Research and evidence–based decision making

Decision makers in the British merchant navy took 263 years to introduce citrus juice as a routine preventive for scurvy following Lancaster’s first demonstration of its value in 1601. ’ The dissemination and uptake of research is not a new problem. The preoccupation with evidence-based medicine and evidence-based decision making is, however, a phenomenon of the 1990s. Egged on by researchers and a general culture of accountability, explicit consideration of formal ‘research evidence’ is now expected in the decision making of politicians, bureaucrats, clinicians and industry. Initial efforts tend to have focused on assembling and disseminating the evidence on clinical practice. The Cochrane Collaboration (an international effort with an Australasian arm) compiles health care effectiveness studies and is but one example of the emerging dedication to synthesising and disseminating health research for clinicians. ‘ Refining meta-analysis, clinical guidelines and other summarisation techniques is a growth area for research, as is the study of effective approaches to changing practitioner behaviour through dissemination of these summaries. To date the yield from these efforts is more sound and fury than substance. The sizes of the Cochrane and other databases expand, but we have little idea of either whether or how decision makers are using them. A few promising dissemination techniques such as audit, opinion leaders or academic detailing seem to work sometimes but not always3 We are far from knowing what works in what setting for what kind of decision making.4 There are several reasons for this spluttering progress. One is that efforts by researchers and by decision makers seem to proceed largely independently. Both have their own (often misplaced) ideas about the other’s environment. Opportunities for ongoing exchange and communication are few. Because most of the study has emanated from researchers, their activity has focused more on understanding the assembly and dissemination than on the uptake and use of research evidence. Because most of the determinations are made by decision makers, their focus is on the applicability, usefulness, and context dependence of research findings. It is like two people trying to assemble a jigsaw puzzle, each with half the pieces-but each working in a separate room. More significant progress may come from a better understanding on each side of the constraints and possibilities of research and decision making. For instance, with increased exposure to decision makers, researchers may come to understand that decision making is not an event, occurring at a specified time in a specified place, but is, rather, a diffuse process with poorly identified participants and locations, and a good sousing of values, preferences and biases to spice the eviden~e. ~ On the other side, exposure of decision makers to research may lead to an understanding that it is not a product to be purchased from the local research supermarket, but is also a process, wherein methodologies and subjects of study may take years to refine and complete.6 What is needed are more opportunities for researchers and decision makers to engage in ongoing exchange throughout their two processes, and treat each other less like customer and store owner in contact only for the time it takes to exchange money for a product. It has been said that the two things one should never watch being made are sausages and public policy; one might add research evidence to this list of taboos. Nevertheless, the less squeamish among the applied research community and decision makers could profit much from closer scrutiny of each other’s respective sausage-making machines. Applied researchers need to congregate around issues, not disciplines, and to coalesce, either inside or outside universities, as organised multidisciplinary units. These units can absorb across many researchers the fixed costs of research transfer programs, and can offer a coherent target with which decision makers can communicate. Decision makers need to recognise the uptake of research as a separate function to its dissemination and establish ‘receptor units’ inside their organisations. These units should not only acquire and insert into decision making processes the summarised research findings, but also offer an identifiable target with which interested applied researchers can communicate. A second reason for the spluttering progress is the emphasis on clinical decision makers. Although clinicians are obviously central to health services, preoccupation with behaviour change of practitioners has tended to obscure the relevance of other potential audiences for health research. Separating potential users of health research into legislative, administrative, clinical and industrial audiences highlights that each wishes to extract different things from research and each has different preferences for the format of di~semination. ~ Legislative decision makers are often not experts in health care, and are most interested in ideas, defendable policy assumptions to define a problem, or in justifications for or effects of actions already taken.8 This is what some have called the ‘enlightenment’ use of research in p01icy. ~ They are better briefed with short memos or face-to-face than with lengthy articles laden with jargon. Administrative decision makers have more specialist knowledge of health care, often seeking research to assist with difficult resource allocations or to diagnose planning problems. This is more instrumental use of re~earch. ~ Administrators are better able to digest longer (but still summarised) versions of research evidence than legislators, may use personal contacts in the research community and attend conferences and workshops. Industry decision makers are oriented toward marketable products and are the most likely of any audience to be trying aggressively to pull findings from the researchers. Formats are less important