Moving Forward on Both Systematic Reviews and Deliberative Processes
Systematic reviews are increasingly seen as helpful "knowledge support" for managers and policy makers, and deliberative processes are starting to be seen as promising, locally contextualized "decision support." Increases to the flow of systematic reviews should be complemented by efforts to facilitate the retrieval, and adapt the presentation, of the available stock of systematic reviews. Research and other evidence should be combined in transparent ways to facilitate cross-context learning. The challenge for managers and policy makers in moving forward will be to avoid the confusion that comes from the branding of both systematic reviews and deliberative processes.
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More than two years into an initiative addressing how to enhance the usefulness of systematic reviews for healthcare managers and policy makers, we've come a long way. Systematic reviews are increasingly seen as helpful "knowledge support" for managers and policy makers (Pope et al. 2005). Deliberative processes, which provide opportunities for managers and policy makers to grapple with the local implications of systematic reviews, as well as the many other types of evidence on which they draw to inform their decision-making, are starting to be seen as promising, locally contextualized "decision support" (Lomas et al. 2005; Pope et al. 2005). I highlight here two potential lessons for managers and policy makers that have come from my participation in this initiative.
Make Use of the Existing Stock of Reviews While Supporting the Future Flow of Reviews
Managers and policy makers often work to timelines of days and weeks, not months and years. Timing or timeliness is one of only two factors that emerged with some consistency in a systematic review of the factors that increased the prospects for research use by policy makers (Lavis et al. 2005b). Three processes could each partly address the challenge of timing/timeliness: (1) facilitating the retrieval of systematic reviews that address the full range of questions asked by managers and policy makers (Lavis et al. 2005a); (2) adapting the presentation of systematic reviews so that they can be more easily scanned for relevance, decision-relevant information, and factors that would influence assessments of local applicability (Lavis et al. 2005a); and (3) engaging managers, policy makers and others in helping to identify researchable aspects of managerial and policy challenges that could be explored through systematic reviews over time frames of six months to three years (Lavis et al. 2005a; Pope et al. 2005).
Relying only on a flow of highly context-sensitive systematic reviews seems wasteful and risky. A systematic review can help managers and policy makers think differently about the challenges they face (i.e., it can support conceptual uses of research) even if differences in the precise focus of studies or in the context in which they were conducted mean that a review cannot help them directly solve a particular problem (i.e., it can't always support instrumental uses of research). As well, there are hundreds or thousands of managerial contexts in a jurisdiction as diverse as Canada. And time frames of six months to three years can be a lifetime in politics. Elections, cabinet shuffles, departmental reorganizations, interest group campaigns, opinion poll volatility and unexpected events mean that priorities can change rapidly. Moreover, identifying the need for a systematic review can be a way of "kicking the issue into the long grass" (i.e., it can be used to delay action, which has been called a symbolic use of research).
Look for Transparency in Approaches to Combining Research and Other Types of Evidence
Managers and policy makers draw on research and many other types of evidence to inform their decision-making (Lavis et al. 2004; Lomas et al. 2005). One general category of approaches to facilitate this process is to solicit the other types of evidence by engaging those locally involved in or affected by a decision (1) in the systematic review process (e.g., setting the context, establishing the question or interpreting the results), (2) in a research study that examines their views and experiences in parallel with the review or (3) in a deliberative process that draws on the systematic review as one input among many. Because interactions between researchers and policy makers constitute the second of two factors that emerged with some consistency in a systematic review of the factors that increased the prospects for research use by policy makers (Lavis et al. 2005a), the first and third approaches could also increase the prospects that the review would be used. All three approaches still allow for the production of a systematic review that can be used as an input to decision-making by those who work in different contexts from those locally engaged through one of the approaches. Merging research and other types of evidence in less than transparent ways complicates cross-context learning.
The second general category of approaches is to conduct a systematic review of studies that examine the views and experiences of individuals, like those locally involved in or affected by a decision, and to do so in parallel with or as part of a review that addresses another question, such as which interventions are most effective or how and why a particular intervention works. Managers in one jurisdiction may be just as interested in learning about the views and experiences of managers and patients in other jurisdictions who are struggling with similar challenges, such as the lack of continuity in primary care, as they may be in learning about whether, how and why particular interventions enhance continuity. Systematic reviews are increasingly addressing just such a diverse array of questions (Lavis et al. 2005a). Perhaps we are not moving from summative to interpretive synthesis (Lomas 2005); more likely we are moving from summative synthesis to a combination of several summative and interpretive syntheses (Pope et al. 2005).
While many interesting research questions remain to be asked about systematic reviews and a great many about deliberative processes, some questions can best be addressed by encouraging innovation and evaluating how well different approaches work in different contexts. The challenge for managers and policy makers in moving forward will be to avoid the confusion that comes from branding. For example, for most researchers the terms "systematic review" and "research synthesis" are synonymous (Cooper and Hedges 1994). But increasingly, we see particular approaches to systematic review being branded, and the combination of a systematic review and other types of evidence being branded. The same holds true for deliberative processes. Cut through the branding, however, and managers and policy makers may discover a treasure trove of information and processes to support their decision-making.
Aller de l'avant avec les examens systématiques et les processus de délibération
De plus en plus, les examens systématiques sont considérés comme étant utiles au « soutien des connaissances » pour les gestionnaires et les décideurs, et les processus de délibération commencent à être perçus comme étant susceptibles de constituer un « soutien aux décisions » localement contextualisé. L'augmentation du nombre d'examens systématiques devrait être complétée par des mesures visant à faciliter l'extraction et à adapter la présentation du stock actuel d'examens systématiques. La recherche et les autres preuves devraient être combinées de manière transparente afin de faciliter l'apprentissage transcontextuel. Le défi pour les gestionnaires et les décideurs qui veulent aller de l'avant sera d'éviter la confusion découlant de la définition des examens systématiques et des processus de délibération.
About the Author(s)
John N. Lavis, MD, PHD
Member, Centre for Health Economics and Policy Analysis
Associate Professor, Department of Clinical Epidemiology and Biostatistics
Associate Member, Department of Political Science
McMaster University, Hamilton, Canada
AcknowledgmentCorrespondence may be addressed to: John N. Lavis, McMaster University, HSC-2D3, 1200 Main St. West, Hamilton, ON, Canada L8N 3Z5; tel.: +1-905-525-9140 (ext. 22907); fax: +1-905-529-5742; email: email@example.com; Web: www.researchtopolicy.ca.
Cooper, H. and L.V. Hedges (eds.). 1994. The Handbook of Research Synthesis. New York: Russell Sage Foundation.
Lavis, J., H. Davies, R. Gruen, K. Walshe and C. Farquhar. 2005a. "Working Within and Beyond the Cochrane Collaboration to Make Systematic Reviews More Useful to Healthcare Managers and Policy Makers." Healthcare Policy 1(2): 21-33.
Lavis, J.N., H.T.O. Davies, A.D. Oxman, J.-L. Denis, K. Golden-Biddle and E. Ferlie. 2005b. "Towards Systematic Reviews That Inform Health Care Management and Policy-Making." Journal of Health Services Research and Policy 10 (Supplement 1): S1:35-S1:48.
Lavis, J.N., F.B. Posada, A. Haines and E. Osei. 2004. "Use of Research to Inform Public Policymaking." Lancet 364(9445): 1615-1621.
Lomas, J. 2005. "Using Research to Inform Healthcare Managers' and Policy Makers' Questions: From Summative to Interpretive Synthesis." Healthcare Policy 1(1): 55-71.
Lomas, J., T. Culyer, C. McCutcheon, L. McAuley and S. Law. 2005. Conceptualizing and Combining Evidence for Health System Guidance. Ottawa: Canadian Health Services Research Foundation.
Pope, C., N. Mays and J. Popay. 2005. "Informing Policy Making and Management in Healthcare: The Place for Synthesis." Healthcare Policy 1(2): 43-48.
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