|Year : 2015 | Volume
| Issue : 1 | Page : 1-2
Archie Cochrane: The Pioneer of Fourth Revolution of Health Care
Jayant N Palaskar
Editor-in-Chief, Journal of Dental and Allied Sciences, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
|Date of Web Publication||19-Oct-2015|
Jayant N Palaskar
Professor and Head, Department of Prosthodontics, Sinhgad Dental College and Hospital, Pune - 411041, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Palaskar JN. Archie Cochrane: The Pioneer of Fourth Revolution of Health Care. J Dent Allied Sci 2015;4:1-2
The objective of this editorial is to increase the awareness of systematic reviews and meta-analysis among dental surgeons and also about Archie Cochrane and his accomplishments.
The systematic review focuses on a research question and reviews all high-quality evidence relevant to that question to make informed decisions in health care. When such reviews analyze statistical data from relevant articles, it is known as meta-analysis. Meta-analysis and systematic reviews are the gold standard of evidence based medicine/dentistry as they lie at the top of the pyramid that constitutes levels of studies for the strength of evidence. The Cochrane system of systematic analysis is widely acknowledged as benchmark amongst all the review systems. Cochrane reviews are systematic assessments of evidence of the effects of healthcare interventions, intended to help people to make informed decisions about health care, their own or someone else's.  Cochrane reviews are needed to help ensure that healthcare decisions throughout the world can be informed by high quality, timely research evidence.  This system is named after Dr. Archibald (Archie) Leman Cochrane (1909-1988), a British Researcher, a revolutionary and visionary physician.
He was the first one in the field of medical sciences to understand the need of a systematic analysis of the abundant scientific data available and to use it in clinical practice. Cochrane stated that "It is surely a great criticism of our profession that we have not organized a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomized control trials (RCTs)."  Cochrane promoted the RCTs and his call for an organized database of RCTs served as a momentum for the formation of the Cochrane Collaboration in 1993 under the leadership of Iain Chalmers. The Cochrane Database of Systematic Reviews is regularly updated and maintained by the Cochrane Collaboration, an organization at the forefront of the evidence based medicine/dentistry revolution.
Archibald Cochrane's most influential mark on healthcare was his 1971 publication, "Effectiveness and Efficiency: Random Reflections on Health Services." This book strongly criticized the lack of reliable evidence behind many of the commonly accepted healthcare interventions at the time.  His criticisms spurred rigorous evaluations of healthcare interventions and highlighted the need for evidence in medicine.  This book advocated the use of RCTs to make medicine more effective and efficient.  Cochrane's book was unique because it used an amalgamation of studies to show that the problem of evidence plagued not just one aspect of medicine but was pervasive.  For example, at the time of the book's publication, tonsillectomies were among the commonest cause of admission of children to the hospital. Cochrane suggested that the operation was too often performed without any indication.  At the same time, Cochrane showed that in contrast to the vast amount of tonsillectomies performed by doctors, hearing problems of the elderly were largely ignored by doctors.  By giving multiple examples, he could convince that many treatment modalities were being practiced without sound scientific evidence. According to a review of his book in the British Medical Journal, "the hero of the book is the RCT, and the villains are the clinicians in the "care" part of the National Health Service (NHS) who either fail to carry out such trials or succeed in ignoring the results if they do not fit in with their own preconceived ideas." 
The search for quality evidence can be difficult and time-consuming, it is further complicated because of increased number of publications and multiple studies concluding contradictory results leading to confusion in deciding final treatment interventions. These problems can be addressed by resorting to systematic reviews, which unlike traditional reviews, adhere to reproducible methods and recommended guidelines. 
This movement toward using current evidence to guide medical decisions can be referred to as the "fourth revolution" of health care; the first three being the introduction of health insurance, the backlash of payers to reduce costs, and outcomes-based research. , Sir William Osler once noted, "The practice of medicine is an art, based on science. Medicine is a science of uncertainty and an art of probability."  The uncertainties of medicine remain prevalent today in spite of great advances in research and technology. It is the sensible use of the best available external evidence from systematic research assimilated with the individual clinical expertise to evaluate the best course of care for a patient.  Cochrane believed that the ultimate duty of medical doctors was to make decisions between alternative therapies based on cost/benefit comparisons.  However, even he realized that RCTs did not always provide an explicit answer when different RCTs provide contradictory results.  Cochrane realized that clinicians would not find a series of RCTs helpful and would not necessarily know which trial was the best.  By conducting a systematic review of RCTs, the reviewers try to eliminate bias (if any) during their review and able to suggest conclusive clinical interventions.
What was said by Cochrane in 1971 for physicians holds true for dental surgeons, who are trying to successfully juggle their role as researchers and clinicians. It is high time that dental fraternity embraces the systematic review approach to evidence-based dentistry (EBD) to offer optimum care, minimize treatment cost, improve efficiency and provide predictable results. Thus, systematic review and meta-analysis shall increasingly play a pivotal role to solidify the scientific foundation of dentistry in general and to help reduce uncertainties in dental decision-making.
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| Authors|| |
Jayant N. Palaskar