Medical-evidence giant Cochrane battles funding cuts and closures

This month, more than 1,000 people will gather in London for a meeting of Cochrane, the group known for its gold-standard reviews of evidence in medicine. The conference marks the 30th anniversary of an organization that helped to spark a worldwide movement to base health care on research.

But in the hallways, some attendees will be discussing whether and how the group can survive. In March, 19 of 52 groups that produce Cochrane’s systematic reviews closed after the UK National Institute for Health and Care Research (NIHR) stopped funding them. And in July, Cochrane UK in Oxford — where the group was founded — revealed that it will close next March, after the NIHR ceased its support.

The closures come amid a major reorganization that will change how Cochrane produces and publishes systematic reviews, instigated partly in anticipation of funding difficulties. Some researchers are concerned that Cochrane will not be able to maintain its output of reviews — which shape the clinical guidelines used by doctors worldwide — or meet the growing demand for more complex, timely evidence syntheses. “I don’t see a very clear or bright future for Cochrane,” says Gabriel Rada, a specialist in evidence-based health care at the Pontifical Catholic University of Chile, Santiago, who previously directed Cochrane Chile.

“What’s happened to groups in the UK is very sad,” says Karla Soares-Weiser, editor-in-chief of the organization’s database of evidence, the Cochrane Library in London. “We want Cochrane to be here for the next generation. And there’s adjustments that we have to make to guarantee that this organization is sustainable for the future.”

Cochrane says that the lost NIHR funding — around £4.2 million (US$5.3 million) — does not affect its core income, which was £8.9 million in 2022. However, a more existential threat looms. Around £6.8 million of that core income came from subscriptions to the Cochrane Library, but Cochrane aims to make all its reviews open access by 2025, putting the revenue at risk. Catherine Spencer, Cochrane’s chief executive in London, says that the group is seriously examining how to make that move “in a way that would ensure that Cochrane is viable into the future”.

Radical reviews

The Cochrane UK centre slated for closure is symbolically important. The Cochrane Collaboration was launched there at a 1993 meeting, convened by physician and researcher Iain Chalmers, that attendees still speak of with zeal.

At the time, decisions in Western medicine tended to be based on conventional wisdom and the opinion of the most senior physician in the room. Chalmers and others at the meeting had the then-radical idea that medical practice should be based on systematic reviews of rigorous research evidence — such as randomized controlled trials — showing whether a treatment is effective. The group was named after physician and epidemiologist Archie Cochrane, who had championed evidence from randomized trials in previous decades.

The group started as a grass-roots organization with a decentralized structure powered by passionate academics who worked for free, and became central in the rise of evidence-based medicine. It established a series of mostly autonomous groups around the world, responsible for producing systematic reviews in areas such as stroke, movement disorders and infectious diseases.

To produce reviews, researchers follow standardized methods to find and analyse all the rigorous evidence on a question such as whether a therapy helps or harms. Systematic reviews are valued for their ability to draw conclusions from multiple, conflicting studies, like extracting a signal from noise. Cochrane developed a reputation for particularly rigorous methods and reviews.

The UK National Health Service was an early funder of Cochrane and its UK-based groups. Later, the NIHR provided support, mainly paying for support staff to help produce reviews.

So when the NIHR confirmed in August 2021 that it would stop funding all the UK-based review groups, the news came as a shock, says Peter Langhorne, a stroke researcher at the University of Glasgow, UK, who was a coordinating editor for Cochrane’s Stroke Group until 2020. In 1993, Langhorne and his colleagues independently published a seminal systematic review¹, which was later regularly updated as part of Cochrane, that showed the effectiveness of specialist stroke units. This led to their widespread adoption, saving tens of thousands of lives.

Long shadow

The Stroke Group’s closure meant that three people lost their jobs, says Langhorne, who is concerned that some important systematic reviews won’t now be done. “I think it’s a real danger that the priorities of patients could be lost,” he says. Around one-third of Cochrane’s reviews in 2022 came from UK groups that have now closed.

But the writing had long been on the wall. A 2017 review of the NIHR’s investment in Cochrane found considerable differences in productivity and review quality between groups. It also noted that reviews were slow to produce, and that many published reviews were out of date or did not address priority topics. What’s more, the same specialist group that helped authors to produce a review would decide whether it was fit to publish, raising concerns within and outside Cochrane about editorial standards. (Cochrane has acknowledged many of these concerns in reports that highlight the need for reform.)

The wider research community also criticized the NIHR for putting all its money for research synthesis into Cochrane, says Žarko Alfirević, a specialist in fetal and maternal medicine at the University of Liverpool, UK, who was coordinating editor for Cochrane’s now-closed Pregnancy and Childbirth Group. That made sense when “Cochrane was the only show in town”, he says, but now “the whole industry of research synthesis is massive”.

The NIHR said in a statement that it remains committed to supporting evidence-informed practice in health care. In May, it announced that it had awarded £22.5 million over five years to nine other groups as part of a new evidence-synthesis programme.

Growing pains

Cochrane now has more than 11,000 members involved in synthesizing or disseminating evidence worldwide. It has published more than 16,000 reviews and has been central in stimulating the now-copious production of systematic reviews and other evidence syntheses. “It shifted the ground,” says Paul Garner, professor emeritus in public health at the Liverpool School of Tropical Medicine and former head of Cochrane’s Infectious Diseases Group. “It was a tremendous example of rapid diffusion of a technology.” A 2021 study² found that more than 80 medical systematic reviews were published every day in 2019; around 7% were Cochrane reviews.

The group has been no stranger to criticism and controversy. Some members dislike how the grass-roots community has morphed into a more business-like, centralized organization. “That’s not the Cochrane that we knew,” says Nancy Santesso, a health researcher at McMaster University in Hamilton, Canada, and deputy director of Cochrane Canada.

Yet she and others acknowledge that reform was necessary as the organization grew — and that such changes are always difficult. “The problem is that you inevitably become corporate,” says Alfirević, “and academics, by definition, hate being told what to do.”

Broad shake-up

Cochrane’s reorganization aims to address many criticisms — for example, it is centralizing all editorial processes and separating them from review development to ensure that reviews are of consistent quality. It is trying to make it easier and quicker to produce reviews by creating evidence-synthesis units, as well as externally funded ‘thematic groups’ that represent broad areas, such as health equity and global ageing. Soares-Weiser says Cochrane’s preliminary data suggest that the throughput of reviews could be maintained despite the UK cuts. She adds that the organization is developing a scientific strategy to focus on high-value reviews in areas aligned with the United Nations Sustainable Development Goals.

The upcoming London meeting, from 4–6 September, is seen as particularly significant because of the upheaval — and because it’s the first in-person Cochrane colloquium in five years, owing partly to the COVID-19 pandemic. Santesso has attended every colloquium since 2002, but this year, “If I go and there isn’t that scientific strength there, then I’m not sure I would go again,” she says.

Even those critical of Cochrane say it’s important that the group survives. Philippe Ravaud, an epidemiologist at Paris City University who led Cochrane France until 2019, argues that improving evidence syntheses requires major reforms, including working with researchers to improve the planning and quality of the clinical trials that will be synthesized. “There is no organization aside from Cochrane that can do that,” he says.

Chalmers, who left the organization in 2003, says he has no sentimentality about the Cochrane collaboration, but says that its function remains as important as ever. “There is no argument about trying to get better, more valid, up-to-date information in the hands of patients and clinicians,” he says. “If the organization didn’t exist, something like it would need to be invented.”