Cochrane Musculoskeletal Group Patient Decision Aids Peter Tugwell

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

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 2

OUTLINE 1. Cochrane Collaboration 2. Cochrane Musculoskeletal Group 3. Knowledge Translation 4. 10 Ways of presenting Musculoskeletal Cochrane Reviews 5. More on Decision Aids 3

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

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

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

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

Impact factor of CDSR 5. 963 top 10 highest General Medical journals

Impact factor of CDSR Abstract 5. 963 downloade very 2 top 10 highest General seconds Medical journals Up from 5. 653 in 2009 Up from 14 th in 2007

Impact factor of CDSR Full text 5. 963 download 3 top 10 seconds highest General Up from 5. 653 in 2009 Medical journals Up from 14 th in 2007

Impact : ‘Cochrane Inside’

The Canadian Cochrane Network and Centre • 2005 -2010; Funded by: • 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

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.

May 2013: 161 COCHRANE MUSCULOSKELETAL REVIEWS

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

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/folinic acid supplementation reduces MTX benefit.

Flow chart

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

Risk of Bias

Stomach problems such as nausea, vomiting or abdominal pain: Ø 35 people out of 100 experienced stomach problems such as nausea when they took MTX alone for their rheumatoid arthritis; Ø 26 people out of 100 experienced stomach problems such as nausea when they took folic acid or folinic acid with their MTX. Ø 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);

Liver problems (as measured by abnormal liver blood tests): Ø 21 people out of 100 experienced abnormal liver blood tests when they took MTX alone for their rheumatoid arthritis; Ø 5 people out of 100 experienced abnormal liver blood tests when they took folic acid or folinic acid with their MTX. Ø 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);

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.

OUTLINE 1. 2. Cochrane Collaboration Cochrane Musculoskeletal Group 3. Knowledge Translation 4. 5. 10 Ways of presenting Musculoskeletal Cochrane Reviews Decision Aids 25

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

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

OUTLINE 1. Cochrane Collaboration 2. Cochrane Musculoskeletal Group 3. Knowledge Translation 4. 10 Ways of presenting Musculoskeletal Cochrane Reviews esp Decision Aids 28

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. 29

Audience 45 minute Patients - To inform personal decisions • • 10 Tailored KT Formats 15 minute Cochrane review Decision aid 5 minute 1 minute • • • Plain language summaries Podcasts • Practitioners • - To support • shared decision making • Policy-makers - To use evidence in policy development • Public/Press • Journal Club • Cochrane review • Dr. Cochrane Review Decision Aid Summary Clinical scenarios in general medical journals • • • Cochrane Review • • • Podcasts Summary of Findings Tables Plain Language Summaries Key points of the Plain Language Summaries Cochrane tweets • Cochrane Tweets • Cochrane tweets Podcasts Summary of Findings Table Plain Language Summaries Podcasts Press releases Plain 30

10 Cochrane KT Formats 1. Cochrane Reviews 2. Cochrane Journal Club 3. Cochrane Decision Aids 4. Cochrane Corners in Journals 5. Cochrane Summary of Findings Tables 6. Cochrane Plain Language Summaries 7. Cochrane Podcasts 8. Cochrane @ Twitter 9. Cochrane Clinical Answers 10. Dr Cochrane

#1 Cochrane reviews

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

#2 Cochrane Journal Club

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

#3 Cochrane Decision aids

#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

Cochrane Review Etanercept Decision 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 selfinjection 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

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

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

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

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 (transcutaneous electrostimulation) 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)?

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

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

Physician receives a one page clinical summary

Web-Based Decision Aids Linda Li et al 48

The Animated Self-serve WEb-based Research (ANSWER) tool Linda Li et al TOPICS • • • About RA Methotrexate MTX Side Effects MTX and Pregnancy MTX and Alcohol Weighing the options 51

#4 Clinical scenarios in journals • Audience: Practitioners • Time: 15 min • Adds evidence to the clinical context

#5 Cochrane Summary of Findings Table • Audience: Practitioners, Policymakers, Press • Time 5 min • Provide at-a-glance results of a systematic review, including gaps in the evidence.

SUMMARY OF FINDINGS TABLE: Abatacept for rheumatoid arthritis Patient or Population: patients with rheumatoid arthritis Settings: International; clinic/hospital Intervention: Abatacept (2 and 10 mg/kg) + DMARDs/biologic Comparison: Placebo +DMARDs/biologic Outcomes Illustrative comparative risks* (95% CI) Relative Effect Placebo Abatacept (2 and 10 (95% CI) +DMARDs/ mg/kg) +DMARDs/ biologic ACR 50% 168 per 1000 371 per 1000 RR 2. 21 improvement (291 to 474) (1. 73 to 2. 82) Follow-up: 12 months Pain The mean pain in measured at end of the control group study on a 100 mm was visual analog scale. 49. 24 mm Scale from 0 (better to 100 (worse). Follow-up: 12 months. Improvement in 393 per 1000 physical function (HAQ: greater than 0. 3 increase from baseline, 0 -3 scale) Follow-up: 12 months Achievement of low 98 per 1000 disease activity state (DAS 28 less than 3. 2, scale 0 -10) Follow-up: 12 months Total serious 121 per 1000 adverse events Follow-up: 6 to 12 months Long-term serious See comment adverse events Follow-up: 2 years The mean pain in the intervention group was 10. 71 lower (12. 97 to 8. 45) No of Participants (Studies) Quality of Evidence (Grade) Comments 993 (3 studies) Moderate 1425 (1 study) Moderate Absolute risk difference= 21% (16% to 27%). Relative percent change=121% (73% to 182%). NNT=5 (4 to 7) Absolute risk difference= 11% (-13% to -8. 5%). Relative percent change=18% (-22% to -14%). NNT=5 (4 to 6) 637 per 1000 (531 to 766) RR 1. 62 (1. 35 to 1. 95) 638 (1 study) Moderate Absolute risk difference= 24% (16% to 32%). Relative percent change=62% (35% to 195%). NNT=5 (4 to 7) 424 per 1000 (278 to 646) RR 4. 33 (2. 84 to 6. 59) 683 (1 study) Moderate 127 per 1000 (105 to 155) RR 1. 05 (0. 87 to 1. 28) 3151 (6 studies) Moderate See comment Not estimable 950 (2 studies) Low Absolute risk difference= 33% (26% to 39%). Relative percent change=333% (184% to 559%). NNT=4 (3 to 5) Absolute risk difference= 1% (-2% to 3%). Relative percent change=5% (-14% to 29%). NNT=n/a Number of patients with SAE: Genovese 2005: 103/357; 23. 4 SAE/100 patient-years; 70% completed the LTE.

#6 Plain Language Summary • Audience: Patients, Public, Press • Time: 5 min • Provides same information from the Summary of Findings Table in plain language plus background information on the condition and intervention.

#7 Cochrane Podcasts • Audience: Patients, Public, Press • Time: 5 min • Author provides commentary on the results of the review and highlights of the findings.

#8 @cochranelibrary (Twitter) • Audience: Public, Press • Time: 1 min • Headline style news items and announcements

#9 Cochrane Clinical Answers • Audience: Practitioners • Time: 15 min • Uses Cochrane evidence to answer one clinical question at time, providing clinicians with the exact information they need.

#10 Dr. Cochrane • Audience: Practitioners • Time: 15 min • Dr Cochrane is a collection of online continuing professional education and development (CEPD) modules based upon Cochrane Reviews • Uses a storyline to convey messages

Holes in one , not holes in the stomach: Preventing NSAID ulcers Lorenzo Moja* Italian Cochrane Centre, Mario Negri Institute for Pharmacological Research, Milan, Italy These Dr Cochrane clinical vignettes are based on Cochrane Reviews published in The Cochrane Library. Dr Cochrane is a unique self-learning experience – the integration of Cochrane evidence with a quirky fictional story and multiple-choice questions provides readers with the opportunity to explore and understand the applicability of a Cochrane Review or Overview in a new way. In this series of fictional clinical vignettes, Dr Cochrane travels across time from the past century to the present day, to solve clinical problems using evidence from Cochrane Reviews. Read the review and listen to the podcast of the review and then test your knowledge with five multiple choice questions. You can find the answers at the end. It was a Saturday evening and Dr Cochrane was enjoying some hors d’oeuvres and a glass of Merlot at a cocktail party hosted by his local golf club. Not long after arriving, he bumped into Ellen and Terry, a couple that he had known for quite some time. Archie quickly caught up on what had been happening in their lives, and Ellen and Terry were particularly excited as their eldest son and his wife were expecting a child. After toasting to the health of their first grandchild, Archie helped himself to more food, but Terry declined.

10 Cochrane KT Formats 1. Cochrane Reviews 2. Cochrane Journal Club 3. Cochrane Decision Aids 4. Cochrane Corners in Journals 5. Cochrane Summary of Findings Tables 6. Cochrane Plain Language Summaries 7. Cochrane Podcasts 8. Cochrane @ Twitter 9. Cochrane Clinical Answers 10. Dr Cochrane

Thankyou ! • Don’t Forget! • Come to our party! • 2013 is the 20 th anniversary of the founding of the Cochrane Collaboration • 21 st global Cochrane Colloquium will be in Quebec City September 19 th – 23 rd 2013