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Introduction

RECOGNIZING THAT RESEARCH IS BUT ONE INPUT TO DECISIONS IS MOTHERHOOD AND APPLE PIE FOR THOSE WHO WORK IN THE HEALTHCARE SYSTEM AND INCREASINGLY EMBRACED AS REALITY BY THE RESEARCH WORLD.1

Still, some researchers continue to be frustrated by poor uptake of their research findings by policy makers and managers. These researchers sometimes fail to fully appreciate the world of policy- and decision-making, where research is only one important consideration. In the same way, some policy makers and managers can be skeptical about the usefulness of research evidence to inform policy and management decision-making.

The theory of "two communities" - the research community and the policy- and decision-making community — is not new.2,3 This theory proposes the existence of two camps, unable or unwilling to take one another's realities or perspectives into account.3 Lindblom and Cohen4 have said that "... in public policy making, many suppliers and users of social research are dissatisfied, the former because they are not listened to, the latter because they do not hear much they want to listen to."

These days, this theory is commonly embraced as a reality, with researchers and decision makers facing different incentive structures in particular. One common complaint from policy makers and managers is that they have little time to read full research reports.5 Since research results from various studies can also be contradictory, policy makers and managers may also face challenges in assessing which evidence is preferred. It is also well-known that pointing to individual studies is not particularly useful or sufficient for informing policy- and decision-making because these provide an incomplete picture in the context of the overall body of research on a given topic.

Of course, evidence suggests that linkage and exchange efforts — efforts to encourage ongoing interaction, collaboration and exchange of ideas between the research and decision-making communities — can be successful. In particular, these efforts can lead to a decision-relevant culture among researchers and a research-attuned culture among policy makers and managers.6,7,8 However, attaining these cultures has its challenges5 and requires much effort from both communities.

Policy makers and managers can make efforts to ensure they receive and apply research findings.6,9 Researchers can present the research evidence in a way that is sensitive to their target audience and encourages such use.9 To better influence policy and management decision-making, researchers should also transfer research evidence as actionable messages based on whole bodies of research knowledge.6,9 Ultimately, both communities may work collaboratively to improve the relevance of research to policy- and decision-making.10

Using research summaries to inform policy and management decision-making

User-friendly summaries of research evidence can be a way for researchers to effectively communicate actionable messages to policy makers, managers and others, particularly in cases where research results are unambiguous. Mythbusters and Evidence Boost are CHSRF's flagship summary products that provide the research evidence behind some of today's major debates in health services management and policy. The Mythbusters series was launched in 2000 in recognition of the large number of myths in the system that could be countered with research evidence. Among the most prominent myths were the theories that the aging population would overwhelm the healthcare system; user fees would ensure better use of the healthcare system; and more money would put an end to emergency-room crunches.

The Evidence Boost series was created in 2004 after feedback suggested there was a need for a positive companion to the Mythbusters, one that summarized unambiguous research in support of taking a particular course of action where there is not already significant uptake. The first issues of Evidence Boost revealed that waiting lists could be managed centrally for better efficiency and that interdisciplinary teams in primary healthcare could effectively manage chronic illnesses.

Why use research evidence to inform policy- and decision-making?

The roots of evidence-based medicine are thought to come from the clinical world.11,12,13 In this context, evidence-based medicine is "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."13 And practicing evidence-based medicine involves "integrating individual clinical expertise with the best available external clinical evidence from systematic research."13

A little more than 10 years ago the popularity of evidence-based medicine spread beyond the clinical world to management and policy.12 The rationale was simple: in the same way that there is a scientific basis to how clinicians make diagnostic and treatment decisions for patients, there was a need for health services managers and public policy makers to use research evidence to inform the organization and delivery of health services.10,14,15 The shift to using the term "evidence-informed" instead of "evidence-based" decision-making was made by CHSRF in 2006 to highlight the reality that evidence is but one input to health system decisions.1

With explicit consideration of formal research evidence having become widely expected as part of the policy- and decision-making process,9 researchers needed to develop tools that would be sensitive to policy makers' and managers' needs. However, "the nature of the relevant research for management and policy was sharply different from that of clinical medicine."12 Today, researchers have many tools available for summarizing research evidence for policy- and decision-making. Two prominent tools are decision support syntheses and research summaries.

Summary versus synthesis: What is the difference?

Although writing syntheses and summaries require similar skills, they seek to accomplish different tasks. Where a formal synthesis can be considered to be the creation of new knowledge, a summary pulls together main messages from a number of published sources. Similarly, syntheses can be rich sources of suggestions for future research as well as sources of evidence to help people make well-informed decisions about healthcare practice,16 while summaries typically serve only the latter function and in a less-formal way.

In particular, syntheses aim to be comprehensive, seeking out all the relevant evidence, favourable or not, and aggregating it into an impartial summary.12 There are many forms of syntheses, ranging from very formal systematic reviews to informal literature reviews. Among some of the most well-known systematic reviews are those produced by the Cochrane Collaboration,17 the Campbell Collaboration,18 the United Kingdom's Centre for Reviews and Dissemination19 at the University of York, and the Joanna Briggs Institute20 in South Australia. CHSRF commissions syntheses aimed at making "best practice" recommendations for a specific area of health services management or policy development.

Summaries are a less-formal way of pulling research together, generally using a more conversational tone. One example is CRISPfacts, a series of newsletter summaries which are an initiative of the University of New Brunswick's Canadian Research Institute for Social Policy.21 Another example is the Mythbusters series, which sets out the research evidence behind public debates on current healthcare issues. These summaries are often a prescription for action and use storytelling techniques to communicate main messages.

The Mythbusters Teaching Resource: What to expect

This teaching resource builds on the Mythbuster model. As such, the resource incorporates all of the major steps CHSRF follows to create and share a Mythbuster. These steps are:

  1. Spotting the Myth
  2. Searching for Evidence
  3. Writing the Summary
  4. Adding Visual Appeal
  5. Undergoing Review
  6. Sharing Evidence-Informed Messages

The teaching resource begins with a story about Ana, a fictional character who walks readers through each of these steps.

Throughout this resource, the term "decision maker" is most often used when referring to the audience or end-user of a research summary. In From Research to Practice: A Knowledge Transfer Planning Guide, the authors argue that, "It's useful to think of all audiences as 'decision-makers' since 'decisions' are what might be improved with research evidence."22 With that said, the target audience for a research summary, including a Mythbuster, may be any number of persons such as policy makers, planners, managers and providers.

Ana's Story

Any similarity, likeness or reference to existing individuals or organizations in this story is entirely coincidental.

Ana is a health services research master's candidate enrolled at one of the CHSRF/CIHR Regional Training Centres.i Having worked as a research assistant with her thesis supervisor and other university-based researchers, Ana has developed strong research skills. Just recently, Ana started a summer internship at a Canadian provincial ministry of health. Working with the director of the ministry's health policy branch, Ana hopes to gain perspective about what it's like to work with those who make decisions about our healthcare system. She also hopes to be able to share her research literacy skills to help her branch rely on evidence-informed policy decisions more often.

It's another day on the job and Ana's boss, Louise, calls Ana into her office.

"I received a call from the minister's office today," says Louise. "The minister has been getting a number of requests for information about our stance on two-tier healthcare. He was scrummed by the national media again today on this. Journalists are asking why the ministry does not support Canadians buying services. They think a greater role for private care will reduce waits in our publicly funded system. There's likely going to be more of these requests coming up, so I'd like you to pull together some of the research on this issue."

Ana is happy to take on the request, though she's a little taken aback by it. Thinking back to one of her health policy courses, Ana wonders, does anyone really believe that a parallel private system is a cure-all for waiting lists?

Spotting the myth

Reflecting on the task ahead, Ana begins to think back to her health policy class again. She remembers discussions about the different kinds of healthcare systems — everything from Canada's largely publicly funded healthcare system to the American two-tier system. One thought that stands out in her mind is that in England and New Zealand, which have parallel private systems, the waiting lists and waiting times appear to be longer in the public system than in Canada's.ii Still, the full details are a little foggy in her head.

Using a news database, Ana begins to scour national and provincial newspapers for some of the news stories Louise had mentioned. Using the search terms wait times, private and health, Ana retrieves more than 500 newspaper articles from January 1, 2006, to September 10, 2007. A number of headlines catch her eye:

  • Quebec to allow limited private health care: To apply to knee, hip and cataract operationsiii
  • Use private contractors to bolster health care, CMA urges; MDs group also pushes for private insurance to cover public careiv
  • MDs launch fresh bid for two-tier carev
  • Hybrid health care system worth consideringvi
  • Bring on two-tier health: Patients suing province over wait timesvii

One letter to the editor tells the story of a patient who travelled to the Mayo Clinic in the United States to have a brain tumour removed. The tumour was pressing on her optic nerve, leading to temporary vision loss. About 10 days post-surgery, the patient's eyesight was restored. Meanwhile, if the patient had opted against paying for surgery in the U.S., she would still have a month and a half to wait before her second scheduled consultation in Ontario.vii

These headlines and reports have Ana second-guessing herself — Is it possible a parallel private system will shorten waits in the public system? And will for-profit ownership of facilities lead to more efficient healthcare? With a search of the latest newspaper articles already exhausted, Ana turns to the Internet, using a common online search engine, Google. One report that arises from the search comes from the Canadian Healthcare Consensus Group and is available on the Atlantic Institute for Market Studies web site. In a 2006 paper, the group argues that strong public- and private-sector healthcare systems go "hand in hand" (p.2). The group further argues that "the virtual exclusion of the private sector from Canada's health care system has deprived Canadians of innovation, investment, best practices, choice and competitive benchmarks against which to judge the performance of all parts of the health care system" (p.2).viii In another report, this one from the Fraser Institute, the argument is strongly against a public system altogether. The authors argue that Canada's publicly funded healthcare system is headed for bankruptcy, all the while legally preventing patients from seeking treatment elsewhere and paying for it out of pocket, unless they choose to leave the country.ix These arguments are compelling and again, Ana finds herself questioning what she once thought to be true about Canadian healthcare.

Searching for evidence

Until now, Ana has spent time conducting informal searches in news databases and on the Internet for information about the role of the private sector in reducing wait times and leading to more efficient healthcare. Now it's time for a formal literature search, from which Ana hopes to draw research evidence from peer-reviewed scientific journals.

A search of the Cochrane Database of Systematic Reviews, including the Cochrane Effective Practice and Organisation of Care Group, comes up short. However, a search using other databases, including MEDLINE, leads to a number of credible sources. Ana comes across a couple of relevant systematic reviews that find for-profit care leads to higher mortality.xii,xiii She also finds relevant health economics literature, showing for-profit hospitals spend significantly more than not-for-profits on administration for each patient day.xiv More searching confirms what Ana had learned in her health policy coursework: that waiting times in England's and New Zealand's public sectors are longer than those in Canada's single-payer system.ii Other, similar studies back up these findings: in particular, in countries where there are both public and private care, including Australia and England, the more care provided in the private sector in a given region, the longer the waiting times for public hospital patients.xv,xvi Ana's literature search also reveals evidence that finds parallel private systems may tend to "cherry pick" patients who are healthier and younger or have conditions that are easy and inexpensive to treat.xvii,xviii Ana knows she has neared the end of her search because many of the same sources keep surfacing. With so many arguments, Ana doesn't know how she'll be able to summarize her findings.

Writing the summary

While working in the ministry of health, Ana has realized that writing for a policy maker audience is nothing like writing an article for an academic journal or a report for a health policy course.

Since writing a research summary for policy makers has a different objective than these, Ana knows she'll need to take a different approach.

To begin, she thinks about what her director, Louise, would want to read. Louise is not immersed in the research world, so she would likely want the findings interpreted to some degree. She's also busy, so she would only want to know about the best available evidence and the "so what" factor of every argument. Knowing first-hand how easy it is to be led astray in the debate over whether Canada should expand its role for private-sector healthcare, Ana decides that her goal in writing a summary of her findings will be to clearly distinguish myth from fact. Having become familiar with briefing notes, Ana decides she'll need to keep her summary concise, too. Of course, writing for policy makers always seems easier than it is. Ana knows she'll have to write and re-write to edit her draft down to two to three pages.

Adding visual appeal

Keeping her arguments short and sweet is easier said than done. But one of the ways Ana accomplishes this is by coming up with snappy headings for each section of her summary. These headings make for a helpful transition for readers and allow Ana to get straight to her point. Ana also chooses to use an Arial font throughout her summary. This clean, plain font will not distract the reader or take away from the content of the summary. Finally, Ana experiments with white space, making sure her summary doesn't look too crowded with text. Ana knows that pages of straight text can be an immediate turn-off for readers, especially those with little or no time to spare.

Undergoing review

Thinking back to when she started this project, Ana remembers she had a bias. At the time, Ana believed what the research evidence later supported — that a parallel private system would not lead to shortened waits and greater efficiency in the public sector. Now that her summary is drafted, Ana wonders if she may have introduced bias into her final product, instead of allowing the research evidence to speak for itself. If this article were for an academic publication, she knows a peer review would most likely be necessary. However, because this report will remain internal, Ana knows that will not be the case here. In keeping with the purpose of a peer review, as she reads through her summary, Ana asks herself critical questions: Have I considered all of the different perspectives or views that exist? Has the summary effectively captured the essence of the major issues?

Sharing evidence-informed messages

Before Ana submits her research summary to her director, Louise, she wonders if what she's written may have a broader reach within the policy-making community. Ana decides to make a recommendation to her director on how to disseminate her work throughout the ministry. For starters, the ministry's research and evaluation branch has a monthly newsletter that profiles new and relevant research for health-system decision makers. Ana will suggest to Louise to start there.

References

  1. Canadian Health Services Research Foundation. 2007. CADRE: CHSRF/CIHR Regional Training Centres.
    http://www.chsrf.ca/Programs/CADRE/CADRERegionalTrainingCentres.aspx
  2. Hughes Tuohy C et al. 2004. "How does private financing affect public health care systems? Marshaling the evidence from OECD nations." Journal of Health Politics, Policy and Law; 29(3): 359-396.
  3. Authier P. 2006, June 9. Quebec to allow limited private health care: To apply to knee, hip and cataract operations. National Post. p. A10.
  4. Foot R. 2007, July 31. Use private contractors to bolster health care, CMA urges; MDs group also pushes for private insurance to cover public care. The Ottawa Citizen. p. A1.
  5. Galloway G. 2007, July 31. MDs launch fresh bid for two-tier care. The Globe and Mail. p. A1.
  6. Moore CM. July 13, 2006. Hybrid health care system worth considering. New Brunswick Telegraph-Journal. p. A7.
  7. Shanks LM. 2007, September 8. Bring on two-tier health: Patients suing province over wait times (Letter to the editor). p. A7.
  8. Canadian Healthcare Consensus Group. 2006. A call to action on health care reform: Consensus group argues that better principles equal better health care.
    http://www.aims.ca/library/CGStatementE.pdf
  9. Rovere M and Skinner BJ. 2007. California Dreaming: The Fantasy of a Canadian-Style Health Insurance Monopoly in the United States.
    http://www.fraserinstitute.ca/admin/books/files/CaliforniaDreaming.pdf
  10. Canadian Medical Association Policy Statement. 2007. It's still about access: Medicare plus.
    http://www.aims.ca/library/CMA.pdf
  11. Canadian Medical Association. 2007. It's about access: Informing the debate on public and private health care.
    http://www.cma.ca/multimedia/CMA/Content_images/Inside_Cma/Media_Release/pdf/2006/about_access_e2.pdf
  12. Devereaux PJ et al. 2002. "Comparison of mortality between private for-profit and private not-for-profit hemodialysis centers: a systematic review and meta-analysis." Journal of the American Medical Association; 288(19): 2449-2457.
  13. Devereaux PJ et al. 2002. "A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals." Canadian Medical Association Journal; 166(11): 1399-1406.
  14. Woolhandler S and Himmelstein DU. 1997. "Costs of care and administration at for-profit and other hospitals in the United States." New England Journal of Medicine; 336(11): 769-774.
  15. Duckett SJ. 2005. "Private care and public waiting." Australian Health Review; 29(1): 87-93.
  16. Besley T et al. 1998. "Public and private health insurance in the UK." European Economic Review; 42(3-5): 491-497.
  17. Schokkaert E and C Van de Voorde. 2003. "Belgium: risk adjustment and financial responsibility in a centralised system." Health Policy; 65(1): 5-19.
  18. Gonzalez P. 2004. "On a policy of transferring public patients to private practice." Health Economics; online pre-publication October 20.
  19. Canadian Health Services Research Foundation. 2005. Myth: A parallel private system would reduce waiting times in the public system. Mythbusters.
  20. Canadian Health Services Research Foundation. 2004. Myth: For-profit ownership of facilities would lead to a more efficient healthcare system. Mythbusters.