http://bmj.com/cgi/content/full/323/7327/1437
BMJ 2001;323:1437-1438 ( 22-29 December )
Editorials
Britain's gift: a "Medline" of synthesised evidence
Worldwide free access to evidence based
resources could transform health care
Medline is an electronic index of nearly 4500 journals from over
70 countries compiled by Washington's National Library of Medicine.
It has been available online since 1971. Later, Hilary Clinton,
then America's first lady, announced worldwide free access to
Medline through the internet (www.ncbi.nlm.nih.gov/entrez/).
Since then the number of people using it has increased exponentially,
and many of them are patients. There is no better free starting point
for finding high quality medical information.
But a search of Medline may be frustrating. Although Medline often includes
abstracts and free access to the full text of some articles (including
those in the BMJ ), clinicians and patients may be
overwhelmed by an avalanche of references and abstracts. They only
rarely have the time and resources to sift through the output of a
search, let alone obtain the full texts of all the articles that may
answer their questions. Clinicians and patients need ready access to
syntheses of valid, up to date information relevant to their questions.
Recent years have seen several initiatives to serve these needs more
effectively. A consensus is growing that the most valid answers to
their questions will come from systematic reviews based on rigorous
research methods. The most obvious manifestation of this trend is
the international Cochrane Collaboration. 1 2 The
Cochrane Library (www.update-software.com/cochrane/),
brings together an unequalled collection of reviews of research
about the effects of healthcare interventions.
Cochrane reviews tend to address fairly specific questions
for
example, is echinacea helpful for a cold? Reviews published in other
web based sources, such as Clinical Evidence (www.clinicalevidence.org, published
by the BMJ Publishing Groupsee
competing interest) draw on the evidence in these specific reviews
to address broader questionsfor
example, what's good for a cold?3 And
because Clinical Evidence is based on questions that
clinicians and patients want answered, this may be the right
starting place for a search for relevant evidence.
Whether a question implies the need for a specific or a broad systematic
review, a mountain of evidence remains to be synthesised before it
will become clear just which questions can be answered using
existing research evidence. But what are clinicians and patients to
do if their search of these new resources shows genuine uncertainty
about the relative merits of alternative forms of care? Their most
imaginative step would be to consult the metaRegister of
Controlled Trials (www.controlled-trials.com)
to assess whether a relevant controlled trial was open to
participants,4
and, if so, to agree that "the trial would be the
treatment."5
Imagine the benefits of linking these sources of information electronicallyand
of making this linked resource freely available. A whole new way of
practising medicine opens up. A clinician and a patient trying to
solve a problem together would start by searching Clinical
Evidence, which might provide a helpful summary of the evidence.
If they wanted to check the pedigree of the summary they could
"drill down into" the Cochrane and other systematic reviews
on which it had been based. This evidence could then inform decisions
about treatment, which would take account of the patient's preferences
as well as the availability of the preferred treatment.
If their search showed uncertainty about the best course of action then they
might look to see if a relevant clinical trial was underway. The
patient might choose to enter such a trial, particularly since
patients tend to do better when they take part in trials.6 The wider
benefit might be that we would more quickly know the answer to many
important questions. For example, we still do not know which
treatments are useful for acute stroke, but if every patient in the
world experiencing a stroke were admitted to trials we would have
enough patients within 24 hours to answer many of these
questions. If there were no trials underway addressing the patient's
question then the patient and doctor would send a signal to a
central database that the question needed answering. This would
allow trials to be designed to answer the questions that mattered
most to patients.
Is this scenario of electronically linked resources serving the interests of
patients and doctors unrealistically fanciful? We believe it is
essential. We need to take advantage of the possibility of designing
intelligent software that will flag the arrival of new data or
substantive changes in the evidence. Without such help it will be
increasingly difficult for people to keep information up to date and
trustworthy.
A way should be found to make this informationlike
the information in Medlinefree
to anyone who has access to the world wide web. Current Controlled
Trials has already undertaken to provide worldwide free access to
the metaRegister of Controlled Trials. Many clinicians and
people in higher education already have free access to both the
Cochrane Library and Clinical Evidence, and both these
resources are either already (or very soon will be) provided free to
everybody in the 100 poorest countries in the world. Why stop
there? These resources could be free to everyone at the point of
use. Wide access would also ensure that errors would be spotted and
quickly corrected.
Is there a rolepossibly
a responsibilityfor
Britain here? Britain has given the world Shakespeare, newtonian physics, the
theory of evolution, parliamentary governmentand
the randomised controlled trial. Tony Blair's speech at the Labour
party conference suggested that the response to the attacks of
11 September must be not just war but also to build a new world
that ultimately destroys extreme inequities. Universal free access
to an integrated information resource built from the Cochrane
Library, Clinical Evidence, and the metaRegister of
Controlled Trials would go some way to reducing the inequities in
access to information for improving health care. For a cost which
might be as little as 10p for each Briton, the British government
has the chance to match Medline by funding universal free access to
the system we have outlined. It would provide a lasting memorial of
the Queen's jubilee next yearand,
in her honour, perhaps it could be called "Lizzie."
Richard Smith
BMJ
Iain Chalmers
UK Cochrane Centre, Oxford OX2 7LG
Footnotes
RS is chief executive of the BMJ Publishing Group, which
publishes Clinical Evidence. He is, however, paid a fixed salary and
would not personally gain financially from extra sales of Clinical
Evidence. IC is director of the UK Cochrane Centre, but has no
financial involvement in the Cochrane Library. RS and IC are also
members of the international advisory group for Current Controlled
Trials but have no financial interest in it.
|
1. |
Clarke M, Langhorne P. Revisiting the Cochrane
Collaboration. BMJ 2001; 323: 821 |
|
2. |
Chalmers I, Dickersin K, Chalmers TC. Getting to grips
with Archie Cochrane's agenda. BMJ 1992; 305: 786-788 |
|
3. |
Barton S. Using clinical evidence. BMJ 2001; 322:
503-504 |
|
4. |
Tonks A. Registering clinical trials. BMJ 1999;
319: 1565-1568 |
|
5. |
Ashcroft R. Giving evidence a fair trial. BMJ 2000;
320: 1686 |
|
6. |
Braunholtz DA, Edwards SJ, Lilford RJ. Are randomized
clinical trials good for us (in the short term)? Evidence for a "trial
effect." J Clin Epidemiol 2001; 54: 217-224 |
|
|||||||
|
|
Rapid Response responses to
this article:
Read all Rapid Response
responses
Time for a Change
Ned Hoke OMD,L.Ac.
bmj.com, 20 Dec 2001 [Response]
Britain's gift: a "Medline" of synthesised
evidence
Ian Needleman
bmj.com, 21 Dec 2001 [Response]
Department of Health facilitates free access to
social care database
Mark Watson
bmj.com, 21 Dec 2001 [Response]
ALL
INFORMATION, DATA, AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR
GENERAL INFORMATION PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE
KNOWLEDGE OR OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED
AS PROVIDING MEDICAL OR LEGAL ADVICE. THE DECISION WHETHER OR NOT TO
VACCINATE IS AN IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU
ALONE, IN CONSULTATION WITH YOUR HEALTH CARE PROVIDER.