How can the Campbell/Cochrane Collaborations be integrated in the PAHO ICT strategy for Evidence-Based Policy for Health

1. How can the Campbell/Cochrane Collaborations be integrated in the PAHO ICT strategy for Evidence-Based Policy for Health Equity?

2. OUTLINE What are the Cochrane/Campbell Collaborations? Are they appropriate for the ‘Gibbons Mode of Production’? Do they include useful information for evidence-based policy for health equity? Can they be usefully linked into public good telecenters such as the Virtual Health Library, Observatories?

3. OUTLINE What are the Cochrane/Campbell Collaborations?

5. Cochrane-Why needed: 1. No Decision maker, clinician or citizen can stay abreast of the literature. 2. Textbooks become quickly out of date 3. Editorial and reviews without SYSTEMATIC* methods are biased and unreliable. 4. MEDLINE and EMBASE cover only half of the world’s journals 5. Trials when found are usually too small individually to have Statistical Power ie Run the risk of missing important results. 6. Even when Systematic Reviews are systematic and high-quality, they become out of date!

6. Cochrane is the ‘Factory’ producing evidence-based systematic reviews.This is separate from the ‘Application Contexts’- where Derivatives are more appropriate.so the VHL and Observatories are complementary not competing.

7. The Cochrane Collaboration Evidence synthesis ‘factory’ policy-makers practitioners consumers Primary studies DERIVATIVES: Dissem/Application

8. Cochrane [and Campbell] will provide the evidence itself BUT they do NOT make policy/ clinical recommendations Increasing establishment of ‘Derivatives’ that package the information for the different users -eg the Policy/Decision-Makers

9. The Cochrane Collaboration Evidence synthesis ‘factory’ policy-makers practitioners consumers Primary studies DERIVATIVES: Dissem/Application Paper/ Disc/CD/Web

10. The Cochrane Collaboration Evidence synthesis ‘factory’ policy-makers practitioners consumers Primary studies DERIVATIVES: Dissem/Application Web; ? VHL ? Observatory

11. What / Who was Cochrane?

12. Archie Cochrane

13. You should consider Archie Cochrane’s book ‘Effectiveness and Efficiency’ for your ‘Desert Island Texts’ of the top 10 books that have made an enormous impact! • 100 pages long • The basis for his parading before the UK Parliament when they were designing the National Health Service - he ‘wore’ a ‘Sandwich Board’ stating: • ‘All Effective Health Care should be free’

14. The Cochrane Collaboration

15. What does this Logo mean?

16. The logo represents meta-analysis of 7 trials of IM corticosteroids given to mothers for foetal maturation in preterm infants [Chalmers et al].

17. In 1992 , the year the Cochrane Collaboration was established it was shown in the UK and US, only 15% of babies born weighing less than 2000gms were receiving antenatal steroids. • In the US, it was estimated that cost-savings would be $3000 per neonate and increasing the frequency from 15% to 60% would save I/3rd of the deaths and $160 million US $.

18. Cochrane Collaboration Objectives To help people make well informed decisions by preparing, maintaining and promoting access to systematic reviews of studies on the effects of health and health care practices and policies.

19. Cochrane Collaboration Entities • COCHRANE CENTRES - 15 • Americas: • Brazilian • Canadian • IberoAmerican • [Mexico {Dr Gladys Faba},Columbia,Chile, Argentina] • U.S.A. • New England, San Francisco

20. Collaborative Review Groups - 50 Consumers & Communication Drugs and Alcohol Group EPOC:Effective Practice & Organisation. Infectious Disease Tobacco Addiction Fields - 10 Complementary Medicine Child Health Health Promotion & Public Health Vaccines Methods Working Groups - 16 Economics Non-randomized studies Networks - 1 Consumer Network Cochrane Collaboration Entitieswith potential equity-orientation

23. Cochrane reviews cited in national/international guidelines/policies relevant to the ten projected leading causes of Disability-Adjusted Life Years in 2020, DEVELOPED REGIONSIschaemic heart disease YesCerebrovascular disease YesUnipolar major depression YesTrachea, bronchus and lung cancers YesRoad traffic accidents YesAlcohol use YesOsteoarthritis YesDementia YesChronic obstructive lung disease YesSelf-inflicted injuries Yes

24. Cochrane reviews cited in national/international guidelines/policies relevant to the ten projected leading causes of Disability-Adjusted Life Years in 2020, IN DEVELOPING REGIONSUnipolar major depression YesRoad traffic accidents YesIschaemic heart disease Yes Yes Chronic obstructive lung disease Yes Cerebrovascular disease YesTuberculosis YesLower respiratory tract infections YesWar injuries YesDiarrhoeal diseases YesHIV infection Yes

25. USE IN POLICY MAKING • UK National Health Service (NHS) requires NHS Trusts and Health Commissions to use Cochrane Library evidence to guide decisions re health care provision

26. OTHER APPLICATIONS • Research agencies now insisting on Cochrane reviews of existing knowledge to justify need for new research • United Kingdom • Australia • Denmark

28. Sally Macintyre was at inaugural meeting and can give more details!

34. OUTLINE What are the Cochrane/Campbell Collaborations? Are they appropriate for the ‘Gibbons Mode of Production”? Do they include useful information for evidence-based policy for health equity? Can they be usefully linked into public good telecenters such as the Virtual Health Library, Equity Observatories?

35. Gibbons New Mode of Production for improved utilisation of scientific Information- elements presented by Dr Pellegrini: Networks of Collaboration Transdisciplinary: Involve Decision makers, researchers, users, funders. Problem Based Multidirectional Can be used in different methods of application

36. Guiding principles • Collaboration • Building on the enthusiasm of individuals • Avoiding duplication • Minimizing bias • Keeping up to date • Ensuring relevance • Ensuring access • Continually improving the quality of its work • Continuity • Enabling wide participation

37. OUTLINE What are the Cochrane/Campbell Collaborations? Are they appropriate for the ‘Gibbons Mode of Production”? Do they include useful information for evidence-based policy for health equity? Can they be usefully linked into public good telecenters such as the Virtual Health Library, Observatories?

38. Do they include useful information re Equity? Cochrane: 31 Reviews/Protocols identified with search for ‘Equity, Disadvantaged,Socioeconomic’ Effects of systems of physician payment. Access to Breast Cancer Screening Daycare for Preschool Children Home Based Social support for socially disadvantaged mothers Infectious Disease : HIV Prevention/Rx, TB therapy Psychiatric Disorder Reviews Adolescent Pregnancy Smoking Alcohol Drugs

39. Do they include useful information re Equity?Campbell Collaboration: Social Work and Social Welfare Review Groups Interventions: Fiscal Policies: Welfare Allowance/Economic Support Public Policies: Housing, Employment, Transport, Environment Affirmative Action Social Work Minority Services Social Services Substance Abuse

40. Do they include useful information re Equity?Campbell Collaboration: Social Work and Social Welfare Review Groups Fiscal Policies: Welfare Allowance/Economic Support- Strategies aimed at the prevention and amelioration of social problems eg poverty, unemployment, social justice. Examples: Antipoverty Programs Programs aimed at addressing inequitable distribution of Wealth Means tested Benefits Child Support Welfare Policies Workfare/Welfare to work.

41. Q: Do the Cochrane and Campbell Collaborations offer useful information for evidence-based policy for health equity? A: They are promising but discussions needed to optimise the potential.

42. OUTLINE What are the Cochrane/Campbell Collaborations? Are they appropriate for the ‘Gibbons Mode of Production”? Do they include useful information for evidence-based policy for health equity? Can they be usefully linked into public good telecenters such the Virtual Health Library, Equity Observatories?

43. Campbell/Cochrane - Can they be usefully linked into the VHL, Observatories? Cochrane and Campbell will provide the evidence itself BUT they do NOT make policy/ clinical recommendations ‘Derivatives’ eg public health telecenters such as VHL and Observatories are needed-that package the information for the different users -eg the Policy/Decision-Makers

44. The Cochrane Collaboration Evidence synthesis ‘factory’ policy-makers practitioners consumers Primary studies DERIVATIVES: Dissem/Application Web; ? VHL ? Observatory

45. Campbell/Cochrane - Can they be usefully linked into the VHL, Observatories, Telecenters? ‘DERIVATIVES’ with ‘Cochrane-Inside’ [cf Intel-Inside] Already developed for Clinicians and Consumers BMJ Books: Clinical Evidence Web-based : VHL, UpToDate Counselling Decision Aids - Paper, telephone, cassette, web Policymakers: Logical to consider for this the PAHO Equidad listserve, Practica Medica Effectiva, VHL, Observatory Initiative .

46. Campbell/Cochrane - Can they be usefully linked into the VHL, Observatories? VHL Cochrane- Dr Abel Packer showed me the Cochrane link! VHL Campbell: need to discuss with Bob Boruch and Steering Committee Observatory - Recommend discussions with both Collaborations [Boruch and Chalmers].

47. Summary: Points Covered What are the Cochrane/Campbell Collaborations? Are they appropriate for the ‘Gibbons/Pellegrini Mode of Production”? Do they include useful information for evidence-based policy for health equity? Can they be usefully linked into public good telecenters such as the Virtual Health Library, Observatories?

48. CAVEAT There are many unresolved issues with Cochrane [and likely with Campbell] Short duration of trials for ethical reasons yet one wants longer/lifetime time projections Methodologic issues re combinability of studies. Equity issues will add another layer of complexity Important to add to Research Agenda.

49. Conclusion Infotech/TIC has enormous potential to help in the war against inequalities and inequities, as long as evidence-based ‘conquering of inequity’ is the driving force, and NOT just the ‘gee-whiz’ of the technology. Pleasing that we discussed the substantive content before the Infotech/TIC discussion.

50. . On a broader note re the whole meeting, I Am impressed that the Pan American Health Organisation Strategy and the design for its implementation as discussed in this conference is making an important contribution to this complex area.