Editorial - Vol 5, No 1:  Evidence-based Health Care

In this edition of Healthcare Review – Online^TM, we return to the important area of evidence-based health care which was introduced in the July 1998 edition, "Evidence-based Medicine".

Increasing pressure on resources is driving moves toward evidence-based health care. To date, many health care decisions have been based principally on values and resources - opinion-based decision-making. As demands on resources in health care increase, decisions will have to be made more explicitly and publicly and be supported by a strong and clear evidence base. Thus, pressure on resources will mean a transition from opinion-based decision-making to evidence-based decision-making ¹ .

In the July 1998 edition, Professor John Øvretveit, Professor of Health Policy and Management at the Nordic School of Public Health in Goteborg, Sweden, considered whether the principles of evidence-based medicine ² that are used in clinical practice could be applied more broadly across other non-clinical disciplines in health care, eg, purchasing and management. The information age and a more educated public puts pressures on managers, and, indeed, politicians, to become evaluation-literate and make use of research.

Øvretveit proposed that there are limitations to evidence-based medicine methods when applied to management decisions and concluded that management decisions should not be based on the model of evidence-based medicine. The paper did not aim to consider in detail the use of research in making health policy decisions, a broader subject involving different decision-making processes and types of research. However, Øvretveit showed how some principles discussed could be applied to policy decision-making, and also how managers could be more effective in implementing policies by using evaluation research and concepts.

In this edition, Dr Eric Deakins, Senior Lecturer, Department of Management Systems, University of Waikato, Hamilton, New Zealand, considers using a simulation approach in the development of a health service knowledge base that would allow clinician-management teams to assist in investigation of policy.

Deakins proposes the use of a simulation approach to generate effective management ’evidence’ for use in the practice of evidence-based health care. In this approach, an effective health care knowledge base is conceptualised as one comprising a clinical trials database component and a management trials model-base component, the latter providing the context within which the clinical interventions take place.

According to Deakins, the ability to learn from "real-life" practice is reduced in complex systems such as health care where feedback from actions can be neither immediate nor unambiguous. A simulation approach, using system dynamics "micro-worlds" that concisely encapsulate the dynamics of a health care system, could be used to generate effective health care management ’evidence’ through testing of ’virtual’ alternatives such as changes in management policy.

The simulation model is not intended to include all detail of, eg, a health care provider system, but to include enough detail to capture the essence of the real system to provide realistic outcomes to various "what-if" scenarios. Model-building involves the expression of how the main elements in a system influence and interact with one another in a causal loop diagram and the development of a structural diagram for computer simulation.

Deakins presents a case study illustrating the challenges involved in creating a "micro-world" that would be suitable for inclusion in such a database or more accurately a "model-base". Strengths and weaknesses of this approach to evidence-based health care are presented and opportunities for future work are described.

In his contribution to this edition, Professor John Øvretveit, Professor of Health Policy and Management at the Nordic School of Public Health in Goteborg, Sweden, highlights one example of the types of management "evidence" considered in Deakin’s paper.

Professor Øvretveit provides a valuable overview of different quality evaluation and indicator schemes, based on the experiences of quality specialists and leaders in the Nordic countries who have applied various schemes in public hospitals and health care services. In this paper, he highlights the lack of research into quality schemes, in particular the limited research into the cost-effectiveness of schemes for both organisation quality assessment and for comparative quality measurement. Importantly, he notes the lack of research to help providers to decide how best to introduce a scheme and to maximise benefit from its use.

Øvretveit’s paper further expands on the concept of an evidence base for use in quality programme development which Øvretveit introduced in his paper "The Convergence of Evidence-based Health Care and Quality Improvement", in the July 1998 edition in this evidence-based health care series. In that paper, Øvretveit discussed evidence-based health care and its convergence with the quality movement and highlighted the lack of an appropriate evidence base for use in quality programme development. He noted that future quality programmes will need to be more evidence-based to make them more effective, through the use of a more reliable knowledge base.

With regard to the data collected in evaluation schemes, Øvretveit highlights the importance of considering those decisions which data are intended to inform, ie, emphasising that decisions should be informed by the data collected.

1. Gray JAM. Evidence based health care. Churchill Livingstone, 1996
2. Evidence-based medicine is defined as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise (acquired through clinical experience and clinical practice) with the best available external clinical evidence from systematic research.