The Cochrane Systematic Review and Evidence-Based Medicine

In this podcast interview, Dr Robert Dellavalle and Dr Torunn Sivesind discuss the Cochrane Systematic Review and evidence-based medicine.

Robert Dellavalle, MD, PhD, MSPH is the Board-Certified Chief of Dermatology at Rocky Mountain Region VA Medical Center, a Professor of Dermatology and Public Health at The University of Colorado, and the Joint Coordinating Editor of Cochrane Skin.

Torunn Sivesind, MD is a Postdoctoral Dermatology Research Fellow at The University of Colorado School of Medicine.

TRANSCRIPT-

Dr. Robert Dellavalle:  Evidence-based medicine, which was pioneered by Archie Cochrane who published a book called "Effectiveness and Efficiency -- Random reflections on Healthcare" back in 1972. He passed away in 1988. In his book, he argued that randomized controlled trials were the best source of evidence in medicine.

From his book and his effort, the organization Cochrane was established in 1992 at Oxford. Cochrane is now a worldwide volunteer organization in evidence-based medicine. We lead efforts in Cochrane Skin, which is 1 of 52 groups within Cochrane. Cochrane, itself, has more than 100,000 members and is in 130 countries.

It's pharmaceutical industry independent to help give the least biased reviews in trying to determine answers to questions, such as what's the best therapy for wart.

When you look at all of the evidence across the literature electronically and summarize it, what techniques that have been pioneered by Cochrane, network meta-analysis, and other various techniques, you'll find that the current evidence supports using salicylic acid is the best therapy for wart.

That isn't to say that things won't change with more additions to the literature, but doing these methods to have the least biased approach to the literature can answer questions in medicine, which is the goal of Cochrane and the goal of Cochrane Skin.

Lauren Mateja:  Is there any impact on having a collaborative environment like this where you're working with the AAD, part of the Cochrane Skin project here? And how that combination of organizational level and international level, at that point you mentioned over 130 countries participating with thousands and thousands of healthcare providers being a part of it. How can that collaboration help continue to drive and improve patient outcomes?

Dr. Dellavalle:  Part of the collaboration with the American Academy of Dermatology that I want to highlight is a lot of the guidelines that the AAD produces are based upon Cochrane review data. Increasingly, the AAD is working with Cochrane to plan and fund the systematic reviews that are needed for the AAD guideline.

Another collaboration is in the distribution of the result of the systematic reviews in a user-friendly format. Then we also have a fellowship that's been in place for about five years where two members of the American Academy of Dermatology get intimately involved with Cochrane's methods, and meetings, and networking.

We have about 10 to 12 dermatologists now who are Cochrane AAD fellows who have had this additional interaction, networking, and training.

Lauren:  Reflecting on some of these limitations of reviews, obviously a major part and a major call right now in medical literature, to begin with, is recognizing underserved groups and finally giving them the attention that they rightfully deserve as our patients. How can recognizing those limitations enhance patient care and our relationships from patient to physician?

Dr. Dellavalle:  That's a great question. We're just beginning to look at how to prioritize efforts in the Cochrane to emphasize equity. Equity is the absence of avoidable and unfair differences in healthcare. We have to. First of all, pilot how we're going to look at this across all of the topics in medicine across all of the world, which is a huge task.

Torunn Sivesind actually did some very pioneering work within the skin systematic reviews. We settle down looking at a very hard outcome in that mortality reduction and seeing which questions are being asked in the Cochrane Library that can potentially affect mortality reduction the most and making sure the answers to those questions are updated or a priority for updating.

We look at mortality across all of the reviews. We look also in the Global Burden of Disease to which disease measures are most important across the world. That work is still in progress because of a comprehensive leap in dermatology, we were able to look at mortality in our 117 or so systematic reviews that have been published.

We found that about 12 of them listed mortality. Those are 12 that are in the running for being systematic reviews that need prioritization for updating to make sure that an equity focus is in them. Though we have different topics, about a third of them were melanoma.

There was also basal cell and squamous cell carcinoma, pemphigoid, necrotizing fasciitis, drug-induced skin rashes like TEN, and topical steroids during pregnancy. All of those questions address mortality. If we find those questions end up to other questions across all of medicine as being very important, then hopefully, we will apply more priority to answering those and keeping them updated.

We will probably do that anyways, but as we've seen more and more systematic reviews across all of the literature that are poor quality as time goes on, even more, important to focus on important questions and to put an equity lens on those questions.

That's what we're beginning to do in skin and also trying to do across all of Cochrane.

Dr. Torunn Sivesind:  It's important to note that this is just one method of trying to begin the process. As Dr. Dellavalle said, it's an immense project to apply an equity lens to all of the systematic reviews. This is one way of ensuring that the most important of these are updated with the focus on equity first. Then we can expand upon that to more reviews over time.

I'm sure we'll learn during this process and maybe come up with better methods. For now, this is one way that we're going about the priorities that are in front of us.

Dr. Dellavalle:  Some of the most important Cochrane reviews that are being done right now are the network meta-analyses that are living have the most expensive treatments for the most common dermatology diseases.

One example of this is the network meta-analysis score, the psoriatic biologic. Determining which of those have the most side effects and have the most benefit are very important to country's budgetary considerations and also to their health ministries. Also, they're very important to guidelines.

Those are obvious priorities within dermatology. Atopic dermatitis similarly has very expensive treatments and needs to be worked into guidelines and budgetary priorities of health ministries.

Lauren:  Even touching upon that atopic dermatitis, I'm sure that'll be very necessary relatively soon given the number of exciting developments kindof held up at the FDA at the moment, but knowing when it is appropriate and these "niches" would be of patients that these therapies that would be appropriate for and is going to be necessary going forward with care.

One thing might be helpful. I know, obviously, the chats from the Cochrane Library is a good reminder of this.

As you're discussing and highlighting all these different reviews, what advice could either of you maybe offer physicians and other healthcare providers to discern maybe what is worthwhile research versus one that sounds flashy and grabs consumer media that has some more limitations?

Going back to that atopic dermatitis, it's a decent JAMA derm article, but I know it was about connecting atopic derm with learning disability. We did publish a Q&A with the corresponding author/lead researcher on that, Dr. Joy Wan. Obviously, that's a very small study, not a whole lot of supporting evidence. It needs more work to tease out the science there.

Any tips that you could provide then about discerning what's good and what is evidence-based medicine versus something that needs a little bit more trials to figure out the results?

Dr. Dellavalle:  I think we do heard back to Dr. Cochrane's call for randomized controlled trials for addressing the most important questions in medicine because that is the least biased method that we currently know of. If you can do a randomized controlled trial and it's feasible, that is what should be done if at all possible.

The unfortunate thing is those take a long time, and they're very expensive. Then we try to use other methods to take the evidence we have to examine the bias and come up with the least biased answers.

We're still at where Dr. Cochrane pointed us to a long time ago, trying to do randomized controlled trials to the most important questions in medicine that we can, and if we can't, coming up with methods to give us the least biased answer from the other evidence that we have.

Dr. Sivesind:  Certainly, I agree with everything that Dr. Dellavalle said, but I think you raised a really important point, which is that there is such an explosion of evidence that's available now online through online journals. It can be overwhelming to face this huge body of literature for physicians and to weed through that to find what are the high-quality studies and to not get bogged down in trying to find evidence that they can use in treating their patients.

That is one of the goals of the Cochrane Library here, is to try to present this high-quality evidence in a usable format and to reach a broader audience because, clearly, the JAAD readership is broad and reaches a big audience.

If we can share some of the Cochrane findings -- and we know that Cochrane has reliable evidence -- then that's a huge benefit to the community.

Lauren:  Anything else that you want to share before we let you go?

Dr. Dellavalle:  Lauren, I also want to encourage people interested in evidence-based dermatology to apply for the Cochrane AAD fellowship to get even more training and interaction in this realm and be more a part of the AAD Cochrane efforts for guideline development and new research technique development.

That's available if you google AAD Cochrane fellowship, you'll come up with the application.