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

1. Cochrane reviews and guideline development: is there anything new under the sun? Professor Cindy Farquhar Cochrane Menstrual Disorders & Subfertility Group NZ Cochrane Branch of the Australasian Cochrane Centre New Zealand Guidelines Group National Women’s Health University of Auckland

2. There’s been a culture change Reasoning based on patho-physiology Randomised controlled trials Guidelines Improved health care Reasoning based on observational studies Systematic reviews

3. Why systematic reviews? Too many studies to consider individually Assists in identifying gaps and planning new research Identifies effective and ineffective treatments Better quality than traditional reviews which tend to be haphazard, biased and contradictory Reduced bias - explicit about inclusion and exclusions, study quality is assessed, more generalisable and greater power

4. Using evidence to improve care? Failure to translate research finding into clinical practice means: 30-40% patients do not get treatments of proven effectiveness 20-25% patients get care that is not needed or potentially harmful Schuster et al 1998 Milbank Memorial Quarterly R Grol (2001) Med Care

5. The Cochrane Collaboration Preparing, maintaining and disseminating systematic reviews of the effects of health care

6. Cochrane Collaboration: mission an international not-for-profit organisation which aims to help people makewell-informed decisions about healthcare by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of health care interventions

7. Scope Questions of clinical intervention Reviews of diagnostic test accuracy Effective practice and organisation of care reviews (eg workforce, quality improvement) Consumer and communication reviews (eg effective methods of consent, ways of involving consumers in research and policy) Public health reviews (eg prevention of childhood obesity, school based interventions)

8. The Cochrane Collaboration in 2011 22,000 contributors in 100+ countries 52 Cochrane Review Groups 13 Cochrane Centres (and branches)* 4100 completed reviews 1900 protocols for reviews underway 600,000 references to completed and ongoing trials in Cochrane Controlled Trials Register

9. Better quality reviews “..we observed far superior reporting standards of Cochrane reviews compared to non-Cochrane therapeutic ones.” “For therapeutic reviews, all the Cochrane ones reported assessing the quality of included studies whereas only half of the non-Cochrane did (43/87 [49.4%]).” “The seven industry supported reviewsthat had conclusions recommended the experimental drug withoutreservations, compared with none of the Cochrane reviews (P= 0.02), although the estimated treatment effect was similaron average (z = 0.46, P = 0.64).”

10. IOM report Overall endorsement of Cochrane Standards Risk of “cutting corners” Reporting bias & unpublished studies Importance of licensing agency data Observational studies Knowledge translation and implementation Relevance, applicability and timeliness

11. The rise and rise in the number of systematic reviews

12. 12 Year-on-year total Abstracts & Full Text downloads (Wiley data only)

13. Cochrane Library and National Licence

14. New Zealander’s use of Cochrane Library

15. Clinicians reliable summary of research inform practice inform patient

16. Podcast feature 16

17. Consumers

18. Policy makers

19. So what is new …..under the sun?

20. So, what’s next? Content development Improved presentation Flexible delivery Partnerships with stakeholders

21. Content development Ensure consistent high quality Improve timeliness Improve accessibility More SoF tables Shorter reviews Different types of review Overviews/Multiple comparison reviews Diagnostic test accuracy reviews Health systems / qualitative reviews

22. GRADE and Summary of Findings table

23. Benefits of GRADE Outcome focussed Provides a summary of key findings Direction and magnitude of any effect Confidence in effect Flexible, intuitive Transparent www.gradeworkinggroup.org

24. Improved presentation

26. Plain language summaries

30. Flexible delivery

31. Accessibility

32. The Cochrane Library on IPAD

33. www.cochranelearning.com password: drcochrane

35. Cochrane Partnerships WHO January 2011 awarded The Cochrane Collaboration a seat on the World Health Assembly allowing the Collaboration to provide input on WHO health resolutions Guidelines Groups Guideline International Network partners with Cochrane

36. And now for guidelines

37. The problem : the ‘know-do’ gap ‘There is a gap between today’s scientific advances and their application: between what we know and what is actually being done. Health work teaches us with great rigour that action without knowledge is wasted effort, just as knowledge without action is wasted resource’. LEE Jong-Wook, past WHO Director General

38. The New Zealand Guidelines Group NZGG is funded by government but is an independent incorporated society Vision Reduce inequalities and improve health outcomes for all New Zealanders Mission Lead the health and disability sectors in driving the effective use of reliable evidence

39. NZGG record in evidence ….. Guidelines – 30 reports including 5 explicit evidenced based reports Evidence and technical reports - 30 Consumer work – 1 major report on development of a consumer forum Complementary and alternative medicine reports – 16 In process – implementation projects, 2 guidelines projects, rapid reviews

40. Cancer topics Breast cancer (2009) Melanoma (2009) Cancer investigation, referral & reduction of disparities (2009) Prostate cancer (2010) Bowel cancer (underway) National Cancer Network (for protocols for chemotherapy)

41. Cardiovascular guidelines: all in one place Cardiovascular Risk assessment and diabetes screening Cardiac risk factor management Smoking cessation Atrial fibrillation and flutter Coronary heart disease Stroke and transient ischaemic heart disease Rheumatic heart disease Prevention of infective endocarditis Heart failure

42. Mental Health Topics Suicide and self harm prevention guidelines (2004) Depression guidelines (2008) Autism Spectrum Disorders (2008)

43. Other topics Gynaecology Heavy menstrual bleeding Fibroids Fertility treatments (ICSI and assisted hatching) Obstetrics Vaginal birth after caesarean section Breech management Injuries Hip fractures Knee injuries Shoulder injuries Management of burns Fluoride for communities

44. But....... We are not complacent......There are challenges ahead!

45. Some of the challenges Our guidelines are big (and costly) Tension between quality, affordability and usefulness Lack of knowledge about where the true evidence-practice gaps are Lack of national data Lack of insight into the bigger/national practice issues Electronic platforms for guidelines Many available But costly….

46. The opportunities New Zealand has a well developed primary care sector “better, sooner, more convenient health care” – connecting primary and secondary health care Newly established Health Quality and Safety Commission We have a focus on new initiatives and innovations…

47. Can we use our electronic connections... NZ Primary Care Doctors use electronic patient medical records

48. 48 Doctor Routinely Receives Reminders for Guideline-Based Interventions or Screening Tests 73 72 54 49 47 39 27 21 16 16 10 Percentages may not sum to totals because of rounding. Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

49. NZGG: what’s new …. Smaller more focused guidelines Prioritised clinical questions More partnerships clinicians, health care organisations, researchers, patient groups More implementation*

50. NZGG’s Implementation Approach Identify key themes to promote Identify the range of audiences – and find out how they want to learn about the messages Primary care, Specialists, Allied health practitioners Consumers and the media Policy makers and funders Software vendors

51. Then we consider… Barriers to implementation Workforce requirements Cost implications Identify incentives that could encourage uptake of the guideline

52. NZGG recent implementation examples Whakawhanuatanga– implementing the suicide and self harm guidelines in emergency departments Autistic spectrum guidelines - Rapid E for priority change area

53. What is a Priority Change Area? It’s an area where there are problems with current practice or service delivery, Examples - where one or more of the following apply: high degree of variation from evidence-based best practice or service delivery Potential for high impact on patient outcomes if practice or service delivery were to become evidence-based Potential for this impact to occur for Maori, Pacific or Asian populations Potential for patients to reach critical points in the care pathway more quickly An area of important or worrying uncertainty about what is best practice.

54. ‘Rapid – E’ is a combination of… Tight and limited topics Clinical evidence review (from existing high quality guidance or from new review) Implementation evidence review Implementation plan Production of media / resources / change tools for active sector engagement Measurement

55. Rapid E Diabetes tools will be launched at the College of GP conference a package of algorithms CME and promotion/education

56. Making it work Stroke guidelines Collaboration between Australian and New Zealand, Stroke Foundation, Colleges 347 pages long 10 chapters

57. From the guideline to the local clinical pathway……

58. Summary Evidence is at the heart of health strategy Evidence needs to be highest possible quality Cochrane groups and New Zealand Guidelines Group are well positioned to deliver high quality evidence to inform decision making Your support and constructive feedback are crucial

59. Thank you