Knowledge to action? Evidence-based health care in context edited by Sue Dopson, Louise Fitzgerald
|Reviewed By:||Steve Harrison|
|Reviewed in:||Public Administration|
|Date accepted online:||02/11/2007|
|Published in print:||Volume 85, Issue 1, Pages 227-253|
Although its transatlantic progenitors have perhaps held more nuanced views, the UK's 'evidence-based medicine' (or evidence-based health care) movement, as it developed from the early 1990s, is substantially founded on simplistic, linear perspectives about the diffusion of research evidence into clinical practice. In brief: evidence on a given topic should be aggregated from multiple valid findings; valid evidence is defined with reference to research designs (especially randomized controlled trials) that seek to minimize bias; most clinicians lack the time and possibly the skills to interpret primary research studies or meta-analyses of them; algorithmic guidelines are therefore an appropriate vehicle for getting 'evidence into practice' or, as this book's title has it, 'knowledge into action'. The evidence-based health care movement has discovered from numerous studies that such guidelines are not self-implementing, yet continues to research this problem with little apparent recognition of the social and context-bound character of the enterprise. Social scientists have been commenting on this delusion for more than a decade, but it is only with the recent appearance of this book and that by Greenhalgh
This volume is the product of a welcome enterprise and its overall findings are important, if perhaps unsurprising to social scientists. First, a social perspective is required in order to understand the translation (or otherwise) of evidence into clinical practice. Such an approach 'scripts in to a much greater extent [than mainstream approaches] the perspectives and concerns of the field' (p. 183). Second, knowledge of context is crucial to the understanding of such outcomes. Moreover, 'context' is not an analytically unproblematic given; rather, it includes both internal and external, both structural and processual factors, and is interpreted, even enacted, by subsets of organizational actors. Third, actors working to implement evidence-based health care need in particular to understand the part of such contexts that is constituted by professional cultures and boundaries. Fourth, 'skilled action' is possible; opinion leaders 'were able to influence and stimulate innovation pathways actively' (p. 185). Again, however, the notion of 'opinion leader' is not unproblematic; the authors rightly remind us that such status derives from its assignment by clinicians rather than by managers. Finally, in case studies where 'best' implementation occurred, formal research evidence and clinical experience were to some extent symbiotic.