Every year the Cochrane Collaboration brings together Cochrane contributors from around the world to discuss, develop and promote Cochrane, and help shape its future.
The most recent event – called the Cochrane Colloquium – was held in Seoul and focused on challenges to evidence-based medicine.
Shauna Hurley, Communications and Engagement Manager at Cochrane Australia attended the Colloquium and has provided this overview of two of its main themes: over-diagnosis and over-treatment; and making evidence health more accessible, more quickly.
Shauna Hurley writes:
Spend a few hours in any given hospital or clinic waiting room, and you can’t help but reflect on the difficult and often harrowing journey people of all ages and backgrounds have through the health system.
A few weeks ago I waited for a friend to have a scan, and watched a steady stream of people file in and out of hospital. Some struggled with language and paperwork, others compared notes on their conflicting diagnoses from Dr Google and a few sat quietly looking worried about uncertain fates.
It seemed to me that despite the promises of rapid technological advances and more health information at our fingertips than ever before, the daily reality of people in the health care system remains a lonely and challenging one on many levels.
It was this perspective that I took with me to this month’s international Cochrane Colloquium in Seoul – an annual event that sees the best and brightest minds in evidence based health care come together to discuss and debate critical health and research questions.
Interestingly, big picture health issues and the experiences and needs of patients like those I observed in the waiting room were explored in equal measure throughout the five-day meeting.
Individuals as people – not patients
The idea that individuals need to be seen as people rather than patients was a common theme, as was the importance of translating research more efficiently and effectively to realise better health outcomes, health literacy and quality of life for people around the globe.
Over 850 participants from 54 countries came together to share diverse perspectives on how this can be achieved. Australia was well represented with around 50 participants and keynote presenters who played a prominent role in plenary sessions and the more than 300 workshops, presentations and special sessions on matters of health policy, clinical practice, technology, research methods and knowledge translation.
It’s a challenge to do justice to the diversity and depth of topics traversed in the full program, so what follows is a snapshot of two critical areas of focus that opened and closed a very wide-ranging and thought provoking Colloquium.
Double trouble: the growing problems of overdiagnosis and overtreatment
Sydney University’s Professor of Public Health Alexandra Barrett opened proceedings by questioning the contemporary assumption that the more advanced diagnostic tests and data we have, the better our collective health will be. Pointing to evidence from screening programs that suggests the opposite may be true, she argued that we may have reached the limits of the ‘find more, do more’ paradigm.
The inherent problem is that the more we test people with ever more sensitive diagnostic machines, the higher the probability of diagnosing and then unnecessarily treating non-progressive diseases.
Coupled with this is the related problem of ever-expanding disease definitions that turn healthy people into patients, meaning few escape being labelled or assigned some kind of medical condition. The resultant psycho-social harms and increasing demands on limited health resources are critical issues globally, and are only set to worsen with the likelihood of genomic testing substantially increasing overdiagnosis and overtreatment.
A role for Cochrane
So how to address such seemingly intractable issues? Alexandra argued that Cochrane should consider the potential for overdiagnosis and overtreatment in all its systematic reviews and continue to advocate for more and better information about the benefits and harms of screening and overtreatment.
Bond University’s Jenny Doust then looked at how overdiagnosis and overtreatment commonly play out at the local and individual level, providing a series of patient snapshots from her Brisbane GP clinic.
The case of an elderly woman on 15 different daily medications highlighted the pervasive problem of polypharmacy and the importance of addressing multiple medications in older adults. At the other end of the spectrum a teenage girl, convinced she had polycystic ovary syndrome due to weight gain and skin problems, was a telling example of the challenges of dealing with internet self-diagnosis.
And a young boy presenting with possible symptoms of ADHD highlighted the difficulty of using guidelines to determine a diagnosis, given guidelines can be part of the problem when they widen disease definitions.
To counter the growing problem of overdiagnosis in clinical practice, Jenny emphasised the importance of a patient-centred approach and set out guiding principles that included: a focus on patient concerns; not doing diagnostic tests ‘just in case’; using diagnostic labels cautiously; using minimal interventions; and reviewing diagnoses and treatments regularly.
Making health evidence accessible more quickly, more efficiently
Bond University’s Paul Glasziou brought together many strands of the week’s themes and debates in his concluding Cochrane lecture, which highlighted the key challenges for evidence based health care and Cochrane’s future.
In part, the message was simple. Cochrane evidence needs to be easier to access and useful for all kinds of audiences both inside and outside the health and research professions. Abstracts need to be clear, concise and useful. Results should be conveyed in words, numbers and images, as multiple formats mean greater accessibility and the ability to cross-reference.
The information reviews contain needs to address critical questions and promote and enable shared decision-making. The slated changes to the Cochrane Library, a greater commitment to translating reviews and new approaches to consumer-led prioritisation of Cochrane reviews are already going some way to address these goals, but Paul’s assessments and recommendations offered more food for thought on all of these issues.
The need to preserve quality
A perhaps more complex and contentious area underlined in Paul’s closing address was the need for Cochrane to produce and disseminate health evidence more quickly and efficiently but without loss of quality or human agency.
He reassured Cochrane contributors who might be concerned about the increasing role of technology that machine learning will in fact help them, not replace them. And most importantly, he argued that the increasing automation of the more time-consuming parts of the systematic review process will give researchers more time to think critically and consider the significance of the results.
Cochrane Australia’s Julian Elliott responded to Paul’s address pointing to many projects already under way to improve efficiency and ensure reviews are more accessible, accurate and up-to-date. Machine learning and crowdsourcing are becoming a central part of review production and their benefits are clear.
New online platforms
Cochrane’s two new online collaboration platforms exemplify this. TaskExchange is an online market-place enabling people from around the globe to post tasks and help each other complete reviews in less time with more help, while Cochrane Crowd enables anyone interested in volunteering to help with health research to sign-up and screen health records for reports of clinical trials.
Both platforms have already proved popular and effective means of connecting people and improving processes, and are set to make a big contribution to Cochrane’s future research.
The final word from Paul resonated with all Colloquium participants, no matter what their divergent views were on the future of medicine, research, methodology or technology. He neatly summed up the original and ongoing aspiration of Cochrane to get the best in high quality health evidence into the hands of people who need it, and concluded with some simple and memorable advice. ‘It’s a great dream. Don’t give up on it.’
An ebook of the presentation abstracts from the Colloquium is available on the event website.