Peter C. Gøtzsche, director of the Nordic Cochrane Centre, shares his experience of being on the Cochrane Board after returning from the GES. 

I have participated in two face-to-face Board meetings. This work has been much more interesting than I thought it would be. If you walk down the Grand Canyon, you will see how beautiful it is, but if you fly over it in a helicopter, you will see something else. To get an overview of all the many challenges a leadership of a large organisation has to deal with and to come up with strategic visions, a helicopter perspective is needed, and not only that, we should focus also on what lies outside our territory.

The needed transition from a volunteer organisation to one that still builds almost entirely on the generous contribution of unpaid volunteers but is more professional with higher quality of our reviews across all review groups continues at full speed. This cannot be done without creating frustration and unhappiness for some, but in my view, our management has generally handled this delicate task very well, putting a lot of hard work into ensuring a sustainable organisation and also into preparing for the Board meetings. As I stated in my election statement, I see it as one of my contributions to ensure that the central management and control does not go too far.

In contrast to the previous Steering Group meetings where membership was based on representativeness of the various Cochrane entities, all the current Board members participate in the discussions and often passionately so. This creates tensions at times but it is a huge improvement, as is also the decision to have external people on the Board, which help us being more outward looking, to the rest of the world.

We have just been in South Africa. Nelson Mandela was a great moral leader, not only for his country but for all of us. My vision for the Cochrane Collaboration is that it becomes the world’s moral leader in healthcare, which is dominated by politics and conflicts of interest. Cochrane must incessantly point out that we need a better world where the clinical trials are not designed, carried out and analysed by those who have a direct financial interest in the outcome, and where the data are manipulated or hidden if they do not please the sponsor. Up to now, Cochrane has been close to invisible in a political context. This should change. We could be a strong political voice because we are well respected for the rigour of our science and because we have good arguments.

We stayed at a hotel in Cape Town. It wasn’t much cheaper than in Europe whereas those who served the food earned so little that they did not have enough money for food at the end of the month although they live under very modest circumstances 50 km away. This is heartbreaking. I feel Cochrane’s political work should include contributing to reducing not only inequality in health but also in income, which is directly related to health.         

Peter C. Gøtzsche

Director of the Nordic Cochrane Centre

Hanna Martikainen conducts PhD research at Paris Diderot University on the French-language translation of Cochrane Systematic Review abstracts. Having previously worked as a translation coordinator and post-editor for Cochrane France, she now teaches a class in post-editing medical LSP at the Department of Cross-Cultural Studies and Applied Languages (EILA) at Paris Diderot University. During the past academic year (2016-2017), second year Master’s students in specialized translation have had a unique opportunity to contribute to the French translation project by post-editing machine-translated Cochrane abstracts and Plain Language Summaries. Now that the project has been renewed for the coming academic year, it seems like a good time to reflect on the first experience, presented here in the students’ own words.

Marie, Angèle, Margarita, Pierre, and Pauline described the profiles and general background of students in their second year Master’s degree in specialized translation:

“We are a group of 20 students from the ILTS (Industrie de la Langue et Traduction Spécialisée) Master’s degree at Paris Diderot University This course is open to students with prior translation experience in which is the case for most of us, but also to students who have technical experience and who speak at least two languages. Each of us does a work placement in different companies where we translate documents from fields including medical, legal, transport, entertainment, automotive, marketing, finance, tourism, and engineering.

Before starting post-editing with Smartling, we already had experience with Systranlinks, but none of our courses had trained us to do medical translation. Regarding CAT tools, we had previously learnt to use Trados Studio and Memo Q (Adriatic). As part of our training, we carry out different translation projects related to real work demands and Cochrane is one of them. Each one of us had the opportunity to post-edit five medical texts for Cochrane. It was a great experience because we discovered a new field and a new way to work with languages.”

Other students discussed the specificities of Machine Translation and Post-Editing. Vera, Marie, Lionelle, Marion, and Justine drew on their own experience to formulate some useful tips for beginner post-editors:

"Post-editing consists of editing automatic translation produced by a machine. You may already have used machine translation such as Google Translate. Post-editing will undoubtedly play an important part in the future of translation, since it will help improve productivity and reduce costs.

There are several differences between human and machine translation: first, style is usually not a priority when post-editing, the most important thing is to convey information. Machine translation is not suitable for every type of text; indeed the output is better with technical documents (such as medical and industrial content). The more repetitive the content, the better it is for the machine.

Automatic translation by the domain-specific engine is mostly terminologically correct, but often syntactically lacking. During the post-editing process, we often had to rephrase or rearrange long and complex sentences (for example, sentences with complex noun groups were often wrong). Other kinds of frequent mistakes include: terms not being translated, mistranslations, grammatical errors, and inconsistencies."

Their advice to beginners who would like to post-edit are:

• Try and read the whole source text before post-editing.
• Do not focus on style more than necessary.
• Do not blindly rely on the platform’s suggestions.
• Keep in mind that the final text has to be of publishable quality.
• Enjoy it!

Another group of students wrote about the specificities of medical English and their importance when translating. Here are some insights from Nadjet, Mélanie, Pauline, and Lucie:

“Regarding terminology in medical content, we noticed that English terms do not necessarily belong to languages for specific purposes (LSP), they often seem very simplified. In French, it is quite the opposite since specialized terminology of Latin origin is almost the only one to be used in both LSP and general language, including in hospitalization reports for patients, such as:

• baby → ‘foetus’
• stroke → ‘accident vasculaire cérébral (AVC)’
• back pain → ‘dorsalgie’
• blood disorder → ‘affection hématologique’

Also, in English, noun groups containing various modifiers of a head are packed, whereas in French, they often need to be unpacked, e.g.:

• TLR2-induced protein → ‘protéine induite par les récepteurs TLR2’
• main study visit → ‘visite au cours de l'étude principale’
• head and neck cancer → ‘cancer des voies aérodigestives supérieures’
• still birth → ‘naissance d'un enfant mort-né’

Finally, the use of passive sentences in English is very common, while we are instructed to avoid them in French as much as possible. However, translating medical content in French implies the use of a lot of passive structures that are very difficult to avoid.”

Last but not least, Joanna, Maya, Camille, Bruno, and Mickaël discussed how their pre-conceived expectations compared to the reality of post-editing:

“We were expecting a system similar to Google translation in its early years – huge terminology issues, not to mention typography and a catastrophic writing style. Actually, it wasn’t as bad as we thought it would be. Terminology was generally quite on point, as was the syntax, though there were several cases where we had to make the sentences more fluid and less 'robotic'.

Despite spell checking and grammatical software, the machine made more mistakes related to language than meaning. The longer the sentences were, the more mistakes occurred. It was sometimes difficult to refrain from rewriting the entire sentence when it was too long or when the syntax was wrong.

We also thought it would be necessary to have medicine-related knowledge; that the various diseases or health problems described in the text were not going to be explained, since it would have been written for people already familiar with this research. In reality, the terminology was most often correct, and the author described the research subject very precisely in the introduction. The first paragraphs gave us a good grasp of the subject. We simply needed to do some extra research to make sure the terminology was accurate and we had correctly understood the process of thought. Of course the machine version is not entirely reliable but it was far more efficient than we expected.

One of the main difficulties was to work as a post-editor and not as a translator. We had to learn to work fast, and accept a sentence that is not perfect. The use of automatic translation takes off some of the stimulation that traditional translation gives you, since the work is already done - at least partly - and you have to keep the proposed structured in order for the process to be time-effective.”

In conclusion, post-editing machine-translated Cochrane texts gave the students a hands-on introduction not only to this recent and booming domain of translation industries, but also to the specificities of medical translation. Moreover, the experience was a professionalizing one, given that the student post-editions were all published on Cochrane websites with acknowledgment given to post-editors.

Read the post-edited French translations

When it comes to health decisions, we want them to be informed by trustworthy, rigorous and reliable evidence. The current gold standard in providing this evidence are Cochrane Reviews, but with false and sensationalized information surrounding us how do we ensure that they remain trustworthy, efficient and sustainable? Here to explore this issue are authors of newly published research in Systematic Reviews, Tari Turner and Karla Soares-Weiser.

Tari Turner & Karla Soares-Weiser 1 Aug 2017

Reprinted with permission from BioMed Central Blog Network

It is perhaps predictable that in an era characterized by a growing expectation that health decisions should be evidence-based, fake news is, as the Merriam Webster dictionary says, “having a bit of a moment”.

At a time when clinicians, policy-makers and consumers are increasingly looking for evidence to support their decisions about health, this “false, often sensational, information” is all around us and it is becoming increasingly unclear what information can be trusted.

Cochrane Reviews have always aimed to be the gold standard in systematic reviews of health research; to provide trusted evidence to guide health decisions. In the growing murk of misleading marketing materials and other subtly or blatantly biased (or just-plain-wrong) health information, now more than ever it is vital that Cochrane Reviews remain trusted, and trustworthy, evidence.

To help ensure Cochrane Reviews remain trustworthy, and can be produced efficiently and sustainably, we conducted a series of interviews and a survey of people involved in producing Cochrane Reviews. We hoped to understand how the process of producing Cochrane Reviews currently works, and what could be done to improve it. The results of this research are published today in Systematic Reviews.

The findings emphasize some things that have been known anecdotally for some time, and especially that creating reliable, timely systematic reviews is incredibly hard-work.

We also identified challenges with the increasing complexity of review methods; with keeping authors on board and on track; and with how long it takes to complete the review process.

There were strong messages about the roles of authors and Review Groups, the main players in review production. There are clear needs to improve clarity of roles and expectations; to ensure continuity and consistency of input; and to support active management of the review process.

It was suggested that Cochrane might consider better ways of building the capacity of and sharing information between authors and Review Groups, and changing the way we work by, for example, breaking reviews into smaller “chunks”.

While the results of this research are, intentionally, primarily relevant to Cochrane Reviews, similar challenges are faced by all systematic reviewers, and the work of developing the solutions will also be shared.

It’s exciting to see people, within Cochrane and beyond, already trying new approaches, and looking for clever solutions to some of these challenges. Production innovations like Living Systematic Reviews, Rapid Reviews and Cochrane Targeted Updates are exploring how systematic reviews can be as useful and timely as possible, while maintaining rigor and reliability.

There is also an important role for new technologies to play in enabling improvements in review production. Cochrane Evidence Pipeline and Cochrane Crowd are already having a substantial impact on reducing the effort required to search for and screen studies for Cochrane Reviews, and Linked Data work is changing the way we think about the data included in our reviews.

There is plenty of work still to do to improve the production of Cochrane Reviews, and that work will be ongoing. The Shorenstein Center at Harvard University says that a key step in combating fake news is “Making the Truth “Louder”” by acting to “strengthen trustworthy sources of information”. We certainly hope that this research, and Cochrane’s response to it, will help to do that.

Liked the blog? Now read the research:

Producing Cochrane systematic reviews—a qualitative study of current approaches and opportunities for innovation and improvement

Tari Turner is a Senior Research Fellow on Project Transform, a three-year flagship health evidence project, which is piloting, refining and scaling-up innovations in evidence production by the global Cochrane network.

Karla Soares-Weiser is Cochrane Deputy Editor in Chief. She has been active in the field of evidence-based healthcare for 20 years, and has extensive experience in preparing systematic reviews and critical appraisal of research evidence.

Heather Bagley (COMET), Sarah Gorst (MRC Hub for Trials Methodology Research), Richard Morley (Cochrane) Bridget Young (COMET) explore how patient-imporant outcomes could be identified for Cochrane Reviews. 

An enthusiastic group of healthcare consumers, Cochrane authors,  and researchers joined a workshop jointly run by Richard Morley (Cochrane Consumer Co-ordinator) and Sarah Gorst (Research Fellow for the Patient Perspectives Theme of the MRC North West Hub for Trials Methodology Research) during the UK Cochrane Centre Symposium in Keble College, Oxford 14-15 March 2017. The aim was to explore how patient-important outcomes could be identified for Cochrane Reviews and to answer these specific questions:

• What are the challenges of gaining a patient perspective about patient-important outcomes in Cochrane Reviews?
• How might core outcome sets (COS) help in a Cochrane Review, and what are the benefits and challenges in introducing a COS for reviews?
• What happens when a relevant COS does not exist? How can we seek patient input to ensure that the outcomes used in reviews are important to patients as well as to clinicians and researchers?

Background

Ill health and treatments can affect people in many ways, making it difficult to select the most appropriate outcomes for research. The Cochrane Handbook emphasises the importance of consumer involvement in decisions about outcomes for reviews, whilst also promoting the use of standardised core outcomes and says review authors “... must ensure that there is effective public and patient involvement to identify the patient-relevant questions for Cochrane Reviews and patient important outcomes.” (training.cochrane.org/handbook)

This is even more important in the light of the recently published ‘Evaluation of NIHR Investment in Cochrane Infrastructure and Systematic Reviews’, which called for “more involvement of Cochrane Consumers, and other stakeholders in the whole systematic review process” including in “question formulation, scoping, outcomes, and dissemination products  (beyond  the  Plain  Language  Summary)”  as a way to “improve  the  relevance  and  uptake  of reviews.” (www.journalslibrary.nihr.ac.uk/nihr-research/evaluation-of-nihr-investment-in-cochrane)

So, what’s the problem with outcomes in research?

There are a number of challenges associated with the use of outcomes in research.  Different studies that look at the same treatments for the same condition often measure different outcomes.  When such studies are completed, we cannot compare or combine their results in systematic reviews and meta-analyses because they have used different outcomes.  The scale of this untidiness is striking. For example, over 25,000 of the outcomes in cancer trials have only been used once or twice (Hirsch 2013). Also, in a case study of Cochrane Reviews of HIV/AIDS, Saldana (2017) reported that outcomes used in trials and reviews were not well aligned.

The presence of selective reporting of outcomes in trials, which occurs when a study team set out to collect information on several outcomes, but publishes the results for only some of the outcomes. This can happen when the findings for particular outcomes differ from those for which the team hoped. Smyth (2010) found empirical evidence of outcome reporting bias, and calculated that 29% of trials displayed it.  Dwan (2008) also showed that outcomes that are statistically significant are more likely to be fully reported, and that studies that report positive or significant results are more likely to be published.

The outcomes used in research and systematic reviews may not be relevant or important to patients. Numerous studies have reported differences in the outcomes identified as important when patients or carers have been involved, for example, Noble and Marson (2016) explored health professionals’ views about outcomes of importance in relation to epilepsy.  When further work was conducted involving patients and carers, they found that whilst the patients and carers agreed with the outcomes identified by the health professionals, they also identified three additional outcome domains of relevance that included depression, anxiety, and independence/need for support. Similarly, Turk (2008) compared the outcomes identified by patients with those identified by health professionals in the area of pain, and reported that, “In addition to confirming the importance of pain relief and improvement in physical and emotional functioning, our results expand on the [IMMPACT] domains by highlighting fatigue, sleep, home and family care, social and recreational activities, interpersonal relationships, and sexual activities.”

What solutions might there be?

If all studies investigating a particular health condition used the same outcomes, they could all be compared and combined. This would reduce research waste by making best use of all the data, and would also reduce selective reporting bias. When a set of main outcomes has been agreed for a health condition, it is called a ‘core outcome set’ (COS).  A COS is “An agreed standardised set of outcomes that should be measured and reported, as a minimum, in all clinical trials in specific areas of health or health care” (COMET: www.comet-initiative.org). Patient input into agreeing outcomes of importance is vital.

How are core outcome sets agreed?

COS have to be relevant to patients, carers and health professionals and other key stakeholders, so the people developing COS need to ensure that the expertise of these groups is used to agree the core outcomes.  To seek such agreement researchers often use ‘consensus methods’ such as the Delphi process which involves a survey and a final consensus meeting to agree which outcomes are the most important, i.e. the ‘core’, outcomes (for further information about the Delphi process see: www.comet-initiative.org/assets/downloads).  Some researchers also conduct interviews with patients to understand their perspectives about important outcomes.

What is the COMET Initiative and how is it helping?

COMET stands for the ‘Core Outcome Measures in Effectiveness Trials’ Initiative. This initiative involves people from around the world from many different areas of health and social care, and was set up to help the development of COS in two main ways:

• firstly, by providing the COMET database (www.comet-initiative.org/studies/search) as a central point where researchers, practitioners and patients could find out which COS that have already been developed or are still under development; and
• secondly, to provide materials to support teams who are working on COS.

Using COS

To date, the following organisations have endorsed COMET:

• Arthritis Research UK (ARUK) www.arthritisresearchuk.org;
• Health Research Board (HRB) www.hrb.ie;
• The IDEAL Collaboration www.ideal-collaboration.net;
• National Institute for Health Research Health Technology Assessment Programme (NIHR HTA) https://www.nihr.ac.uk/about-us/how-we-are-managed/boards-and-panels/programme-boards-and-panels/health-technology-assessment/;
• Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) www.spirit-statement.org.

According to Professor Hywel Williams (Chair of the NIHR HTA Commissioning Board), “Patients and professionals making decisions about health care need access to reliable evidence. The…COMET database will help researchers across the NIHR family and beyond when choosing the outcomes to include in the studies that will establish this evidence base.”

Increasingly COS are being identified as part of the Cochrane Review process and Section 5.4.1 of the Cochrane Handbook (‘Listing relevant outcomes’) states: “… several clinical areas are developing agreed core sets of outcome measures for use in randomized trials, and consideration of these in defining the detail of measurement of outcomes selected for the review is likely to be helpful.”

How do we involve patients when there isn’t a COS available?

The literature that describes the involvement of consumers in identifying outcomes in systematic reviews is limited. While evaluating the experience of public research partners involved in a systematic review, Vale (2012) identified the importance of consumers being “involved at the stage when the questions are being developed to give them the opportunity to influence which outcomes should be investigated”. Morley (2016) recently sought to identify the extent of consumer involvement in systematic review production within Cochrane. His team found a number of published studies that described consumer involvement in setting outcomes that are important to patients: including Kelson (1999), which identified case studies from the Pregnancy and Childbirth and Musculoskeletal review groups; Ghersi (2002), which identified the impact of consumer involvement in the Breast Cancer Group; and Coon (2015), which reported end-user involvement in a systematic review of quantitative and qualitative research of nonpharmacological interventions for attention deficit hyperactivity disorder delivered in school settings.

Additionally, recent work commissioned by the UK Cochrane Centre and led by Sally Crowe, explored ways of identifying cost effective, robust and evidence-based outcomes that involved stakeholders in in asthma, chronic rhinosinusitis and breastfeeding (training.cochrane.org/resource/CLL-webinar-consumers-terrified).

Meanwhile Cochrane’s Project ACTIVE (training.cochrane.org/ACTIVE) is bringing together evidence, information and resources about the involvement of people in systematic reviews so that Cochrane authors can access published examples of ways of involving people throughout the systematic review process (Pollock 2016).

Nevertheless, there is no consensus on the best methods for involving patients in the Cochrane  Review process where an appropriate COS does not exist, or, in cases where a COS does exist, for choosing outcomes, for example, for inclusion in the ‘Summary of findings’ table where a maximum of seven outcomes is required and the existing COS contains eight or more outcomes.

Workshop discussions

The presentations at the workshop (as mentioned above) were followed by a lively discussion in which participants explored the benefits and challenges of patient input into the selection of outcomes for reviews; considered how the use of COS could help; and potential methods to use when employing the patient perspective to select patient-important outcomes for reviews where an relevant COS currently does not exist.

The workshop participants identified the following benefits of involving consumers:

• ensuring the relevance of systematic reviews to patients by using more relevant outcomes and keeping research grounded in people’s real life concerns;
• identifying outcomes that clinicians and other stakeholders might not have described;
• enhancing public engagement with research;
• increased ownership of the results by patients, which leads to increased uptake of research findings; and
• giving patients the opportunity to make a valuable contribution to research.

Several challenges in involving consumers were voiced, including:

• funding and capacity issues;
• difficulties in identifying patients to engage;
• ensuring diversity (especially of seldom-heard populations);
• difficulties in resolving diversity of opinions and priorities;
• challenges that may arise if the identified outcomes are difficult to measure;
• potential conflicts between patients’ experience of illness and previous received knowledge of a condition;
• difficulties in communication between patients and clinicians; and
• the lack of tried and tested methods that could be used.

What next?

There was considerable enthusiasm among participants about the possibility of involving consumers in identifying outcomes in systematic reviews. However, it was also agreed that more research was needed to identify effective methods for doing this, in order to provide guidance for review authors.

In the meantime COMET has published its new Handbook that can be accessed at www.comet-initiative.org. The COMET People and Patient Participation, Involvement and Engagement (PoPPIE) Working Group has produced resources for researchers seeking patient and public input into COS development (www.comet-initiative.org/ppi/researchers). ‘Involving People - A learning resource for systematic review authors’ is a new resource for Cochrane authors who want to involve consumers in Cochrane Reviews will be launched in September 2017 and will be available at training.cochrane.org.

Acknowledgements

The content of some of this article is based on the COMET Core Outcome Set Plain Language Summary (www.comet-initiative.org/assets/downloads).

References

Julie Wood is Head of Cochrane's Communications and External Affairs team, as well as Co-chair of the newly formed Knowledge Translation Advisory Group. Here she provides an update on the development of Cochrane's Knowledge Translation Framework, and outlines next steps for Cochrane contributors to get involved with implementation.

Cochrane has focused much of our work on producing systematic reviews. To achieve our vision, however, we need to not only produce high-quality reviews, but also ensure that we produce the right reviews - and ensure that they reach those who need the evidence at the right time. Knowledge translation (KT) is the vital ‘other half’ of achieving our ambitions as set out in Strategy to 2020.  
 
During the past 12 months there have been wide-ranging consultations for and contributions to the KT Framework, from across the Cochrane Community. Cochrane Groups and contributors already undertake a broad range of KT activities, so there is much to build upon in delivering Cochrane’s KT ambitions.
 
Cochrane’s Governing Board approved the KT Framework in April 2017. Now is the time to draw upon the Cochrane community's vast expertise to help define a formal implementation plan that we can submit to the Cochrane Governing Board in Cape Town in September. We have established a KT Advisory Group, which will lead and supervise KT implementation, together with recommendations on the key work priorities for Cochrane during the next 12 to 24 months. Once established, these priorities will be taken forward by working groups. 

We invite the Cochrane community to provide comments on the knowledge translation priorities for Cochrane. Please also let us know, by sending an email to Sylvia de Haan by 31 July, your interest to join one of the following thematic working groups:

• Embed prioritization
• Improve and scale up of existing products
• Translate
• Grow capacity in our users
• Formalize strategic partnerships
• Convene deliberative dialogues
• Build KT infrastructure and common language

This is a very exciting new era for Cochrane in shaping our KT implementation plans. KT is essential in achieving Cochrane’s vision, and effective KT maximizes the benefit of the work done by our thousands of contributors. Your contributions will ensure our fundamental commitment to the use and impact of Cochrane evidence.
 
We look forward to discussing more with you and taking your questions.

With my best wishes,
 
Julie Wood 
Cochrane’s KT Advisory Group Co-chair
 

The Targeted Updates project aims to provide policy-makers, in particular guideline developers, with up-to-date information from Cochrane Reviews, tailored to their needs and working to a fast timeline. Targeted Updates use Cochrane Reviews as their foundation, but focus on updating selected comparisons and outcomes, working in close consultation with key stakeholders. In this post, the team describes their next case study. For more information, please see the blog post introducing the Targeted Updates project, the blog post describing the first case study, the second case study, and the third case study.
 

Case Study D: Question identified by a Guideline Developer

1. Context

The National Blood Authority (NBA) in Australia was in the process of running a pilot to develop a more efficient and cost effective process for updating the ‘Patient Blood Management’ (PBM) guidelines. The NBA identified which parts of the guidelines were relevant to Cochrane Reviews, and this helped to inform the initial discussions regarding which topic to take forward as a Targeted Update. A review from the Injuries Cochrane Review Group (CRG) was of particular interest to the NBA. The NBA contacted Cochrane Australia to determine when there would be an update of this review. Cochrane Australia recommended that they contact the Targeted Update project team. Following initial contact, the Targeted Update team discovered that the review had been recently updated, and was ready for publication. We informed the NBA that the review was soon to be available, but they still asked the Targeted Update team to produce a Targeted Update for their question of interest. This was because (1) their question and PICO differed slightly from the full review update, and (2) they were interested in obtaining this information in a more accessible format.

2. Process

We began by liaising with the original Cochrane Review’s author team, and by conducting an initial assessment of the latest version of the full Cochrane Review. The Co-ordinating Editor of the Injuries Group was an author on the review of interest. Therefore, he was directly engaged in the project and involved in all discussions from the start. The original review question was modified, as the NBA in this case were interested in a subgroup analysis of the results from the full review. Because the review had recently been updated and published, the Targeted Update was completed by the Targeted Update team, with content expertise from the CRG, within two weeks, and peer reviewed within another two weeks. The final output differed slightly from the standard Targeted Update template, as the NBA specifically requested the presentation of relevant forest plots. Feedback from the NBA was very positive, indicating that they would be likely to commission further Targeted Updates as part of their standard guideline updating process in the future.

3. Output

Antifibrinolytic drugs for acute traumatic injury

4. Feedback from the National Blood Authority

The Director of the NBA, Jen Roberts, spoke as part of the Australasian Cochrane Symposium Plenary in November 2015. During this presentation, she discussed her experience of working with the Targeted Update project, both positive and negative.

Overall, the NBA were very positive regarding their experiences.

“The targeted update was a joy to do.”

One of the main learning points they noted from their experience was the importance of setting clear PICO criteria that exactly match the research question under investigation;

“When we’re commissioning a targeted update, it’s really critical to get your PICO alignment really right, and sometimes your initial review didn’t align perfectly with a Cochrane Review.”

“That PICO alignment and the effort in that before you kick off is really important.”

They also noted some difference of opinion between the Targeted Update Team, and the clinical reference group regarding the GRADE process;

“There were some issues we’ve discovered that were in relation to editorial independence. Our clinical reference group didn’t agree with the grading of some of the outcomes using the GRADE process, and that’s now to be put to the clinical reference group in the next few weeks.”

Finally, the NBA were impressed with the speed at which the work was completed, and the high quality of the document produced by the team;

“It took about four months to negotiate the contract and about four weeks for the Cochrane Group to produce that update which was extraordinary and of really high quality.”

5. Feedback from you

We are very interested to know what you think about these Targeted Update documents, and the project in general. We would really appreciate it if you could take just five minutes to read through and answer this short list of questions. Thank you very much for your participation!

6. Who are the team

Targeted Update team involved in production

• Rachel Marshall
• Karla Soares-Weiser

Review authors

• Ian Roberts

CRG team

• Ian Roberts
• Emma Sydenham

Cochrane Reviews are systematic reviews of research in health care and policy, and are internationally recognized as a high-quality source of evidence for decision-making. They collate and summarize all the best available research evidence on the effects of healthcare interventions or the accuracy of diagnostic tests into a systematic review.

Outcome selection data in systematic reviews needs to be relevant to patients, clinicians and policy-makers if the findings of a review are to influence practice and future research. Missing data, or inconsistent reporting of outcome data, in clinical research can negatively affect the quality of evidence within a systematic review. A potential solution is an agreed standardized set of outcomes known as a core outcome set (COS). These represent the minimum that should be measured and reported in all clinical trials of a specific condition, and are also suitable for use in clinical audit or research other than randomized trials.
 
Among its many international collaborators, Cochrane is working with the COMET (Core Outcome Measures in Effectiveness Trials) Initiative, which brings together people interested in the core outcome sets.

We spoke with Hywel Williams (Cochrane Skin), Anne-Marie Glenny (Cochrane Oral Health) and Jochen Schmitt (Cochrane Skin) about their involvement with COMET, core outcome set development and the opportunities for Cochrane to engage in this work. 

All three Cochrane contributors emphasize the importance of core outcome sets (COS) for review production. 

‘For me, the lack of common outcomes that are valid and meaningful to health care professionals and patients are one the most important obstacles for preventing any sensible form of comparison between different studies of skin diseases’, says Hywel Williams. ‘The lack of pooled analysis or pooling of very different outcomes in a desperate attempt to make some form of summative comparisons will continue until core outcomes for clinical trials are developed and used.’
Anne-Marie Glenny adds: ‘We have many reviews with a vast number of differing outcomes that mean no pooling of data is possible. We hope that developing COS will encourage trialists to focus on common, patient-focused outcomes and reduce research waste.’
 
The work of COMET in the COS environment is very important. COMET provides a searchable database, a networking facility, and a resource for methodological advice. Cochrane Skin has made the development of core outcome sets a priority, and has set up an international collaboration called the Cochrane Skin Group Core Outcome Set Initiative (CSG-COUSIN). In oral health, there is such a diverse range of outcome measures across reviews (including pain, gingivitis, mortality, caries, mucositis) that it is beyond the Group’s capacity to develop COS for all relevant areas. However, support is provided to review authors if this is something they wish to pursue. 

Jochen Schmitt refers to the importance of cooperation among reviewers, trialists, and methodologists to resolve the current problems of "outcome heterogeneity". He continues explaining why he feels Cochrane Review Groups (CRGs) could play a key role in this: ‘They are widely accepted, globally acting, and the COS topic is really central for the Cochrane mission to become the leading advocate for evidence-informed healthcare. Since the establishment of CSG-COUSIN the annual Skin Group meeting always spends half a day on COS.’ 

So what is it that CRGs can do to strengthen COS development? The inclusion of the topic in Group meetings is a very practical suggestion and will stimulate thinking and reflection about COS development in the Group’s thematic area of work. Hywel Williams says: ‘Most systematic reviewers spend a lot of time thinking about their outcomes, so it is natural that many will want to become involved in collaborative initiatives that develop core outcomes. At Cochrane Skin, we point potential review teams to existing core outcome set initiatives in skin at title registration form stage, and encourage our reviewers to have a dialogue with those developing core outcome sets.’ But Anne-Marie Glenny acknowledges, ‘The time it takes to get involved may be an obstacle for authors to engage. We should identify priority areas where COS would really be beneficial, which is not necessarily the case for all reviews. We need to think carefully about resources required before embarking and about how the resulting COS will be incorporated into updating/ongoing reviews.’

In addition to the work of COMET, Jochen Schmitt emphasizes the importance of discipline specific COS-groups because of the need for specific clinical expertise and a detailed understanding of clinical trials and review issues necessary for appropriate COS development and their implementation. It is also essential to prevent the development of more than one COS for one indication, a situation already happening in pain therapy, thus adding to outcome heterogeneity rather than resolving it. Jochen Schmitt also points to another challenge: ‘COMET is primarily dedicated to develop core outcome domain sets. This is an important first step, but the selection of the best core outcome measurement instrument is essential to make COS really meaningful.’ 
 
So what does this all mean for Cochrane reviewers? This is well summarized by the following statement from Hywel Williams: ‘If, like Cochrane Skin, your review outcomes are all over the shop and plagued with a multitude of unvalidated and clinically meaningless outcomes that prevent pooling of trials, then tackle the problem head on by developing a collaboration with those interested in, and who have methodological expertise in developing core outcome sets.’

About COMET
COMET brings together people interested in the development and application of agreed standardized sets of outcomes (core outcome sets). COMET aims to collate and stimulate relevant resources, both applied and methodological, to facilitate exchange of ideas and information, and to foster methodological research in this area. This is being achieved through:

• Development of a searchable database of completed and ongoing projects in core outcome set development;
• Development of a repository for project protocols and other documents (such as questionnaires), with the intention that this will be searchable;
• Maintenance of these resources in a publicly available searchable database;
• Preparing guidance on developing and reporting core outcome sets;
• Preparing guidance on integrating patient reported outcomes into core outcome sets; and
• Guidance on obtaining funding to develop core outcome sets.

For more information, please contact:
Hywel Williams: Hywel.Williams@nottingham.ac.uk
Anne-Marie Glenny: cochraneoralhealth@manchester.ac.uk
Jochen Schmitt: Jochen.Schmitt@uniklinikum-dresden.de

A new chapter for Cochrane

As an evidence-producing and knowledge-diffusing organization Cochrane’s past, present, and future success is built on the quality of the people it attracts and retains. We are so proud of the tens of thousands of volunteers who work for us because we know that what we do and the impact for good that we have as an organization are rooted in their efforts.

That’s why I’m delighted to announce a new initiative which I believe will transform Cochrane in the future. This month we are proud to launch our new Cochrane Membership scheme, making it easier than ever before for anyone to become a part of our global community of supporters, passionate about improving healthcare decisions.

Cochrane’s world is now wider! The Membership scheme is the pivotal organizational initiative which will enable us to grow our collaboration, attracting many new people with a wider range of experience and  skills into our work, and allowing us to recognize their contributions and sustain our global activities.

This month’s launch is the first phase of our Membership scheme, which will continue to evolve and improve in the coming months and years. I wanted to share with you what this means for the existing Cochrane community, and how will it will affect your work.

Membership recognizes the enormously valuable contribution of our current collaborators. Here are just a few ways in which Membership will support your Cochrane activities:

• Better guidance for new contributors: New online resources provide clear pathways to a variety of opportunities with no added impact on limited Group resources.
• No data protection responsibility: Our new infrastructure handles all data protection issues centrally so you don’t have to worry about keeping your lists up to date.
• Better reporting: You will have improved reporting of the Cochrane activity in your country or topic area to inform the work of your Group.
• More effective communication: A new central email system directs information about the work of your Group which will ensure more effective targeted dissemination.
• Easier skillset identification: The new Membership scheme will make it easier for you to be able to find the people who want to help you with your activities: whether that’s potential peer referees, participants for priority setting, or appropriate attendees for your training sessions.
• Systematic implementation: We’ll provide training and support to help Groups maximize the potential of our new system.
• Better, clearer and more comprehensive ways to recognize the work of our contributors: There will be a track-record of all contributions made, with easy access to eligibility for Cochrane’s annual awards, certificates, and potential accreditation.

For those who are brand new to Cochrane, Membership makes it easier to join us, to make contributions to Cochrane’s work, and to be a part of our global community. It allows new members to:

• Develop new skills and interests
• Work with like-minded colleagues and collaborators
• Grow professional and social networks
• Receive world class training from world leading experts in the fields of medicine, health policy, research methodology, and consumer advocacy
• See their contributions recorded and recognized
• Influence how Cochrane is run through voting for its Governing Board members and resolutions in the Annual General Meeting

This month’s launch sees the creation and completion of our central membership database that will store details of all Cochrane contributors and will track your contributions to Cochrane, whether that is as an author, translator, Crowd participant, Task Exchange contributor or a learner. The system will be able to recommend activities to new members to help them expand their skills, experience, and expertise, making it easier for people to contribute to Cochrane’s work without increasing the workload of our existing Groups.

Over the next few weeks, we will be notifying our existing members of our launch, and working with Review Groups in re-directing their website “Get Involved” information to our new "Join Cochrane" pages on Cochrane.org. We are also streamlining the process of accessing and updating your Cochrane account - get more information here about how to keep your personal profile up to date, sign up for more information, and access all Cochrane tools. We will update you each month with progress on Cochrane Membership, as well as information on the introduction of new and exciting features. All these announcements will feature within our Community website, and through our Membership pages.

We will be announcing the launch of Cochrane Membership to a wider world at the Global Evidence Summit in Cape Town in September; encouraging new supporters to join us; and you will see new features on the Cochrane.org website with a more public launch at the Global Evidence Summit in Cape Town in September.

Cochrane Membership signals a huge change for the organization. It opens our doors to the world in a new expansive way, and announces that everyone is welcome to join us and make a contribution – large or small – to our global mission. But in a fundamental way, Cochrane Membership is simply the continuation and development of what we are and have been for 24 years: an open collaboration of brilliant people from around the world all working together to inform and impact health decision making.

With my very best wishes,

Mark Wilson
Cochrane CEO

Dear Colleagues,

Cochrane’s Editor in Chief, David Tovey, wrote to you last on 20 April following a highly successful meeting of the Co-ordinating Editors (Co-Eds) Board and consultations with Managing Editors, Information Specialists, and the Methods community in Geneva. Participants at this meeting discussed proposed Cochrane Review Group (CRG) Structure & Function reforms and the ongoing sustainability review of CRGs. As you may know, the related paper and its recommendations, presented by the Structure and Function Project Team (chaired by David and including myself and Co-Eds Nicky Cullum, Jonathan Craig, and Martin Burton), were subsequently accepted by the Cochrane Governing Board in full.

Since then, the Project Team and the CEU have been working on the individual CRG sustainability reviews; communicating their recommendations to the most affected Groups; engaging with Groups in the planning of new CRG Networks, and developing an implementation strategy for them.

We’re pleased to inform you that we are nearing completion of the sustainability reviews for all of Cochrane’s 51 CRGs, focusing on those Groups with the most pressing issues, and want to provide you with a fuller update for the next stage of our Structure and Function changes.

The sustainability review reports were created based on standardized criteria and information from Archie, CEU screening and copy-editing reports, and an independent assessment from the Editor in Chief of each Group’s performance over the last five years. The reports contain critically important information on all aspects of review production. Specifically, each CRG was evaluated based on its productivity, quality of output measured against standard criteria, review timeliness and impact within local and global health settings, leadership, contribution to Cochrane, and financial sustainability.

Based on these assessments, we have identified 13 CRGs which are at the highest risk of producing reviews that fail to meet the agreed standards, and an additional three CRGs currently most vulnerable in terms of resources and future sustainability.

The Project Team has made specific recommendations for each of the 13 CRGs at highest risk of producing reviews that fail to meet the agreed standards. We are now in the process of implementing these recommendations, which in general terms include working closely with other CRGs who may provide oversight and mentorship, reducing CRG  scope, prioritization of relevant reviews, and mandatory screening of reviews prior to final editorial approval. In addition, we are closely monitoring and providing support to the three CRGs considered vulnerable in terms of their resources.

The results from this sustainability review will also inform a full Implementation Plan entitled ‘The Structure and Function of Cochrane Review Groups: implementation of Networks and Editorial Board’, which will be completed by the Project Team by mid-August, shared with the Cochrane community, and presented for approval to Cochrane’s Governing Board in Cape Town in September 2017.

Following the extensive analysis, consultation, and debate on CRG reforms that have taken place in recent years, and with a clear steer from the Governing Board, this Implementation Plan will summarize the changes we will be making to ensure Cochrane addresses the challenges it faces in relation to the production of a comprehensive set of timely, high-quality reviews, relevant to our stakeholders. These challenges have been described in previous documents, and include:

• inconsistent quality of reviews submitted for publication;
• fragmented and inconsistent approaches across the CRG community to managing scope, editorial processes; and prioritization;
• excessive times to protocol and review publication;
• delayed and fragmented approaches to implementation of methodological and technological innovation;
• challenge of managing 51 CRGs to ensure consistent adherence to standards and processes.

The Plan includes the establishment of eight CRG Networks. It will set out structure and function changes that seek to promote stronger editorial processes, the improved use of resources, more effective ways of prioritizing review topics and identification of evidence gaps, as well as greater communication between Groups and sharing of resources. Each Network will be led by a newly-appointed Senior Editor who will report to Cochrane’s new Editorial Board. These eight Networks will cover the thematic areas of:

• Acute/Emergency Care
• Neurology/Mental Health
• Cancer
• Circulation and Breathing
• Two networks covering Long-term Conditions
• Public Health
• Women, Children, and Family

We want to facilitate the creation of vibrant and robust Networks of sustainable, nimble, and connected CRGs. These CRGs will be able to actively prioritize the reviews that are most important to stakeholders, and ensure the efficiency of their editorial processes and the consistent quality of their outputs. We also want to foster systems that can reliably innovate, and scale up changes, advocate for learning programmes that meet the needs of CRGs more effectively, and work with others to ensure maximum impact for our reviews.

The Plan will outline the relevant functions and activities of all of the Networks; the CRGs involved; their full scope, prioritization, support and training; and knowledge translation engagement. However, as a brief overview, here are the principal areas of the proposed implementation phase:

• The allocation of CRGs to one of the eight Networks based on full scope, the WHO global burden of disease, shared methodological issues, geographical proximity, and feedback received during the 2017 Co-Eds Board meeting discussions in Geneva.
• The elucidation of the key functions of the CRG Network, and the core attributes, responsibilities, and accountabilities of the new roles of Senior Editor, Network Associate Editors, and of the CEU management team.
• Clarification of the mechanisms of governance and accountability for CRGs, including the establishment of a Memorandum of Understanding with each Co-ordinating Editor, and a regular five-year accreditation process considering the role of leadership, strategic planning, editorial teams, and financial sustainability.
• Definition of the responsibilities of the Editorial Board and the Methods Support Unit, based on decisions taken by the Cochrane Governing Board in Cape Town in September.

We hope you will find this information useful and timely. ‘The Structure and Function of Cochrane Review Groups: implementation of Networks and Editorial Board’ document will be finalized in the next few weeks and we will share this with you the week beginning Monday 14 August, ahead of its presentation for approval to Cochrane’s Governing Board in Cape Town in September 2017. In addition, we will provide regular communication updates through our monthly Reviews and Methods Digest.

We recognize that there may be many questions about what this means for you and the future functionality of CRGs. Some of these questions may not have definitive answers until after Cochrane’s Governing Board has met in Cape Town. However, in the meantime we have established an email address where you can submit questions, and one of the Project Team will respond to your enquiry: SFinfo@cochrane.org.

We look forward to the next few months of work as we engage more closely with you and other members of the CRG community to move these changes forward together.

With our best wishes,

Karla Soares-Weiser, Acting Editor in Chief

Martin Burton, Co-ordinating Editor, ENT Group

Jonathan Craig, Co-ordinating Editor, Kidney & Transplant Group

Nicky Cullum, Co-ordinating Editor, Wounds Group

Mark Wilson, CEO