As Cochrane's 20th anniversary year comes to a close, it is a good time to reflect on what we have learnt and to consider how well the organisation will overcome the challenges ahead. Recently, as a passenger with a well-known commercial airline, one of us (JC) experienced the stark difference between an ageing Boeing 747 and one of the new state-of-the-art, double-decker Airbus A380s. On the outbound leg, after about 45 minutes, when typically one is starting to flick through the in-flight entertainment while pretending to work, and contemplating how to negotiate the joys of in-flight dining, the whole plane was jolted and dropped. People who weren't belted in ended up on the floor, and flight attendants were sent flying. Concerned, we looked out of the window, expecting to see the sea come up to greet us. It might have been OK if it wasn't for one flight attendant who was busy crawling up the aisle crying out helpfully, "Oh my god, this is it, this is it! Crash positions!". At this point I (JC) sent a plaintive text to my wife indicating that my best times might have come and gone. A few minutes went by, and the pilot's voice on the speaker system confirmed our creeping realisation that it was actually OK and it was just unexpected turbulence. The rest of the flight was relatively uneventful, and spent patching up four passengers and crew with minor injuries in difficult and cramped conditions, with equipment that wasn't really fit for purpose. 36 hours later, the return journey was undertaken on an A380 and couldn't have been more different. Quiet, effortless, spacious travel as it should be. Of course, such a comparison was confounded by the turbulence, which can affect any flight and is dependent on the weather rather than airliner type, but the overall comparison in passenger experience between travel on a 747 and an A380 is pretty clear. No need for randomised comparisons here.
Such differences are expected. The 747 first flew in 1969, and the A380 36 years later in 2005. The world of technology in 2005 wasn't even conceivable in 1969, such are the changes that have occurred. At the same time, international travel has increased, as have travellers' expectations.
Planes? Cochrane? Actually it was David Sackett, one of the pioneers of the Collaboration, who first made the connection when in 1995 he described Cochrane as "an airplane that we are trying to put together after it has taken off". Reflecting now on how Cochrane has been put together, effectively the structure hasn't really changed since it was founded 20 years ago. It is still built on Review Groups, Centres, Fields, and Networks, and the remit of these groups hasn't changed substantially. And as with our expectations of efficiency, safety, affordability, and availability of air travel, our expectations for Cochrane have moved on apace, encompassing validity, range and quality of providers, complexity, timeliness, and accessibility.
What has changed in the past 20 years, and what is likely to change by 2020? In 1993 the first Cochrane Colloquium attracted 77 individuals from nine countries, and now we have more than 30,000 contributors from all over the world, speaking dozens of languages. In 2020 we may have 100,000 contributors with (hopefully) an even more global distribution. The Cochrane Database of Systematic Reviews started with 36 reviews in 1995 and now includes over 5500 reviews. If we are to achieve our vision where decisions about health and health care are informed by high-quality, relevant, and up-to-date synthesised research evidence, then arguably we need 50,000 reviews. Back then, we only had reviews of randomised controlled trials; now we also have reviews of non-randomised studies, qualitative evidence, and test accuracy studies. To achieve relevance and currency in the future we will need reviews of prognosis and prevalence. Then, we breathed a sigh of relief if we generated a summary estimate, and now we have the Cochrane risk of bias tool and Summary of Findings tables, and in the future we will have risk of bias 4.0 across all study designs. Then, we had floppy disks published four times a year. Now we have publish online when ready, and in future we will have reviews in multiple and different forms provided on multiple and different platforms.
When Cochrane started, it was the sole supplier of reviews; now we supply 20% of reviews of effectiveness, and the marketplace will become more crowded and competitive. Then, we had a single funder; now we have multiple funders who seem committed to a stable Cochrane budget but who will increasingly require open access as well. Then, Cochrane had one employee; now we have more than 30, with a restructured Central Executive , a CEO, and an Editor in Chief. At that first colloquium we had four Centres, four Review Groups, and one Field. Now we have 14 Centres, 19 Branches, 16 Methods Groups, 11 Fields and Networks, and 53 Review Groups. However, while Cochrane's basic structure has largely stayed the same, huge changes have occurred in the external environment: IT, health, publishing, and research. The rate of change to 2020 will increase, and Cochrane must be positioned to benefit from these changes.
We face major challenges. The time taken from title registration to publication is too long. We have limited impact in many countries, particularly in low- and middle-income countries, where we have few contributors. We are unable to respond to new review types with the required nimbleness, and our capacity to update reviews appears to be falling (even for high-impact, globally important reviews). We have a fixed income stream, but we need to do more. We have gaps and duplications across our topics, and Review Groups have conflated and at times conflicting roles (training authors, editing reviews, authoring reviews). And more and better methods are around the corner.
After 20 years it is timely to celebrate our many successes, but it is also timely to confront the challenges we face and collectively decide whether our structures are fit for purpose to carry us through to 2020 or whether we can and should do things differently At the 21st Cochrane Colloquium, in Quebec City, Canada, The Cochrane Collaboration Steering Group signed off on a proposal to review the structure and function of Review Groups over the next year. We think such a project is needed to confront the external and internal challenges that Cochrane faces in implementing its ambitious Strategy to 2020.
The 747 has served the travelling public very well over the past 40 years, but different models are better suited for modern travel. And Cochrane would be a unique organisation if it did not require some structural refreshment to achieve its global vision.
Please contribute to the consultation phase of the Review Group structure and function project. We need to hear from you.
Jonathan Craig1, Jeremy Grimshaw2, David Tovey3
1Jonathan Craig (email@example.com), Professor of Clinical Epidemiology, Sydney School of Public Health, University of Sydney, Australia, and retiring Co-Chair of The Cochrane Collaboration Steering Group (2009 to 2013); 2Jeremy Grimshaw (firstname.lastname@example.org), Senior Scientist, Ottawa Hospital Research Institute, Canada, and Co-chair, The Cochrane Collaboration Steering Group; 3David Tovey (email@example.com), Editor in Chief, The Cochrane Library, and Deputy CEO, The Cochrane Collaboration, London, UK.
How to cite: Craig J, Grimshaw J, Tovey D. A 747 in the age of A380s: how can Cochrane learn from the past and compete 20 years on? [editorial]. Cochrane Database of Systematic Reviews 2013;(12):ED000074.
1. Jadad A. Getting together in Oslo. Cochrane News, Issue 5, November 1995. www.cochrane.org/sites/default/files/uploads/cochrane_news/CochraneNews-issue5.PDF
3. The Cochrane Collaboration. Cochrane Strategy to 2020. www.cochrane.org/community/organisation-administration/cochrane-strategy-2020 (accessed on 11 December 2013).
Competing interests: The authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf. JC is Co-ordinating Editor of the Cochrane Renal Group (renal.cochrane.org). JG is Co-chair of The Cochrane Collaboration Steering Group, Director of Cochrane Canada (ccnc.cochrane.org) and principal investigator for grant funding for Cochrane Canada from the Canadian Institutes for Health Research, and Joint Co-ordinating Editor of the Cochrane Effective Practice and Organisation of Care Review Group (epoc.cochrane.org). DT is an employee of The Cochrane Collaboration.
Image credit: The Cochrane Collaboration
Feedback: Please contact David Tovey (firstname.lastname@example.org), The Cochrane Library Editor in Chief, with feedback on this editorial and proposals for future editorials.