Cochrane Musculoskeletal Group & Patient Decision Aids

1. Cochrane Musculoskeletal Group & Patient Decision Aids May 25, 2013 Peter Tugwell

2. Learning Objectives Update on the Cochrane Musculoskeletal Group Participants will learn different knowledge translation strategies to disseminate the results of systematic reviews. Participants will have an overview of 10 different strategies and will be able to access them and/or get ideas to build their own

3. OUTLINE Cochrane Collaboration Cochrane Musculoskeletal Group Knowledge Translation 10 Ways of presenting Musculoskeletal Cochrane Reviews More on Decision Aids

4. 5,131 completed reviews 2235 review protocols 674,519 RCTs The Cochrane Library 4

5. Come to our party! 2013 is the 20th anniversary of the founding of the Cochrane Collaboration 21st global Cochrane Colloquium will be in Quebec City September 19th – 23rd 2013

6. Cochrane Collaboration in 2013 • 40,000 contributors in 100+ countries • 25,000 authors • 53 Cochrane Review Groups • 13 Cochrane Centres Please Join! Open to everyone who is committed to the Cochrane Collaboration Principles

7. Global coverage of Cochrane Library – ½ worlds population now free one-click access Green – national license, Red – free access, Blue – Institutions.

8. Impact factor of CDSR 5.963 top 10 highest General Medical journals

9. Abstract downloadevery 2 seconds Impact factor of CDSR 5.963 Up from 5.653 in 2009 top 10 highest General Medical journals Up from 14th in 2007

10. Full text download3 seconds Impact factor of CDSR 5.963 Up from 5.653 in 2009 top 10 highest General Medical journals Up from 14th in 2007

11. Impact :‘Cochrane Inside’

12. The Canadian Cochrane Network and Centre • 2005-2010; Funded by: • CIHR • CIHR Institutes: •  Institute of Gender and Health •  Institute of Health Services and Policy Research •  Institute of Human Development, Child and Youth Health •  Institute of Infection and Immunity •  Institute of Musculoskeletal Health and Arthritis •  Institute of Nutrition, Metabolism and Diabetes • CADTH (2005-2008) 12

13. Cochrane Musculoskeletal Group • Registered in 1993 in Ottawa, Canada, the Cochrane Musculoskeletal Group • 161 Cochrane Reviews in Cochrane Library • 31 consumer representatives • In 2005, a second editorial base was established at Cabrini Institute, University of Melbourne, Australia. • Satellites in France, Scotland, Wales and USA.

14. May 2013: 161 COCHRANE MUSCULOSKELETAL REVIEWS

15. Hot off the Press! Folic Acid with MTX in RA Shea et al Cochrane Musculoskeletal GroupIn press May 31, 2013

16. Objectives: To perform a systematic review of the benefits and harms of folic /folinic acid 1)in reducing the mucosal, gastrointestinal, hepatic and haematologic side effects of Methotrexate (MTX). 2.) To assess whether or not folic/folinicacid supplementation reduces MTX benefit.

17. Flow chart

18. Results Best estimate of what happens to people who take folic acid or folinic acid while on MTX

20. Risk of Bias

21. Stomach problems such as nausea, vomiting or abdominal pain: • 35 people out of 100 experienced stomach problems such as nausea when they took MTX alone for their rheumatoid arthritis; • 26 people out of 100 experienced stomach problems such as nausea when they took folic acid or folinic acid with their MTX. • Thus: 9 fewer people out of 100 experienced stomach problems such as nausea up to 6 to 12 months after starting folic acid or folinic acid with their MTX (9.0% absolute improvement);

22. Liver problems (as measured by abnormal liver blood tests): • 21 people out of 100 experienced abnormal liver blood tests when they took MTX alone for their rheumatoid arthritis; • 5 people out of 100 experienced abnormal liver blood tests when they took folic acid or folinic acid with their MTX. • Thus: 16 fewer people out of 100 had liver problems up to 6 to 12 months after they starting folic acid or folinic acid with their MTX (16.0% absolute improvement);

24. Folic acid and folinic acid for reducing side effects in patients receiving methotrexate for rheumatoid arthritis • Conclusions. There was a clinically important significant reduction shown in • the incidence of GI side effects, • hepatic dysfunction • discontinuation of MTX treatment for any reason. • The results support a protective effect of supplementation with either folic or folinic acid for patients with rheumatoid arthritis during treatment with MTX.

25. OUTLINE Cochrane Collaboration Cochrane Musculoskeletal Group Knowledge Translation 10 Ways of presenting Musculoskeletal Cochrane Reviews Decision Aids

26. Knowledge translation CIHR definition ‘Knowledge translation is a dynamic and iterative process that includes the synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the healthcare system.’ 26

27. Knowledge Translation Knowledge to Action loop From: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006 27

28. OUTLINE Cochrane Collaboration Cochrane Musculoskeletal Group Knowledge Translation 10 Ways of presenting Musculoskeletal Cochrane Reviews esp Decision Aids

29. 10 Formats for presenting Cochrane Review Knowledge Translation to Clinicians and Patients: Update from Cochrane Musculoskeletal Group Tamara Rader, Jordi Pardo , Anne Lydiatt, Dawn Stacey, Elizabeth Ghogomu, Lara J.Maxwell, Jasvinder A. Singh, Rachelle Buchbinder, France Légaré, Nancy Santesso, Peter Tugwell.

30. 10 Tailored KT Formats

31. 10 Cochrane KT Formats • Cochrane Reviews • Cochrane Journal Club • Cochrane Decision Aids • Cochrane Corners in Journals • Cochrane Summary of Findings Tables • Cochrane Plain Language Summaries • Cochrane Podcasts • Cochrane @ Twitter • Cochrane Clinical Answers • Dr Cochrane

32. #1 Cochrane reviews

33. #1 Cochrane reviews • Audience: Policymakers, Practitioners, Public, Press • Time: 45 min to browse • Consistent format, rigorous methods

35. #2 Cochrane Journal Club

37. #2 Cochrane Journal Club • Audience: Practitioners, Pupils • Time: 45 min • Provides clinical results and context, a tool for teaching and self-directed learning

38. #3 Cochrane Decision aids

39. #3 Cochrane Decision aids • Audience: Patients, Practitioners • Time: 45 min for patients, 15 min summary for practitioners • Supports shared decision making • Key features • options • asks personal values/preferences • benefits and harms • quality appraised

40. Cochrane Review EtanerceptDecision Aid • Take etanercept (Enbrel®): Once or twice a week, you have an injection under the skin in different parts of the thigh or abdomen. A nurse or doctor teaches you how to do this. A family member or friend can also learn. You store the drug in a refrigerator and warm it to room temperature prior to use. Most people who fear self-injection are able to give these injections with mild or no discomfort. • Decline etanercept (Enbrel®). You may wish to discuss other treatment options with your doctor

41. Cochrane Review Etanercept Decision Aid Step 1: What are the benefits ?

42. Cochrane Review Etanercept Decision Aid Step 1: Side Effects and Harms

43. Cochrane Review Etanercept Decision Aid Step 2: What matters most to you?

44. COCHRANE REVIEW DECISION AIDS http://musculoskeletal.cochrane.org/Decision-aids • Osteoarthritis • What are my options for managing hip or knee arthritis? • Should I use TENS (transcutaneouselectrostimulation) for osteoarthritis? • Should I have ultrasound for osteoarthritis? • Osteoporosis • Should I take alendronate (Fosamax®)to prevent fractures? • Should I take etidronate (Didronel®)to prevent fractures? • Should I take risedronate (Actonel®)to prevent fractures? • Rheumatoid arthritis • Should I take abatacept (Orencia®)for rheumatoid arthritis? • Should I take etanercept (Enbrel®) for rheumatoid arthritis? • Should I take tocilizumab (Actemra®)for rheumatoid arthritis? • Should I take methotrexate (Rheumatrex®)for rheumatoid arthritis? • Should I take methotrexate (Rheumatrex®)for rheumatoid arthritis alone or with other disease-modifying anti-rheumatic drugs (DMARDS)?

45. COMPARING MORE THAN ONE OPTION THE “STEPPED CARE DECISION AID”

46. Step 1: What are the benefits and harms of each option? 100 faces illustrate the benefits of the intervention

47. Physician receives a one page clinical summary

48. Web-Based Decision AidsLinda Li et al