1. Christopher Eccleston Centre for Pain Research The University of Bath c.eccleston@bath.ac.uk

2. Order of service Cochrane Collaboration Methods Communication Methods Development Other

3. Cochrane Collaboration Founded in 1993 Iain Chalmers Following Archie Cochrane Principles of Evidence for all 52 CRGs Centres & Fields Volunteer Consumerist Quality Control over Bias Living Library

4. Cochrane Collaboration Review Group Pain, Palliative & Supportive Care PaPaS http://papas.cochrane.org Established in 1998 Based in Oxford Updates 2 years Cochrane Database Systematic Reviews The Cochrane Library Field Editors

5. Current Status Editorial Board –Mike Bennett –Andrew Moore –Tim Steiner –Amanda Williams –Acute Pain Vacancy Title to Protocol to review 120 reviews 70 protocols and titles 2 overviews IASP SIG Systematic Reviews ACTINPAIN Writing Group

6. Quality improvement (Actinpain)

7. Methods Guidance? Common Methods RevMan (free) Supported (Title Reg) Professional Searching Published Protocols International (not English) Meta-analysis Bias Control Communication www.cochrane-handbook.org/

8. Features Standard description of condition/intervention Full description of studies (Tables) Assessment of heterogeneity –Clinical pooling like with unlike –Statistical (small n) Sub-group analyses –(dose)

9. Meta-analysis + Effect sizes Forest plots Assumptions –Fixed effects Assume variation is sampling error Violations –Heterogeneity –Small n Junk in Junk out –Quality of primary

10. Communication Abstracting Plain Language Summary Risk of Bias Tool Summary of Findings Podcast Journal Club PICO

11. Risk of Bias

12. Summary of Findings Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008 Apr 26;336(7650):924-6.

13. The GRADE system classifies the quality of evidence in one of four grades: GRADEDEFINITION High ⊕⊕⊕ ⊕ Further research is very unlikely to change our confidence in the estimate of effect. Moderate ⊕⊕⊕  Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low ⊕⊕  Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very Low ⊕  Any estimate of effect is very uncertain.

14. Journal Club

16. Methods 1: Outcomes Use outcomes (IMMPACT) chronic Pain reduction: 30% moderate, 50% Good Other –Time to re-medication – non-pain outcomes Not recommended –Odds ratios –Analgesic consumption No use of group means –Pain relief has a U shaped distribution –Response analysis on dichotomous data Adverse events

17. Core outcomes

18. Methods 2: ROB Use of quality rating scales? Jadad scale Non-pharmacological interventions?

19. PaPaS RAG

20. Methods 3: GRADE

21. Alternative?

22. Methods 4: NNT Inverse of the absolute risk Benefits –Easier to understand –Compare between treatments easily Costs –More is worse –Can hide effect (EMEA Report) Never an NNT alone RR, NNT, NNH, percentage improvement

23. Stabilizing a review Publication bias Stabilizing (not updating)

24. Not discussed Overclaiming –No effective or no evidence of effect Quality control in non-pharmacological trials Language of confidence Simplify vs simplistic (95% read abstract) 30 or 50 or 70 Responder analysis vs response analysis Does pain relief drive QoL outcomes? Comparing treatments –Overview reviews –Stopping rules, Switch rules –Indirect comparisons Judgement biases –Behavioural economics (choices) –Myth of rational man

25. Communication What is the risk doctor? Tell it to me straight. What are my chances doctor? Tell it to me straight.

26. Thank you