Livia Puljak1*, Dalibora Rako2. Enhancing medical practice in Croatia through The Cochrane Collaboration. Biochemia Medica 2009;19(3):260-5. http://dx.doi.org/10.11613/BM.2009.024
1 Croatian Branch of Italian Cochrane Center, Department of Anatomy, Histology and Embryology, University of Split School of Medicine, Split, Croatia
2 Croatian Center for Global Health, University of Split School of Medicine, Split, Croatia
Corresponding author*: livia [at] mefst [dot] hr
Croatian Branch of Italian Cochrane Center was established in 2008 to promote evidence-based medicine, The Cochrane Collaboration and The Cochrane Library in Croatia, and to encourage Croatian healthcare workers to become authors of Cochrane systematic reviews. Ever since it was established in 1993 The Cochrane Collaboration has been devoted to preparing, maintaining and promoting systematic reviews for the benefit of clinical medical practice. The Cochrane Library is a result of the international effort of thousands of volunteers and very few professional staff employed at Cochrane entities. Besides systematic reviews of interventions in medicine, The Cochrane Library recently started publishing also systematic reviews of diagnostic test accuracy, as diagnosis is critical component of health care. The main goal of Croatian branch ofThe Cochrane Collaboration is to provide education in Croatian language and to encourage healthcare stakeholders in Croatia to engage more actively in using and producing the best evidence that will benefit patients and clinical practice. The present article provides review of structure and basic information about The Cochrane Collaboration, The Cochrane Library, access to this resource in Croatia and goals for the Croatian Branch of Italian Cochrane Center.
Key words: systematic reviews; The Cochrane Collaboration; The Cochrane Library; diagnostic accuracy tests
Croatian branch of Italian Cochrane center (CBICC) was established in 2008 and brought a whiz of fresh air into evidence-based medicine (EBM) movement in Croatia. CBICC is one of 26 international centers of The Cochrane Collaboration, and preparations for establishing CBICC took about two years. All this effort was invested because a group of enthusiasts from University of Split School of Medicine and Croatian Medical Journal saw The Cochrane Collaboration as an opportunity for enhancing medical practice and introducing Croatian healthcare workers to The Cochrane Library, important source of information for clinical decisions.
The Cochrane Collaboration
The Cochrane Collaboration is a unique, worldwide, non-profit organization that aims to help people make well-informed decisions about all forms of health care by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of health care interventions (1).
A systematic review is a literature review focused on a single question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine. An understanding of systematic reviews and how to implement them in practice is becoming mandatory for all professionals involved in the delivery of health care. Systematic review may contain meta-analysis, a statistical method that combines results of several different studies, but there are also systematic reviews where meta analysis is not appropriate for various reasons (2).
Since systematic reviews are based on demanding methodology, they can be of variable quality and quickly become out of date, The Cochrane Collaboration is addressing all these issues by avoiding duplication, encouraging authors to update their reviews, promoting its resources and providing support to review authors.
The Cochrane Collaboration was founded in 1993 and named after British epidemiologist, Archie Cochrane. Data from The Cochrane Library in 2004 show that there are more than 11,500 people working within The Cochrane Collaboration in over 90 countries, half of whom are authors of Cochrane Reviews. The number of people has increased by about 20% every year for the last five years. The increase in the number of contributors from low, lower-middle and upper-middle income countries has been even greater, to more than 1000 (9.3%) in 2004 - up by 42% since 2003, and by 248% since 2000 (3).
The members of The Cochrane Collaboration are organized into groups, known as ‘entities’, of which there are five different types: Cochrane Review Groups – made of people who prepare, maintain and update Cochrane reviews and people who support them in this process, Cochrane Centers - like CBICC who support Cochrane people and activities in their geographic and linguistic area, Methods Groups that develop new methodologies for Cochrane reviews, Networks that focus on dimensions of health care other than specific health care problems, such as the setting of care, the type of consumer or the type of interventions, and Consumer Network, which provides information and a forum for networking among consumers (mostly patients) (3).
The main product of The Cochrane Collaboration is The Cochrane Library, which is published by John Wiley and Sons Limited, and this cooperation with a commercial publisher has some advantages and disadvantages. The advantage of this cooperation is that The Cochrane Collaboration does not need to spend its scarce resources and staff on the process of publishing and advertising the reviews, and royalties that are earned through subscriptions are shared between Wiley and The Cochrane Collaboration. The main disadvantage is that commercial publisher is - commercial, so The Cochrane Library is not an open-access publication. To access it, one has to have either institutional or personal subscription. Multiple countries have purchased nation-wide access, which means that every computer in that country can freely access The Library. Also, Wiley provides The Cochrane Library access free-of-charge to the poorest countries. To prevent conflict of interest, Cochrane entities are limited when it comes to using funds from corporate sponsors, especially pharmaceutical companies.
The Cochrane Library
The Cochrane Library is a collection of databases that contain high-quality, independent evidence to inform healthcare decision-making. Cochrane systematic reviews represent the highest level of evidence on which to base clinical treatment decisions. In addition to Cochrane Reviews, The Cochrane Library provides other sources of reliable information: other systematic reviews abstracts, technology assessments, economic evaluations, and individual clinical trials – all the current evidence in one single environment (4). The Cochrane Library has the following resources: Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Health Technology Assessment Database and National Health Service Economic Evaluation Database. The second edition of The Cochrane Library in 2009 contained 5785 items, comprising 3826 complete systematic reviews and 1959 protocols (4).
Systematic reviews of diagnostic test accuracy
For Croatian Society of Medical Biochemists, it is probably the most important to emphasize that in 2003, The Cochrane Collaboration decided to develop a database of systematic reviews of diagnostic test accuracy that complement the Cochrane Database of Systematic Reviews (CDSR). Methodology for systematic reviews of test accuracy has progressed during the last decade, and these reviews are now regularly published in medical journals. A working group, led by members of the Screening and Diagnostic Tests Methods Group, with input from the Steering Group and several Collaborative Review Groups, has been convened to lead this development and to produce methodology, software and books (5).
Diagnostic test accuracyis the ability of a diagnostic test to show the difference between patients with and those without disease (6). In a study of test accuracy, the results of the test under evaluation, the index test, are compared with those of the reference standard determined in the same patients. The development of the methodology for systematic reviews of diagnostic test accuracy studies has made important progress in recent years, but still diagnostic test accuracy reviews face two major challenges: they are limited by the quality and availability of primary test accuracy studies and secondly, more development is needed in the area of interpretation and presentation of the results of diagnostic test accuracy reviews (5). Here lies the opportunity for Croatian authors to engage in reviews of diagnostic test accuracy and thus contribute to the medical practice.
Publishing a Cochrane systematic review
When a person wants to start a Cochrane systematic review, the first step is to browse The Cochrane Library and content of its interest and to check whether there is already published systematic review on this subject. If there is no such review, a person needs to determine to which one of 52 Cochrane Review Groups belongs his or her area of interest. The next step is contacting the Review Group and suggesting a title of the review. Since The Cochrane Collaboration is determined to avoid duplication, one title belongs only to one author or group of authors. Once the title is accepted, no other person can start preparing a Cochrane systematic review with the same topic. After submission of a title, the Review group expects the author(s) to submit a protocol within 6 months. A protocol consists of introduction - description of background knowledge about the subject, and description of methods that will be used, including details about search strategy, keywords for searching literature and databases that will be searched. When the protocol is submitted, the Review group evaluates it and then sends it to two peer-reviewers and sends feedback to authors. When the protocol is accepted, it is published in The Cochrane Library. After that, the authors start to review literature based on the protocol and to prepare full systematic review. Usually it takes 12-24 months for authors to prepare a review after the protocol is accepted.
The Cochrane Library is international publication indexed in Current Contents and its impact factor for year 2008 is 5,1. This means that a publication in The Cochrane Library is very valuable not only for advancement of medicine, but also for advancement of career, and that it can be used for academic promotion in Croatia. Preparation of a systematic review with the Cochrane methodology is not simple, but the most important distinction between Cochrane Review Group and some other international publication is that a Review Group is willing to work with its authors until protocol or review are good enough for publication. As long as an author is willing to learn and make corrections, he or she will eventually publish a systematic review. In other journals, publications are not offered to editorial team as titles, but as finished product - completed article - which may easily be rejected.
Access to The Cochrane Collaboration in Croatia
Although we like to think that we are very poor country, according to the World Health Organization Croatia actually belongs to upper middle income countries and we are not eligible for this free charity access. Therefore, Ministry of Science, Education and Sports of the Republic of Croatia is paying access to The Cochrane Library, but only for members of the so-called biomedical consortium, which includes medical schools and hospital in Croatia, which are connected to Croatian Academic and Research Network (CARNet).
Croatian healthcare workers and consumers may browse the web site of The Cochrane Library and have an insight in its content, but they cannot access full-text articles on that web site. Students and employees from the biomedical consortium institutions may access full-text articles of The Cochrane Library by visiting first Center for online databases (www.online-baze.hr), then choosing OVID SP portal, through which they are navigated to EBM Reviews of The Cochrane Library. Proxy servers enable members of the biomedical consortium to use their user names and passwords to access The Cochrane Library and many other free resources even from distant location. The CBICC is planning to lobby for a nation-wide free access to The Cochrane Library in Croatia and every support in this effort will be welcome.
Croatian Branch of Italian Cochrane Center and its goals
The main goal of CBICC is knowledge translation, including continuing education and dissemination of information about available research evidence. For this purpose, First Croatian Cochrane Symposium was organized on June 27, 2009 at the University of Split School of Medicine. In addition, CBICC is preparing free online continuing education course about preparation and maintenance of a Cochrane systematic review in Croatian language, that will be available to Croatian healthcare workers, and for which they will be able to get continuing education credits from their respective professional associations. The CBICC would like to provide education about The Cochrane Collaboration and The Cochrane Library in Croatian language to motivate Croatian healthcare workers and consumers to engage actively in evidence-based medicine by using its principles and creating its best evidence.
The CBICC has many more ambitious goals, for instance securing funds for temporary scholarships that will enable full-time opportunities for creating systematic reviews, lobbying for nation-wide access and establishing a Cochrane Review group in Croatia. But, to begin with, more effort is needed for raising awareness that The Cochrane Library exists, that it is available to biomedical consortium and that Croatian healthcare workers can become part of it. The past decades have seen The Cochrane Collaboration develop into mature and internationally recognized organization that meets its goals (7). Hopefully, the Croatian branch of The Cochrane Collaboration will be able to accomplish the same in a near future.
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