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Issue 478, 4 March 2002

Leeds in worldwide scheme to widen knowledge and improve patient care

How can you find out whether fish oil cures schizophrenia, whether praying will alleviate ill-health or whether alternative Chinese medicine can help your stomach ache? How effective is the latest drug or treatment you've been offered? Although clinical trials are carried out into all new drugs, and some of the more surprising alternative treatments, it's not always easy to draw clear conclusions from them, either as a healthcare professional or as a patient.

Two groups at Leeds are part of an international collaboration seeking to put that right. The Cochrane collaboration is reviewing clinical trials to provide an overview of the evidence. There are 63 groups worldwide relating to different conditions; at Leeds one looks at schizophrenia, and the other at upper gastrointestinal and pancreatic diseases. Each group is managed by an editor, who oversees the reviews carried out by volunteers, whether academics, healthcare professionals or even interested parties.

Editor of the Cochrane schizophrenia group Professor Clive Adams (pictured left) said: "Lots of things influence medical practice, such as accessibility to treatment, commercial priorities, history and habit, patient preferences and a doctor's own clinical experience. It's always better to work from proven clinical trials – but there are too many to keep all the findings in your head. Cochrane groups provide an overview, by scientifically evaluating the trials, how well they were carried out and their findings.

"The reviews follow a set procedure, to ensure that any bias on the part of the reviewer is taken out of the equation. Reviewers may themselves wish for a certain outcome, but our system ensures a balanced result. In fact, the trials of fish oil as a treatment for schizophrenia were reviewed by two former fishermen, one of whom had a daughter suffering from schizophrenia. They were both greatly disappointed that nothing could be proved in the treatment's favour."

Editor of the Cochrane upper gastrointestinal and pancreatic diseases group, Professor David Forman (pictured below), said: "Cochrane groups look at a huge range of treatments from traditional Chinese medicine for stomach ache to the latest drug treatment for a potentially fatal cancer.

"The trials we review are not just of drugs, but also of mundane bits of treatment or equipment which can transform patients' lives. For example, when people with oesophageal cancer have problems swallowing, there is a type of 'spring' which, placed into the oesophagus, can help. It's made of either plastic or metal and one of our reviews looked at which material was best.

"Ultimately, such evidence should be available in a GP's consulting room or at a hospital bedside. It should form part of every medic's training. The aim of the groups is to ensure the instinctive reaction of every medic when faced with a new problem or unsure if a treatment is up to date becomes: what does Cochrane say?"

The Cochrane collaboration is widely respected by health professionals, and is used as the basis for many official guidelines and recommendations for treatment, including those put together by the new government body, the National Institute for Clinical Excellence (NICE). However, ensuring that the reviews provided by Cochrane filter through to medical practice is not always straightforward, as the recent study by obstetrics and gynaecology researchers at Leeds has shown (see page 1).

The reviews themselves have begun to set the agenda, by identifying areas where treatments are used which have never been truly tested. One such area is the use of anti-psychotic medicines for people with learning difficulties, also suffering from schizophrenia.

Professor Adams: "People with learning difficulties require long-term care from the health service, and so a substantial amount of resources go to this group. Yet there is no data on the long-term effects of the drugs they are given.

"Similarly, when patients suffering from schizophrenia are admitted to hospital during a psychotic episode, they are routinely given a prescription for 'drugs as required'. There have been no studies into the necessity or effectiveness of such a practice, which gives no clear indication of drugs or dosage. Cochrane helps to identify such 'black holes' where unquestioned practice and habit continue without any real scientific or medical basis."

Just as reviewers may come from anywhere in the world, so the trials studied are worldwide. The Cochrane collaboration has also helped show which countries carry out the most trials, and which are not 'pulling their weight'.

The greatest number of trials are carried out in the US, but comparison of number of trials with GDP shows the US produces 124 percent of the trials they should. The UK however is well in the lead, carrying out 200 percent. Other economically developed counties like Germany and Japan are falling well short of the number of trials which could be expected from them, at 35 and 15 percent respectively.

Cochrane reviews enable trials to be collected together and properly surveyed, to find out which, if any, have value. Reviews can consider anything from five to several hundred trials, involving sometimes just 60 people, sometimes thousands. The reviews sometimes reveal poor quality of analysis, or flawed methodology, rendering the results clinically meaningless.

There is now a Cochrane database of trials, and each group has a database for its own specialist area. In schizophrenia there are about 5,000 trials; in the upper gastrointestinal and pancreatic diseases around 15,000, reflecting the broader scope of the group.

The goal of all this work is to ensure patients receive better treatment. But ultimately the role of the Cochrane groups is to provide the evidence, after which it is for the health services in each country to ensure their doctors use that valuable resource to provide care based on the best scientific evidence available.

Trainee doctors – 'Cochrane should be part of every medic's training, so their instinctive reaction when faced with a new problem becomes: what does Cochrane say?'

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