COCHRANE: HANDS OFF WOUND CARE!–PROF DAVID LEAPER RESPONSE

I am surprised, and somewhat disappointed, that the Cochrane Wounds Group has felt the need to write such a self protective justification of the Cochrane review process in a letter that is 200 words longer than my editorial!

Thankfully, we do seem to have some important points in common, such as the necessity for evidence‐based practice and standards, but our widest disagreement is based on the helpfulness of Cochrane reviews to help practitioners specifically in the field of wound care. These reviews have not led to helpful guidelines or to changes in practice in wound care, other than (arguably) in the value of compression therapy as part of the treatment for venous ulcers. We all want the best for our patients but to leave them, and their carers, stranded with the advice that ‘more research is needed’ is not acceptable and why I believe justified in saying that an expert panel is required to interpret all the data available to draw up guidelines.

Decisions still have to be made for our patients on a day‐to‐day basis, even if they do not have a level of evidence that we should like. Time‐honoured practices have to remain until there is evidence to displace them; in my view, this is not likely to happen simply by undertaking a systematic review. Although the rigid Cochrane review process has worked well in other fields of clinical medicine, it has not done so in wound care and any clinical expertise included in the panels involved has been hardly touched. This is precisely what NICE and SIGN do and I have personal experience of being involved with them as well as with several Cochrane reviews at all stages of their development. In an ideal world, only level I evidence‐based medicine may be admissible (also arguably), but this is not the case in virtually all the aspects of wound care; it was predictable that the scientific, methodological approach was not likely to help much at the patient–practitioner interface.

The group talks about the huge amount of unpaid time practitioners put into Cochrane reviews: I have done this myself but have had so much more satisfaction in being involved with advice to SIGN and chairing a NICE guideline development group. Surely a preliminary cursory opinion by an ‘expert group’ could have saved a huge amount of time and effort? The gaps in knowledge identified by the reviews involving wound care were already known to those practising in the field, who were also aware of the likelihood (or not) of adequate randomised controlled clinical trials ever being initiated. Some members of this same Cochrane Wounds Group have entered into such studies that failed to identify appropriate end points and failed to recruit in time, not surprisingly, the required numbers of patients. The methodology and findings of their well‐funded study was criticised in an accompanying editorial 1, 2.

I firmly believe that observational studies can give cogent answers and support current best practices in wound care. I accept that in other fields meta‐analysis has been able to identify and change poor practice. However, in their response to my editorial, specifically about wound care, I believe the Cochrane Wounds Group are being naïve and superficial. Their concern that we should be able to explain to our patients that our interventions are supported by the latest and best scientific evidence is verging on the ridiculous and is probably an impossible goal in wound care practice. It begs the question of whether many of them are in touch with day‐to‐day clinical care, although to be fair several experienced clinicians were involved in their recent clinical study (1). Of course, we should like high‐quality research in this field but I fear it may be unattainable, particularly in the current financial climate, but those studies that are funded must have a hope of showing a clear difference to change practice. There are alternatives to the RCT, as I suggested in my editorial, and I remain certain that expert opinion and guidelines remain a staple in this field, as they have been well accepted elsewhere 3, 4.

David Leaper Visiting Professor ¹