Archie Cochrane

Transcription

My name is... [in several languages] [music] >>Narrator: In October 1993 approximately eighty like-minded individuals working in health care around the world gathered at the Summertown Pavilion on Middle Way in Oxford, UK. >>Chalmers: We wrote as late as July inviting people to come to what we called a first colloquium in October. And we didn't promise them any travel. We said we'd give them sandwiches and coffee but that was it. They'd have to find the funds. And they came from all over the world. >>Garner: It was organised in quite a rush and there was a lot of people from all over the place, not quite knowing what it was, what it was all about, but all anxious to move forward and it was a very energising and powerful meeting. >>Narrator: For two days the group discussed how they should organise the working structure for what would become The Cochrane Collaboration - an international effort to improve health care by finding and promoting the best possible scientific evidence. [music] To understand what kind of evidence was under discussion we need to go back 20 years earlier in the career of the man who brought the group together, Iain Chalmers. >>Chalmers: I had worked as a clinician in places where all the time there were questions coming up about what is the right treatment and this included in this country in the UK but also in the Gaza Strip >>Narrator: Working in a Palestinian refugee camp Iain observed that interventions he was taught in medical school probably caused unnecessary suffering. >>Chalmers: People had a variety of opinions about how to treat particular circumstances and you had to ask the question, "Who was right?" Now i didn't know how to go about judging who was right. My training at medical school hadn't left me with any tools with which to investigate that possibility. So, when i came back from the Middle East, I read a book by someone I hadn't heard of up until then called Archie Cochrane, Effectiveness and Efficiency: Random Reflections on Health Services. He asked the question, "How can we have a rational health service if we don't know which of the things being done within it are useful and which are useless or possibly even harmful?" >>Narrator: In his book Archie Cochrane drew attention to randomised trials. >>Chalmers: I'd never heard of randomized trials, I'd been six years qualified, I'd never heard of it. And so, I started to look into this and basically it was like getting a compass in a jungle of conflicting incompatible clinical opinions about how to practise. And so that started me on the trail of looking for reports of these studies in the field which i had chosen to work in which was obstetrics. >>Narrator: Starting around 1974 and for the next 10 years Iain and a team of about 100 people would search out relevant reports of randomised trials in obstetrics. >>Chalmers: Also looking at the possibility of analyzing similar studies together so that one can start to address the way that you're misled by the play of chance. Now, I didn't know that round about that time Gene Glass named that process meta-analysis, but in effect that's what I was describing in this outline proposal for this work. And whereas other people were doing it for specific treatments, we were completely mad and ambitious and decided we ought to try to do it for all of our specialty, for the whole of obstetrics. >>Narrator: This work culminated in a two volume 1300 page publication as well as a paperback for consumers, to give them access to this research. >>Gyte: I was a member of the National Childbirth Trust and I remember Iain Chalmers coming to give a presentation. And I remember very clearly being aghast because this presentation was about a review that showed a particular suture material causing more painful intercourse for women three months after birth. And yet he said lots of hospitals were still using it. And I was just incensed really. >>Chalmers:We realized that the books would be out of date when they were published; all books are, so we started publishing electronically in 1988. It was called the Oxford Database of Perinatal Trials. It was that electronic publishing vision that made it possible to conceptualise what The Cochrane Collaboration might do if there was sufficient support for it. >>Garner: I remember the editorial in the British Medical Journal calling for people to collaborate. And I was in a hotel room in Lahore and wrote to Iain saying it was very important this initiative that he was setting up, the Cochrane Centre as it was then, included problems from developing countries and people from developing countries in the process because sometimes both of those get forgotten. >>Chalmers: We left people in no doubt at all that if this was going to be done, it needed international collaboration. We had demonstrated with the model of the perinatal work that it was possible to do it. Our job was to facilitate. So, if that facilitation was going to happen we needed to get in touch with all of our allies around the world and to say, "Are you up for this?" [music] >>Collins: Many doctors were resistant to the idea that you could combine the evidence from different trials that address the same question. They were all saying, "Our trial is special. You can't combine it with any other trial. >>Becker: Nobody knew what a systematic review was. And in fact, they were kind of distrustful: "Well, you didn't do any research, you just read some studies." When we did our first review, I wasn't able to convince very many people to stop using anti-biotics based on a Cochrane Review, whereas now as I say it's part of the quality criteria. >>Collins: What has changed over the last 20, 30 years is the recognition that you can usefully combine trials that address the same or similar questions to work out whether or not treatments work. >>Gyte: It was actually all about only using interventions when the were effective and it proved that a lot of the routine interventions that had been around before actually just didn't work or had adverse effects. And so they eventually were stopped. Routine shaves, routine enema, routine episiotomy, they're all gone now. >>Gray: Within, I think about a year we'd found 400,000 trials that have been in MEDLINE, but had not been indexed. There was the equivalent of billions of dollars of worth of research that you couldn't find. So, the best search in the world could only find 13,148 trials when there was probably at that time 350,000, 400,000 trials in MEDLINE but just unfindable. >>Dickerson: And their had also been, for many years concern that not all trial are published and so how do we find trials period that have been initiated? And so there had been a group working over the years saying we really need trials registration, but to be honest, it's always been a small group, you know. Academics saying these things in print but didn't really get anywhere and I think Cochrane's being behind trials registration and amassing a really large and meaningful register of published trials itself made a difference that we now have trial registration worldwide. So for me, one of the most important things we've done has had to do with getting all the clinical trials in one place. >>Langhorne: Clinical practice guidelines were relatively novel in the early '90s, and now, we were doing an exercise within the Stroke Group. All the Western clinical practice guidelines are similar and they all reference Cochrane Reviews in large numbers. And so it's become kind of embedded in the normal practice of quality improvement. >>Farquhar: When I go to meetings, international meetings on obstetrics and gynecology, without a doubt people are quoting Cochrane Reviews probably in every presentation on evidence or what's best practice or guidelines. >>Adams: Have I seen in the last 20 years as to whether people with schizophrenia are getting better care? Yes, I think I have. It has a huge journey yet to go, enormous and, but what didn't used to be there is accessible evidence that can be used either by policy-makers or people with schizophrenia themselves or the clinicians, the busy clinician. >>Volmink: We established the South African Cochrane Centre. We made it a very clear goal that we would prioritize the conditions that are important to Africa. We worked very closely with the collaborative Review Groups. We have, together, been able to substantially increase the number of reviews that are relevant to Africa. >>Liberati: One of the major achievements has been to convince people that really accumulating evidence is essential. This was very much Archie Cochane's message. >>Aronson: I think that when Cochrane said that evidence about health care should be brought together and synthesised so that all the evidence would be available, now it seems to us obvious. But actually, at the time, it wasn't at all obvious, and this was a new idea that Cochrane was delivering that was in a way a challenge to the medical profession - get on and do this. >>Gotzsche: I realized that being a doctor, I could help one patient at a time but by joining the Cochrane Collaboration I could help tens of thousands of patients at a time by doing a Cochrane Review. [music]