Transcript)
20

Risk of Bias
21
Stomach problems such as nausea, vomiting or
abdominal pain

• 35 people out of 100 experienced stomach problems
  such as nausea when they took MTX alone for their
  rheumatoid arthritis
• 26 people out of 100 experienced stomach problems
  such as nausea when they took folic acid or
  folinic acid with their MTX.
• Thus 9 fewer people out of 100 experienced
  stomach problems such as nausea up to 6 to 12
  months after starting folic acid or folinic acid
  with their MTX (9.0 absolute improvement)

22
Liver problems (as measured by abnormal liver
blood tests)

• 21 people out of 100 experienced abnormal liver
  blood tests when they took MTX alone for their
  rheumatoid arthritis
• 5 people out of 100 experienced abnormal liver
  blood tests when they took folic acid or folinic
  acid with their MTX.
• Thus 16 fewer people out of 100 had liver
  problems up to 6 to 12 months after they starting
  folic acid or folinic acid with their MTX (16.0
  absolute improvement)

23
(No Transcript)
24
Folic acid and folinic acid for reducing side
effects in patients receiving methotrexate for
rheumatoid arthritis

• Conclusions. There was a clinically important
  significant reduction shown in
• the incidence of GI side effects,
• hepatic dysfunction
• discontinuation of MTX treatment for any reason.
• The results support a protective effect of
  supplementation with either folic or folinic acid
  for patients with rheumatoid arthritis during
  treatment with MTX.

25
OUTLINE

1. Cochrane Collaboration
2. Cochrane Musculoskeletal Group
3. Knowledge Translation
4. 10 Ways of presenting Musculoskeletal Cochrane
   Reviews
5. Decision Aids

26
Knowledge translation

• CIHR definition
• Knowledge translation is a dynamic and
  iterative process that includes the synthesis,
  dissemination, exchange and ethically-sound
  application of knowledge to improve the health of
  Canadians, provide more effective health services
  and products and strengthen the healthcare
  system.

27
Knowledge Translation

Knowledge to Action loop From Graham ID et
al. Lost in Knowledge Translation Time for a
Map? Journal of Continuing Education in the
Health Professions, 2006
27
28
OUTLINE

• Cochrane Collaboration
• Cochrane Musculoskeletal Group
• Knowledge Translation
• 10 Ways of presenting Musculoskeletal Cochrane
  Reviews
• esp Decision Aids

29
10 Formats for presenting Cochrane Review

• Knowledge Translation to Clinicians and Patients
  Update from Cochrane Musculoskeletal Group
• Tamara Rader, Jordi Pardo , Anne Lydiatt, Dawn
  Stacey, Elizabeth Ghogomu, Lara J.Maxwell,
  Jasvinder A. Singh, Rachelle Buchbinder, France
  Légaré, Nancy Santesso, Peter Tugwell.

30
10 Tailored KT Formats
Audience 45 minute 15 minute 5 minute 1 minute
Patients - To inform personal decisions Cochrane review Decision aid Plain language summaries Podcasts Key points of the Plain Language Summaries Cochrane tweets
Practitioners - To support shared decision making Journal Club Cochrane review Dr. Cochrane Decision Aid Summary Clinical scenarios in general medical journals Podcasts Summary of Findings Tables Plain Language Summaries Cochrane Tweets
Policy-makers - To use evidence in policy development Cochrane Review Podcasts Summary of Findings Table Plain Language Summaries
Public/Press Cochrane Review Podcasts Press releases Plain Language Summaries Cochrane tweets
31

• 10 Cochrane KT Formats
• Cochrane Reviews
• Cochrane Journal Club
• Cochrane Decision Aids
• Cochrane Corners in Journals
• Cochrane Summary of Findings Tables
• Cochrane Plain Language Summaries
• Cochrane Podcasts
• Cochrane _at_ Twitter
• Cochrane Clinical Answers
• Dr Cochrane

32
1 Cochrane reviews

33
1 Cochrane reviews

• Audience Policymakers, Practitioners, Public,
  Press
• Time 45 min to browse
• Consistent format, rigorous methods

34
(No Transcript)
35
2 Cochrane Journal Club
36
(No Transcript)
37
2 Cochrane Journal Club

• Audience Practitioners, Pupils
• Time 45 min
• Provides clinical results and context, a tool for
  teaching and self-directed learning

38
3 Cochrane Decision aids
39
3 Cochrane Decision aids

• Audience Patients, Practitioners
• Time 45 min for patients, 15 min summary for
  practitioners
• Supports shared decision making
• Key features
• options
• asks personal values/preferences
• benefits and harms
• quality appraised

40
Cochrane Review Etanercept Decision Aid

• Take etanercept (Enbrel) Once or twice a week,
  you have an injection under the skin in different
  parts of the thigh or abdomen. A nurse or doctor
  teaches you how to do this. A family member or
  friend can also learn. You store the drug in a
  refrigerator and warm it to room temperature
  prior to use. Most people who fear self-injection
  are able to give these injections with mild or no
  discomfort.
• Decline etanercept (Enbrel). You may wish to
  discuss other treatment options with your doctor
  

41
Cochrane Review Etanercept Decision Aid Step 1
What are the benefits ?
42
Cochrane Review Etanercept Decision Aid Step 1
Side Effects and Harms
43
Cochrane Review Etanercept Decision Aid Step 2
What matters most to you?
44
COCHRANE REVIEW DECISION AIDS http//musculoskelet
al.cochrane.org/Decision-aids

• Osteoarthritis
• What are my options for managing hip or knee
  arthritis?
• Should I use TENS (transcutaneous electrostimulati
  on) for osteoarthritis?
• Should I have ultrasound for osteoarthritis?
• Osteoporosis
• Should I take alendronate (Fosamax)to prevent
  fractures?
• Should I take etidronate (Didronel)to prevent
  fractures?
• Should I take risedronate (Actonel)to prevent
  fractures?
• Rheumatoid arthritis
• Should I take abatacept (Orencia)for rheumatoid
  arthritis?
• Should I take etanercept (Enbrel) for rheumatoid
  arthritis?
• Should I take tocilizumab (Actemra)for
  rheumatoid arthritis? 
• Should I take methotrexate (Rheumatrex)for
  rheumatoid arthritis?
• Should I take methotrexate (Rheumatrex)for rheuma
  toid arthritis alone or with other
  disease-modifying anti-rheumatic drugs (DMARDS)?

45
COMPARING MORE THAN ONE OPTION

• THE STEPPED CARE DECISION AID

46
Step 1 What are the benefits and harms of each
option?
100 faces illustrate the benefits of the
intervention
47
Physician receives a one page clinical summary
48
Web-Based Decision AidsLinda Li et al
49
(No Transcript)
50
(No Transcript)
51
The Animated Self-serve WEb-based Research
(ANSWER) toolLinda Li et al

• TOPICS
• About RA
• Methotrexate
• MTX Side Effects
• MTX and Pregnancy
• MTX and Alcohol
• Weighing the options

52
4 Clinical scenarios in journals

• Audience Practitioners
• Time 15 min
• Adds evidence to the clinical context

53
(No Transcript)
54
5 Cochrane Summary of Findings Table

• Audience Practitioners, Policymakers, Press
• Time 5 min
• Provide at-a-glance results of a systematic
  review, including gaps in the evidence.

55
SUMMARY OF FINDINGS TABLE Abatacept for rheumatoid arthritis SUMMARY OF FINDINGS TABLE Abatacept for rheumatoid arthritis SUMMARY OF FINDINGS TABLE Abatacept for rheumatoid arthritis SUMMARY OF FINDINGS TABLE Abatacept for rheumatoid arthritis SUMMARY OF FINDINGS TABLE Abatacept for rheumatoid arthritis SUMMARY OF FINDINGS TABLE Abatacept for rheumatoid arthritis SUMMARY OF FINDINGS TABLE Abatacept for rheumatoid arthritis
Patient or Population patients with rheumatoid arthritis Settings International clinic/hospital Intervention Abatacept (2 and 10 mg/kg) DMARDs/biologic Comparison Placebo DMARDs/biologic Patient or Population patients with rheumatoid arthritis Settings International clinic/hospital Intervention Abatacept (2 and 10 mg/kg) DMARDs/biologic Comparison Placebo DMARDs/biologic Patient or Population patients with rheumatoid arthritis Settings International clinic/hospital Intervention Abatacept (2 and 10 mg/kg) DMARDs/biologic Comparison Placebo DMARDs/biologic Patient or Population patients with rheumatoid arthritis Settings International clinic/hospital Intervention Abatacept (2 and 10 mg/kg) DMARDs/biologic Comparison Placebo DMARDs/biologic Patient or Population patients with rheumatoid arthritis Settings International clinic/hospital Intervention Abatacept (2 and 10 mg/kg) DMARDs/biologic Comparison Placebo DMARDs/biologic Patient or Population patients with rheumatoid arthritis Settings International clinic/hospital Intervention Abatacept (2 and 10 mg/kg) DMARDs/biologic Comparison Placebo DMARDs/biologic Patient or Population patients with rheumatoid arthritis Settings International clinic/hospital Intervention Abatacept (2 and 10 mg/kg) DMARDs/biologic Comparison Placebo DMARDs/biologic
Outcomes Illustrative comparative risks (95 CI) Illustrative comparative risks (95 CI) Relative Effect (95 CI) No of Participants (Studies) Quality of Evidence (Grade) Comments
Outcomes Placebo DMARDs/ biologic Abatacept (2 and 10 mg/kg) DMARDs/ biologic Relative Effect (95 CI) No of Participants (Studies) Quality of Evidence (Grade) Comments
ACR 50 improvement Follow-up 12 months 168 per 1000 371 per 1000(291 to 474) RR 2.21(1.73 to 2.82) 993 (3 studies) Moderate Absolute risk difference 21 (16 to 27). Relative percent change121 (73 to 182). NNT5 (4 to 7)
Painmeasured at end of study on a 100 mm visual analog scale. Scale from 0 (better to 100 (worse). Follow-up 12 months. The mean pain in the control group was49.24 mm The mean pain in the intervention group was 10.71 lower(12.97 to 8.45) 1425(1 study) Moderate Absolute risk difference -11 (-13 to -8.5). Relative percent change-18 (-22 to -14). NNT5 (4 to 6)
Improvement in physical function (HAQ greater than 0.3 increase from baseline, 0-3 scale) Follow-up 12 months 393 per 1000 637 per 1000(531 to 766) RR 1.62(1.35 to 1.95) 638(1 study) Moderate Absolute risk difference 24 (16 to 32). Relative percent change62 (35 to 195). NNT5 (4 to 7)
Achievement of low disease activity state (DAS 28 less than 3.2, scale 0-10)Follow-up 12 months 98 per 1000 424 per 1000(278 to 646) RR 4.33(2.84 to 6.59) 683(1 study) Moderate Absolute risk difference 33 (26 to 39). Relative percent change333 (184 to 559). NNT4 (3 to 5)
Total serious adverse eventsFollow-up 6 to 12 months 121 per 1000 127 per 1000(105 to 155) RR 1.05(0.87 to 1.28) 3151(6 studies) Moderate Absolute risk difference 1 (-2 to 3). Relative percent change5 (-14 to 29). NNTn/a
Long-term serious adverse eventsFollow-up 2 years See comment See comment Not estimable 950 (2 studies) Low Number of patients with SAE Genovese 2005 103/357 23.4 SAE/100 patient-years 70 completed the LTE. Kremer 2006 149/593 16.3 SAE/100 patient-years 90.5 completed the LTE
56
6 Plain Language Summary

• Audience Patients, Public, Press
• Time 5 min
• Provides same information from the Summary of
  Findings Table in plain language plus background
  information on the condition and intervention.

57
(No Transcript)
58
7 Cochrane Podcasts

• Audience Patients, Public, Press
• Time 5 min
• Author provides commentary on the results of the
  review and highlights of the findings.

59
(No Transcript)
60
8 _at_cochranelibrary (Twitter)

• Audience Public, Press
• Time 1 min
• Headline style news items and announcements

61
(No Transcript)
62
9 Cochrane Clinical Answers

• Audience Practitioners
• Time 15 min
• Uses Cochrane evidence to answer one clinical
  question at time, providing clinicians with the
  exact information they need.

63
(No Transcript)
64
10 Dr. Cochrane

• Audience Practitioners
• Time 15 min
• Dr Cochrane is a collection of online continuing
  professional education and development (CEPD)
  modules based upon Cochrane Reviews
• Uses a storyline to convey messages

65
Holes in one ,not holes in the stomach
Preventing NSAID ulcers Lorenzo Moja Italian
Cochrane Centre, Mario Negri Institute for
Pharmacological Research, Milan, Italy
These Dr Cochrane clinical vignettes are based on
Cochrane Reviews published in The Cochrane
Library. Dr Cochrane is a unique self-learning
experience the integration of Cochrane evidence
with a quirky fictional story and multiple-choice
questions provides readers with the opportunity
to explore and understand the applicability of a
Cochrane Review or Overview in a new way. In this
series of fictional clinical vignettes, Dr
Cochrane travels across time from the past
century to the present day, to solve clinical
problems using evidence from Cochrane Reviews.
Read the review and listen to the podcast of the
review and then test your knowledge with five
multiple choice questions. You can find the
answers at the end. It was a Saturday evening
and Dr Cochrane was enjoying some hors doeuvres
and a glass of Merlot at a cocktail party hosted
by his local golf club. Not long after arriving,
he bumped into Ellen and Terry, a couple that he
had known for quite some time. Archie quickly
caught up on what had been happening in their
lives, and Ellen and Terry were particularly
excited as their eldest son and his wife were
expecting a child. After toasting to the health
of their first grandchild, Archie helped himself
to more food, but Terry declined.
66

• 10 Cochrane KT Formats
• Cochrane Reviews
• Cochrane Journal Club
• Cochrane Decision Aids
• Cochrane Corners in Journals
• Cochrane Summary of Findings Tables
• Cochrane Plain Language Summaries
• Cochrane Podcasts
• Cochrane _at_ Twitter
• Cochrane Clinical Answers
• Dr Cochrane

67
Thankyou !

• Dont Forget!
• Come to our party!
• 2013 is the 20th anniversary of the founding of
  the Cochrane Collaboration
• 21st global Cochrane Colloquium will be in Quebec
  City September 19th 23rd 2013