Publications
APS Bulletin • Volume 14, Number 1, 2004
Palliative Care
Arthur G. Lipman, PharmD, Department Editor
Evidence-based Pain Management and Palliative Care: The Cochrane Collaboration and its Pain, Palliative, and Supportive Care Collaborative Review Group
Arthur G. Lipman, PharmD FASHP
Evidence-based medicine (EBM) is defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients (Sackett et al, 1996). The United States has been slower to adopt EBM than the United Kingdom (UK), Canada, and other nations with national health services that mandate evidence-based care. But EBM is increasingly recognized throughout the United States as the most effective way clinicians can provide effective care.
The Cochrane Collaboration, an international not-for-profit organization that prepares, maintains, and disseminates systematic reviews of the effects of health care, is at the forefront of promoting EBM. The Collaboration is named for the British physician and epidemiologist Archie Cochrane, who, in 1987 (the year before he died), referred to a systematic review of randomized controlled trials (RCTs) of care during pregnancy and childbirth as “a real milestone in the history of randomized trials and in the evaluation of care,” suggesting other specialties emulate the methods used. Cochrane emphasized reviews of research evidence must be prepared systematically and kept up to date to include new evidence.
The Cochrane Collaboration
The Collaboration developed in response to Cochrane’s call for systematic, up-to-date reviews of all relevant healthcare RCTs. The methods used to prepare and maintain reviews of controlled clinical trials and advocated by Cochrane were adopted by the UK National Health Service (NHS). Just over a decade ago, the NHS provided funds to establish a Cochrane Center to collaborate with others in the UK and elsewhere to facilitate systematic reviews of RCTs across all areas of health care.
In October 1992, the Cochrane Center opened in Oxford to create a collaborative international response to Cochrane’s agenda. This idea was outlined at a meeting organized 6 months later by the New York Academy of Sciences. In October 1993, 77 people from 11 countries attended what became the first Cochrane Colloquium, at which they founded the Cochrane Collaboration. In October 2003, nearly 1,000 of us from around the world attended the 11th Cochrane Colloquium in Barcelona, Spain.
Cochrane Collaboration Principles
The Cochrane Collaboration helps people make well-informed healthcare decisions by preparing, maintaining, and ensuring the accessibility of systematic reviews of the effects of healthcare interventions. A trip to the Cochrane Collaboration Web site at www.cochrane.org provides a wealth of organizational information; the document, “A Brief Introduction,” outlines the Collaboration’s mission statement, principles, and structure. In summary, the Collaboration is built on 10 principles: collaboration, building on the enthusiasm of individuals, avoiding duplication, minimizing bias, keeping up to date, striving for relevance, promoting access, ensuring quality, continuity, and enabling wide participation. Evidence-based healthcare concepts are foundational to the Cochrane Collaboration. Much has been written in this area, and useful references are readily available; two examples are listed in this article’s reference list (Dawes et al., 2000; Wiffen, 2001).
A systematic review is the best method to identify, select, and critically appraise all relevant research on the effectiveness of a treatment. Aspects of the Cochrane Collaboration and of its main publication, The Cochrane Library, have been described elsewhere (Wiffen & Fairman, 2001). Patients, clinicians, and health policy makers can use systematic review evidence to define optimal care and keep up to date about the effectiveness of new treatments. Systematic reviews undertaken by the Cochrane Collaboration are published in The Cochrane Library, which is available by subscription as a CD-ROM (issued quarterly) or online via the Internet. Published reviews include background and methods, a detailed analysis with graphical displays where appropriate, an abstract, and a 100-word synopsis (the clinical “bottom line”).
The Cochrane Library includes these healthcare databases:
- The Cochrane Controlled Trials Register, a bibliographic database of controlled trials that contains more than 300,000 references to randomized controlled trials
- The Database of Abstracts of Reviews of Effectiveness (DARE), which features structured abstracts of more than 2,000 systematic reviews that have been critically appraised by reviewers at the NHS Center for Reviews and Dissemination in York and by others from organizations such as the American College of Physicians’ Journal Club and the journal, Evidence-Based Medicine
- The Cochrane Methodology Register, a bibliography of articles on the science of research synthesis.
Cochrane Library contents are compiled through the activities of six key structures that comprise the Cochrane Collaboration: Cochrane Centers, Fields, the Consumer Network, Methods Groups, the Steering Group, and Collaborative Review Groups (CRGs).
Cochrane Centers
Cochrane Centers are located worldwide (two in North America; seven in Europe, and one each in Asia, Africa, Australasia, and South America). Centers share responsibility for helping to coordinate and support members of the Collaboration through the provision of training, translations, and funding, and they promote the objectives of the Collaboration at national levels.
Fields
Fields are Cochrane groupings that focus on dimensions of health care other than health problems, such as the setting of care (e.g., primary care), the type of consumer (e.g., older people), the type of provider (e.g., nurses) or the type of intervention (e.g., physical therapies). People working in fields or networks hand-search specialty journals, help to ensure priorities and perspectives in their field of interest are reflected in the work of collaborative review groups, compile specialized databases of reviews, coordinate activities with relevant agencies outside the Collaboration, and comment on systematic reviews relating to their particular area.
Consumer Network
The Cochrane Consumer Network works to ensure the perspectives and needs of consumers are incorporated into Cochrane systematic reviews and into the operation of the Cochrane Collaboration. Consumers participate throughout most of the organization. Collaborative review groups, fields/networks, and Cochrane centers all seek input and feedback from consumers, which the Cochrane Collaboration considers essential to fulfill its goals.
Methods Groups
Methods groups comprise individuals with an interest and expertise in the science of systematic reviews. They provide advice and support to the Collaboration and individual reviewers in the development of the methods of systematic reviews. As they carry out their reviews, reviewers employ a series of methods to assemble, appraise, and sometimes synthesize data from the trials that are relevant to their questions. In doing so, they draw on the work of Cochrane methods groups, methodologists who have come together to improve the validity and precision of systematic reviews.
Steering Group
The Cochrane Collaboration Steering Group is elected to develop policies and strategies for the Collaboration. It has several subgroups responsible for specific tasks.
Collaborative Review Groups
An international multidisciplinary group from around the world that shares an interest in developing and maintaining systematic reviews relevant to particular health areas comprises CRGs. Groups are coordinated by an editorial team that edits and assembles completed reviews for inclusion in the Cochrane Library. There are currently 50 CRGs based in a number of countries, each addressing a particular healthcare area. The Pain, Palliative, and Supportive Care Group (PaPaS) is one such group, and has its editorial base at the Pain Research Unit, Oxford, UK. PaPaS strives to generate evidence about the effectiveness of healthcare treatments relevant to the prevention and treatment of pain; the relief of symptoms resulting from the disease process, interventions used in the management of the disease, and symptom control (i.e., palliative care in its widest sense); and the support of patients and caregivers through the disease process.
Examples of Cochrane Library reviews from the palliative care field include:
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The coordinating editor of PaPaS, Phillip Wiffen, MSc MRPS, based in Oxford, UK, coordinates palliative and supportive care reviews. Dan Carr, MD, at the New England Medical Center and Tufts University School of Medicine in Boston, MA, coordinates pain reviews, and Doug McCrory, MD, at Duke University in Durham, NC, coordinates headache reviews. Art Lipman, PharmD, at the University of Utah Pharmacotherapy Outcomes and Pain Research Groups at the University of Utah in Salt Lake City, is currently developing a third U.S. PaPaS subcenter assisting with pain and palliative care reviews.
PaPaS has an international team of editors and peer reviewers including clinicians, investigators, statisticians, and consumers who support and advise the individuals who are preparing systematic reviews. More than 100 people based in 18 countries currently contribute to PaPaS reviews. Most reviewers are practitioners who are researching review topics in their own time; some are researchers who have obtained funding to work full-time on a review, or are undertaking a review as part of a higher degree.
Unfortunately, PaPaS cannot provide funding to undertake reviews; however, in-kind help (assistance with literature and bibliographic searches, non-English translation, formatting, etc.) is provided with training, and mentors support new reviewers and assist with the development of search strategies to identify trials appropriate for inclusion in systematic reviews. PaPaS maintains a database of all known RCTs and clinical controlled trials related to pain and palliative and supportive care, regardless of language of publication. This database is used as a resource by reviewers to identify trials for possible inclusion in systematic reviews.
Many quality pain and palliative care trials have been running for more than 40 years. Almost 20,000 RCTs have been identified across all types of pain and interventions, including pharmacology, physical, psychological, and complementary medicine. Within palliative care, more than 1,200 studies have been identified, many of which describe palliative chemotherapy. Within many health systems, palliative care research interest and activity are growing rapidly, but many key questions remain unanswered, and our understanding of treatment for a number of conditions is lacking. The concept of evidence-based methodologies is just now becoming established in the area (Lipman, Jackson, & Tyler, 2000; Wiffen, 1998). The palliative care literature is not prominent in the bibliographic databases. The PaPaS group actively has been hand-searching palliative care journals to find the relevant studies, but it has identified a number that are not readily available and others that are only published in Asian languages. A systematic review should describe the whole of the world’s literature on a topic; English language papers alone are not sufficient.
To learn more about the Cochrane Collaboration, the Cochrane Library, and the PaPaS group, visit the Collaboration Web site at www.cochrane.org.
References
Dawes, M., Davies, P., Gray, A., Mant, J., Seers, K., & Snowball, R. (2000). Evidence-based practice. London: Churchill-Livingstone.
Lipman, A., Jackson, K., & Tyler, L. (2000). Evidence-based Symptom Control in Palliative Care. New York: Pharmaceutical Products Press.
Sackett, D.L., Rosenberg, W.M., Gray, J.A., Haynes, R.B., & Richardson, W.S. (1996). Evidence based medicine: What it is and what it isn’t. British Medical Journal, 312, 71–72.
Wiffen, P. (1998). Evidence-based care at the end of life. Palliative Medicine 12, 1–3.
Wiffen, P. (2001). Evidence based pharmacy. Oxford: Radcliffe Medical Press.
Wiffen, P.J., & Fairman, F.S. (2002). The Cochrane Collaboration Pain Palliative and Supportive Care Collaborative Review Group. Journal of Pain & Palliative Care Pharmacotherapy, 16(2), 69–80. >
Arthur G. Lipman, PharmD FASHP, is professor, College of Pharmacy, director of clinical pharmacology, pain management and research centers, and a member of the Pain Medicine and Palliative Care Advisory Group, Huntsman Cancer Institute, and University of Utah Health Sciences Center, Salt Lake City, UT.
Please direct your comments or suggestions about this article or department to Arthur G. Lipman, PharmD FASHP, Department Editor, at alipman@hsc.utah.edu.