The South Asian Cochrane Network

Dr. Prathap Tharyan MD, MRCPsychProfessor of Psychiatry

Editor, Cochrane Schizophrenia GroupCoordinator, South Asian Cochrane Network

Prof. BV Moses Centre for Research and Training in Evidence Based Health Care

Christian Medical College, Vellore, India

EVIDENCE BASED MEDICINE

• “Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” (Sackett, et al 2001)

Why do we need EBM?

Wherever health care is provided and used, it is essential to know which interventions work, which do not work, and which are likely to be harmful.

This is especially important in situations where health problems are severe and the scarcity of resources makes it vital that they are not wasted

EBM has a particular relevance to the developing world

The chronology of an infection

Bitten by the Cochrane bug (Clive Adams) in 1995,in Oxford, UK

Protocol for systematic review published in Issue 1, 1996

Review published in Issue 1, 1997

Updated twice, in 2002 and 2005

An April Fool’s Day joke?

Kenneth Warren Prize 2002

Cochrane Colloquium in Stavanger

Statutory Warning!

Attending Cochrane Colloquia may be fatal

to your free time in years to come

The Cochrane Collaboration

Collaborative Review Groups

Fields

The Consumer Network

Centres

Steering Group Methods

Groups

South African

Australasian

Chinese

Brazilian

Nordic

German

ItalianIberoamerican

Dutch

UK

Canadian

New England

San Francisco

NZ Branch

Thai CochraneNetwork

SACN

Cochrane CentresCochrane Centres

Chinese

Exploratory meeting: Goa December 2004

South Asian Cochrane Network

Exploratory meeting at Goa; December 2004

The South Asian Cochrane Network

Network Sites in India

Vellore

ChennaiManipal

Mumbai

Delhi

Chandigargh

www.cochrane-sacn.org

Prof BV Moses Centre for Clinical Trials & EBM

Network Sites in Pakistan

Network Site in Sri Lanka

Ragama

Network Site in Bangladesh

Goals of the SACN

Goal 1: To raise awareness about the Cochrane Collaboration and evidence based practice in South Asia

Goal 2: To train and support contributors to the Cochrane Collaboration in South Asia

Goal 3: To promote access to The Cochrane Library for South Asia

Goal 4: To ensure a sustainable structure for the South Asian Cochrane Network

Goal 5: To represent and advocate for high quality research in South Asia

To train and support contributors to the Cochrane Collaboration in South Asia

Protocol Development Workshop CMC Vellore, July 2004

Protocol Development Workshop, Aga Khan University, Karachi, April 2006

Sensitization workshops

18 in different parts of India, Sri Lanka since 2005

Post Graduate Institute; Colombo Dec 05

Review Completion workshops

SACN participation in systematic reviews (Issue 3, 2005)

Country Reviews Protocols Titles Total

India 11 19 33 63

Pakistan 1 3 9 13

Sri Lanka 2 1 3

Nepal 2 2

Combined 15 23 42 81

SACN participation in systematic reviews (Issue 3, 2006)

Country Reviews Protocols Titles Total

India 15 23 39 77

Pakistan 3 6 9 18

Sri Lanka 2 2 3 7

Nepal 2 2

Combined 22 31 52 104

Growth of contributors in India

2000 2002 2003 2004 2005 2006

Authors 11 15 20 31 42 80

Editors 2 1 2 5 5 5

Others 2 15 18 28 19 35

Total 19 31 40 64 76 120

The Cochrane Collaboration’s response to the tsunami, 2004

Nagapattinam District 73 affected villages 1,96,184 population 36,860 homes 6053 human lives lost 5023 livestock perished 40 relief camps 36,664 people in camps

Evidence for interventions to be used after disasters?

Media pressure to provide counselling to survivors

Psychological debriefing for preventing post traumatic stress disorder (PTSD) (Cochrane Review). Rose S, Bisson J, Wessely S. In: The Cochrane Library, Issue 4, 2003.

Brief single session debriefing increases odds of PTSD in long term

The Cochrane Collaboration & the Asian tsunami

Tsunami working group Free country-wide access to the Cochrane

Library to all affected countries Evidence based summaries of relevant

effective interventions List of priority reviews that need updating List of interventions that need to be reviewed

www.cochrane.org

Usage statistics of The Cochrane Library (Jan-June 2005)

Country Jan Apr May June

Thailand 632 821 1527 1914

Indonesia 49 363 532 366

India 385 581 603 624

Malaysia 145 231 236 293

Pakistan 24 52 46 66

Sri Lanka 11 33 42 43

Dissemination of Evidence Aid Ministry of Health Indian Council of Medical Research Director General of Health Services Non-governmental aid agencies Following the Mumbai floods Following the earthquake in

Pakistan and Kashmir

Influencing health policy in India Workshop for senior faculty of the Indian

Council of Medical Research (ICMR) (October 10, 2006)

Using Cochrane reviews to inform health policy and care

Primaquine for preventing relapses in people with Plasmodium vivax malariaGalappaththy GN L, Omari AAA, Tharyan P. Cochrane Database for Systematic Reviews Issue 1, 2007

Background Plasmodium vivax infections contribute to a significant proportion

of the malaria infections in many countries. Primaquine is the most widely used drug for treating the dormant liver stage. Different primaquine dosing regimens are in use.

WHO recommends 15 days of Primaquine following chloroquine; India recommends 5 days of primaquine following chloroquine

Objectives To compare primaquine regimens for preventing relapses in

people with P. vivax malaria.

Search strategy We searched the Cochrane Infectious Diseases

Group's Specialized Register (January 2006), CENTRAL (The Cochrane Library 2006, Issue 3), MEDLINE (1966 to October 2006), EMBASE (1974 to January 2006), LILACS (1982 to January 2006), conference proceedings and reference list of articles. We also contacted researchers, the World Health Organization, malaria mailing lists, and selected pharmaceutical companies.

Selection criteria Randomised and quasi-randomised controlled

trials comparing (1) primaquine plus chloroquine with chloroquine alone and (2) the standard primaquine regimen (15 mg/day for 14 days) with other regimens containing primaquine in people with P. vivax malaria.

Data collection & analysis All authors independently assessed trial eligibility

and quality, and extracted data. We calculated odds ratios (OR) with 95% confidence intervals (CI) for dichotomous data, and used the random effects model if there was significant heterogeneity.

Main resultsNine RCTs (3423 participants) met the

inclusion criteria. Most from IndiaPakistan, Afganistan, Thailand

Reviewers' conclusions Primaquine (15 mg/kg/day for 14 days) plus

chloroquine is more effective than chloroquine alone or primaquine (15 mg/kg for 5 days) plus chloroquine in preventing relapses of P. vivax malaria.

Primaquine (five days) plus chloroquine appears no better than chloroquine.

Countries advocating the five-day regimen should follow the World Health Organization's recommendation of the 14-day primaquine plus chloroquine regimen.

Alternative regimens need to be evaluated in randomised controlled trials, which should also consider variations in regional P. vivax strains and the possibility of primaquine resistance, re-infection, and adherence in those who relapse.

Promoting access to The Cochrane Library

Promoting access to the Cochrane Library Many countries have a national provision Many countries have free access via Bireme,

HINARI, INASP/PERI India in low income group but not eligible Previous attempts to get ICMR/DBT to purchase

a national subscription had failed ICMR/DST purchased national subscription to

Cochrane Library- deal brokered by SACN with John Wiley & Sons

“Developing countries like India, with limited resources and many competing priorities, are even more in need than developed countries of the wherewithal to access the best scientific evidence in order to make informed decisions about health care policy and practice, and to improve the health of what amounts to one sixth of humanity. The ICMR has shown tremendous leadership and commitment in getting to this point…..”

(Dr. Tikki Pang, Director, Research Policy and Cooperation, World Health Organization)

Free access to the Cochrane Library to anyone in India

The Telegraph, Kolkatta; Feb 3, 2007

Free access to the Cochrane Library to anyone in India

Free access to the Cochrane Library to anyone in India

ICMR Advanced Centre for Research and Training in

Evidence Based Healthcare at CMC Vellore

Goal I: Build capacity among network sites of the South Asian Cochrane Network

Theme 1 Building/increasing capacity, support and co-ordination of network sites in India

Activity 1.1 Establish a ‘train-the-trainers’ program to build training capacity at the Network sites across India

Activity 1.2 Co-ordinate Cochrane systematic review training

activities in India Activity 1.3 Monitor Cochrane Systematic review training

activities in India Activity 1.4 Identify areas of strengths in network sites and

facilitate the development of programmes that optimally use these strengths to design activities that further the overall goals of the proposal

GOAL 2: Identifying and prioritizing

locally relevant areas for research Theme 2 Prioritizing systematic reviews and identifying

evidence-practice gaps Activity 2.1 In collaboration with clinicians, policy makers,

researchers and consumers identify areas where evidence exists but needs to be synthesized in systematic reviews

Activity 2.2 In collaboration with clinicians, policy makers, researchers and consumers identify areas where randomized trials are required

Activity 2.3 Encourage funding agencies / ethics committees to require that evidence from systematic reviews is included in funding applications for randomized trials before new trials are funded / permitted

GOAL 2: Identifying and prioritizing

locally relevant areas for research Theme 3 Training and supporting review authors in India Activity 3.1 Provide introductory sessions / workshops

regarding the role of systematic reviews in healthcare at local, regional and national conferences

Activity 3.2 Provide workshops that train review authors in developing protocols for systematic reviews

Activity 3.3 Provide workshops on basic and advanced statistics in meta-analysis

Activity 3.4 Provide workshops to help authors’ complete systematic reviews

Activity 3.5 Provide mentorship programmes for review authors Activity 3.6 Providing help in running searches for trials and

retrieving trials to include in systematic reviews Activity 3.7 Develop distance learning technology/packages for

systematic reviews

GOAL 2: Identifying and prioritizing

locally relevant areas for research Theme 4 Maintaining a register of published and

unpublished trials from South Asia Activity 4.1 Establish a register of published trials from Indian

and South Asian Medical and International journals conducted in India and South Asia

Activity 4.2 Hand-search South Asian journals that are not indexed to identify clinical trials

Activity 4.3 Search conference proceedings from South Asia for unpublished trials

Activity 4.4 Establish a register of dissertations to identify unpublished trials

GOAL 3 Informing healthcare decisions through the uptake of evidence from systematic reviews

Theme 5 Promoting use of The Cochrane Library Activity 5.1 Publicize the national provision to The

Cochrane Library Activity 5.2 Provide training on using The Cochrane

Library Activity 5.3 Evaluate existing training materials for The

Cochrane Library and develop additional training materials as required

GOAL 3 Informing healthcare decisions through the uptake of evidence from systematic reviews

Theme 6 Disseminating information in The Cochrane Library

Activity 6.1 Prepare and disseminate Evidence Updates (two-page summaries of Cochrane reviews) in areas of national health priority

Activity 6.2 Prepare and disseminate introductions to evaluating systematic reviews and Evidence Updates

Activity 6.3 Evaluate use of Evidence Updates by clinicians

GOAL 3 Informing healthcare decisions through the uptake of evidence from systematic reviews

Theme 7 Disseminate information about Systematic reviews, The Cochrane Library and Evidence Based Practice

Activity 7.1 Write articles in the lay press on evidence based practice

Activity 7.2 Write articles in medical journals on understanding and undertaking systematic reviews, and on evidence based practice

Activity 7.3 Encourage medical journal editors to include information about and links to the Cochrane Library, the Cochrane Collaboration and evidence based resources, and include evidence

based summaries in journal websites and in print editions

GOAL 4: Increasing capacity and skills for evidence-based practice Theme 7 Increase capacity among policy makers to

access, appraise, and implement evidence based policy Activity 7.1 Hold workshops for policy makers on the role of

systematic reviews, the Cochrane Library and other EBM resources in providing reliable evidence on interventions used in healthcare

Activity 7.2 Include policy makers in workshops that support the production of systematic reviews

Activity 7.3 Appraise national guidelines for the inclusion of evidence-based recommendations

Activity 7.4 Attempt to change policy through dissemination of reliable evidence from systematic reviews when needed

GOAL 4: Increasing capacity and skills for evidence-based practice Theme 8 Increasing capacity among clinicians to access,

appraise and implement evidence based practice Activity 8.1 Hold workshops in local, regional and national

conferences on evidence based practice Activity 8.2 Develop distance education tools in evidence based

practice and on auditing clinical practice against evidence-based guide lines

Activity 8.3 Identify barriers to evidence-based practice and develop strategies to implement such practice

Activity 8.4 Introduce modules on systematic reviews, critical appraisal and evidence based practice in undergraduate and postgraduate curricula

Activity 8.5 Develop and offer fellowships and short courses in research methods, critical appraisal, accessing evidence based guidelines and using evidence from systematic reviews

Activity 8.6 Attempt to get systematic reviews accredited as a legitimate research activity for post-graduate dissertations and MSc training programmes

GOAL 5: Improving the conduct and reporting of research in India Theme 9 Encourage the prospective registration of

clinical trials in India and the region Activity 9.1 Collaborate with the WHO International Clinical

Trials Registry Platform and the Indian Clinical Trials Register Activity 9.3 Evaluate the quality of conduct and reporting of

trials from India Activity 9.3 Strengthen the functioning of the Indian

Association of Medical Journal Editors Activity 9.4 Facilitate learning in the planning, implementing

and the conduct of clinical trials that are scientifically valid. Activity 9.5 Facilitate learning of ethical issues in the conduct

and reporting of clinical trials

GOAL 5 Improving the conduct and reporting of research in India Theme 10 Developing capacity for methodological

research in evaluating healthcare interventions Activity 10.1 Conduct methodological research in the

area of systematic reviews of interventions Activity 10.2 Undertake systematic reviews of diagnostic

tests Activity 10.2 Offer PhD programmes in evidence based

healthcare research Activity 10.3 Conduct pragmatic trials of

interventions when there is limited or no evidence

GOAL 6 Contributing to the Cochrane Collaboration and coordinating Cochrane activities in South Asia Theme 11 Establishing a South Asian Cochrane Centre

and Network Activity 11.1 Establish a South Asian Cochrane Centre and

Network with its coordinating centre at CMC Vellore as an independent Centre of the Cochrane Collaboration

Activity 11.2 Integrate training and support activities within all countries in South Asia

Activity 11.3 Host the mid-year meeting of Cochrane Centre Directors and Cochrane Collaboration Steering Group in Vellore in April 2008

Activity 11.4 Organize an annual EBM seminar/conference in different locations in India and the region

Lessons learned

“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it’s the only thing that ever has.”

[Margaret Mead]

The power of collaboration

EVIDENCE BASED MEDICINE

•“Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” (Sackett, et al 2001)Challenges:

Generalization of Evidence

Incorporating patient's values

Particularizing the Evidence

PROBLEMS WITH SYSTEMATIC REVIEWS & EBM No evidence of effect vs. Evidence of no

effect Evidence versus recommendations Evidence based medicine versus

Evidence based health care Conflicts of interest

FAITH OR FATE BASED MEDICINE

Traditional community resources for mentalhealth: a report of temple healing from India

BMJ 2002;325:38-40

•“Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” (Sackett, et al 2001)

Join us:www.cochrane-sacn.org

Protocol Development Workshop: June 25-27, 2007

CMC Vellore, INDIA

EVIDENCE BASED MEDICINE

“GOOD CLINICAL MEDICINE WILL ALWAYS BLEND THE ART OF UNCERTAINTY WITH THE SCIENCE OF PROBABILITY”

OSLERUsing GOOD QUALITY SYSTEMATIC REVIEWS TO PROVIDE EVIDENCE will increase the amount of science in the blend

If we produce evidence relevant to us, then EBM will have some relevance in the region