John N. Lavis

Knowledge translation of research findings

BackgroundOne of the most consistent findings from clinical and health services research is the failure to translate research into practice and policy. As a result of these evidence-practice and policy gaps, patients fail to benefit optimally from advances in healthcare and are exposed to unnecessary risks of iatrogenic harms, and healthcare systems are exposed to unnecessary expenditure resulting in significant opportunity costs. Over the last decade, there has been increasing international policy and research attention on how to reduce the evidence-practice and policy gap. In this paper, we summarise the current concepts and evidence to guide knowledge translation activities, defined as T2 research (the translation of new clinical knowledge into improved health). We structure the article around five key questions: what should be transferred; to whom should research knowledge be transferred; by whom should research knowledge be transferred; how should research knowledge be transferred; and, with what effect should research knowledge be transferred?DiscussionWe suggest that the basic unit of knowledge translation should usually be up-to-date systematic reviews or other syntheses of research findings. Knowledge translators need to identify the key messages for different target audiences and to fashion these in language and knowledge translation products that are easily assimilated by different audiences. The relative importance of knowledge translation to different target audiences will vary by the type of research and appropriate endpoints of knowledge translation may vary across different stakeholder groups. There are a large number of planned knowledge translation models, derived from different disciplinary, contextual (i.e., setting), and target audience viewpoints. Most of these suggest that planned knowledge translation for healthcare professionals and consumers is more likely to be successful if the choice of knowledge translation strategy is informed by an assessment of the likely barriers and facilitators. Although our evidence on the likely effectiveness of different strategies to overcome specific barriers remains incomplete, there is a range of informative systematic reviews of interventions aimed at healthcare professionals and consumers (i.e., patients, family members, and informal carers) and of factors important to research use by policy makers.SummaryThere is a substantial (if incomplete) evidence base to guide choice of knowledge translation activities targeting healthcare professionals and consumers. The evidence base on the effects of different knowledge translation approaches targeting healthcare policy makers and senior managers is much weaker but there are a profusion of innovative approaches that warrant further evaluation.

Towards systematic reviews that inform health care management and policy-making.

Objectives To identify ways to improve the usefulness of systematic reviews for health care managers and policy-makers that could then be evaluated prospectively. Methods We systematically reviewed studies of decision-making by health care managers and policy-makers, conducted interviews with a purposive sample of them in Canada and the United Kingdom (n=29), and reviewed the websites of research funders, producers/purveyors of research, and journals that include them among their target audiences (n=45). Results Our systematic review identified that factors such as interactions between researchers and health care policy-makers and timing/timeliness appear to increase the prospects for research use among policy-makers. Our interviews with health care managers and policy-makers suggest that they would benefit from having information that is relevant for decisions highlighted for them (e.g. contextual factors that affect a reviews local applicability and information about the benefits, harms/risks and costs of interventions) and having reviews presented in a way that allows for rapid scanning for relevance and then graded entry (such as one page of take-home messages, a three-page executive summary and a 25-page report). Managers and policy-makers have mixed views about the helpfulness of recommendations. Our analysis of websites found that contextual factors were rarely highlighted, recommendations were often provided and graded entry formats were rarely used. Conclusions Researchers could help to ensure that the future flow of systematic reviews will better inform health care management and policy-making by involving health care managers and policy-makers in their production and better highlighting information that is relevant for decisions. Research funders could help to ensure that the global stock of systematic reviews will better inform health care management and policy-making by supporting and evaluating local adaptation processes such as developing and making available online more user-friendly ‘front ends’ for potentially relevant systematic reviews.

Examining the Role of Health Services Research in Public Policymaking

Conceptual, methodological, and practical issues await those who seek to understand how to make better use of health services research in developing public policy. Some policies and some policymaking processes may lend themselves particularly well to being informed by research. Different conclusions about the extent to which policymaking is informed by research may arise from different views about what constitutes health services research (is it citable research or any professional social inquiry that can aid in problem solving?) or different views about what constitutes research use (is it explicit uses of research only, or does it also include tacit knowledge or the positions of stakeholders when they are informed by research and are influential in the policymaking process?). Some conditions may favor the use of research in policymaking, like sustained interactions between researchers and policymakers. Results from an exploratory study on the use of health services research by Canadian provincial policymakers illustrate these issues.

Use of research to inform public policymaking

To improve health and reduce health inequalities, public policymakers need to find the best solutions to the most burdensome health problems, the best ways to fit these solutions into complex and often overstretched and underresourced health systems, and the best ways to bring about the desired changes in health systems. Systematic reviews can inform public policymaking by providing research-based answers to these questions. Public policymakers can encourage more informed policymaking by asking to see systematic reviews on priority issues, commissioning reviews when none exists, and placing more value on such work in their deliberations and in their interactions with stakeholders. Donors and international agencies can encourage more informed public policymaking by supporting national and regional efforts to undertake reviews and assess their local applicability, and by supporting regional or worldwide efforts to coordinate review and assessment processes.

Research, public policymaking, and knowledge-translation processes: Canadian efforts to build bridges.

&NA; Public policymakers must contend with a particular set of institutional arrangements that govern what can be done to address any given issue, pressure from a variety of interest groups about what they would like to see done to address any given issue, and a range of ideas (including research evidence) about how best to address any given issue. Rarely do processes exist that can get optimally packaged high‐quality and high‐relevance research evidence into the hands of public policymakers when they most need it, which is often in hours and days, not months and years. In Canada, a variety of efforts have been undertaken to address the factors that have been found to increase the prospects for research use, including the production of systematic reviews that meet the shorter term (but not urgent) needs of public policymakers and encouraging partnerships between researchers and policymakers that allow for their interaction around the tasks of asking and answering relevant questions. Much less progress has been made in making available research evidence to inform the urgent needs of public policymakers and in addressing attitudinal barriers and capacity limitations. In the future, knowledge‐translation processes, particularly push efforts and efforts to facilitate user pull, should be undertaken on a sufficiently large scale and with a sufficiently rigorous evaluation so that robust conclusions can be drawn about their effectiveness.

Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis

Objective To compare quality of care in for-profit and not-for-profit nursing homes. Design Systematic review and meta-analysis of observational studies and randomised controlled trials investigating quality of care in for-profit versus not-for-profit nursing homes. Results A comprehensive search yielded 8827 citations, of which 956 were judged appropriate for full text review. Study characteristics and results of 82 articles that met inclusion criteria were summarised, and results for the four most frequently reported quality measures were pooled. Included studies reported results dating from 1965 to 2003. In 40 studies, all statistically significant comparisons (P<0.05) favoured not-for-profit facilities; in three studies, all statistically significant comparisons favoured for-profit facilities, and the remaining studies had less consistent findings. Meta-analyses suggested that not-for-profit facilities delivered higher quality care than did for-profit facilities for two of the four most frequently reported quality measures: more or higher quality staffing (ratio of effect 1.11, 95% confidence interval 1.07 to 1.14, P<0.001) and lower pressure ulcer prevalence (odds ratio 0.91, 95% confidence interval 0.83 to 0.98, P=0.02). Non-significant results favouring not-for-profit homes were found for the two other most frequently used measures: physical restraint use (odds ratio 0.93, 0.82 to 1.05, P=0.25) and fewer deficiencies in governmental regulatory assessments (ratio of effect 0.90, 0.78 to 1.04, P=0.17). Conclusions This systematic review and meta-analysis of the evidence suggests that, on average, not-for-profit nursing homes deliver higher quality care than do for-profit nursing homes. Many factors may, however, influence this relation in the case of individual institutions.

SUPPORT Tools for evidence-informed health Policymaking (STP).

AbstractThis article is the Introduction to a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers. Knowing how to find and use research evidence can help policymakers and those who support them to do their jobs better and more efficiently. Each article in this series presents a proposed tool that can be used by those involved in finding and using research evidence to support evidence-informed health policymaking. The series addresses four broad areas: 1. Supporting evidence-informed policymaking 2. Identifying needs for research evidence in relation to three steps in policymaking processes, namely problem clarification, options framing, and implementation planning 3. Finding and assessing both systematic reviews and other types of evidence to inform these steps, and 4. Going from research evidence to decisions. Each article begins with between one and three typical scenarios relating to the topic. These scenarios are designed to help readers decide on the level of detail relevant to them when applying the tools described. Most articles in this series are structured using a set of questions that guide readers through the proposed tools and show how to undertake activities to support evidence-informed policymaking efficiently and effectively. These activities include, for example, using research evidence to clarify problems, assessing the applicability of the findings of a systematic review about the effects of options selected to address problems, organising and using policy dialogues to support evidence-informed policymaking, and planning policy monitoring and evaluation. In several articles, the set of questions presented offers more general guidance on how to support evidence-informed policymaking. Additional information resources are listed and described in every article. The evaluation of ways to support evidence-informed health policymaking is a developing field and feedback about how to improve the series is welcome.

Use of evidence in WHO recommendations

BACKGROUND WHO regulations, dating back to 1951, emphasise the role of expert opinion in the development of recommendations. However, the organisations guidelines, approved in 2003, emphasise the use of systematic reviews for evidence of effects, processes that allow for the explicit incorporation of other types of information (including values), and evidence-informed dissemination and implementation strategies. We examined the use of evidence, particularly evidence of effects, in recommendations developed by WHO departments. METHODS We interviewed department directors (or their delegates) at WHO headquarters in Geneva, Switzerland, and reviewed a sample of the recommendation-containing reports that were discussed in the interviews (as well as related background documentation). Two individuals independently analysed the interviews and reviewed key features of the reports and background documentation. FINDINGS Systematic reviews and concise summaries of findings are rarely used for developing recommendations. Instead, processes usually rely heavily on experts in a particular specialty, rather than representatives of those who will have to live with the recommendations or on experts in particular methodological areas. INTERPRETATION Progress in the development, adaptation, dissemination, and implementation of recommendations for member states will need leadership, the resources necessary for WHO to undertake these processes in a transparent and defensible way, and close attention to the current and emerging research literature related to these processes.

SUPPORT Tools for evidence-informed health Policymaking (STP) 1: What is evidence-informed policymaking?

AbstractThis article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers. In this article, we discuss the following three questions: What is evidence? What is the role of research evidence in informing health policy decisions? What is evidence-informed policymaking?Evidence-informed health policymaking is an approach to policy decisions that aims to ensure that decision making is well-informed by the best available research evidence. It is characterised by the systematic and transparent access to, and appraisal of, evidence as an input into the policymaking process. The overall process of policymaking is not assumed to be systematic and transparent. However, within the overall process of policymaking, systematic processes are used to ensure that relevant research is identified, appraised and used appropriately. These processes are transparent in order to ensure that others can examine what research evidence was used to inform policy decisions, as well as the judgements made about the evidence and its implications. Evidence-informed policymaking helps policymakers gain an understanding of these processes.

Effects of policy options for human resources for health: an analysis of systematic reviews

BACKGROUND Policy makers face challenges to ensure an appropriate supply and distribution of trained health workers and to manage their performance in delivery of services, especially in countries with low and middle incomes. We aimed to identify all available policy options to address human resources for health in such countries, and to assess the effectiveness of these policy options. METHODS We searched Medline and Embase from 1979 to September, 2006, the Cochrane Library, and the Human Resources for Health Global Resource Center database. We also searched up to 10 years of archives from five relevant journals, and consulted experts. We included systematic reviews in English which assessed the effects of policy options that could affect the training, distribution, regulation, financing, management, organisation, or performance of health workers. Two reviewers independently assessed each review for eligibility and quality, and systematically extracted data about main effects. We also assessed whether the policy options were equitable in their effects; suitable for scaling up; and applicable to countries with low and middle incomes. FINDINGS 28 of the 759 systematic reviews of effects that we identified were eligible according to our criteria. Of these, only a few included studies from countries with low and middle incomes, and some reviews were of low quality. Most evidence focused on organisational mechanisms for human resources, such as substitution or shifting tasks between different types of health workers, or extension of their roles; performance-enhancing strategies such as quality improvement or continuing education strategies; promotion of teamwork; and changes to workflow. Of all policy options, the use of lay health workers had the greatest proportion of reviews in countries with a range of incomes, from high to low. INTERPRETATION We have identified a need for more systematic reviews on the effects of policy options to improve human resources for health in countries with low and middle incomes, for assessments of any interventions that policy makers introduce to plan and manage human resources for health, and for other research to aid policy makers in these countries.