Supporting the use of cochrane reviews in health policy and management decision-making: Health systems evidence

Andrzej Dudzinski/Science Photo Library The idea that research evidence should play a more prominent role in health policy and health system management has been frequently promoted and widely accepted during the past decade.[1, 2, 3] However, bridging the gap between what has been learned through research and what is considered salient by policy‐makers and stakeholders is rarely straightforward. Nevertheless, there are several activities that have promise for better linking evidence to action.[4] One approach, sometimes called 'facilitating user‐pull', places emphasis on creating 'one‐stop shops' for relevant, high‐quality and optimally packaged systematic reviews and related products.[4] These types of efforts have recently gained more recognition and are viewed as key elements for strategies to strengthen national health systems,[5] as was noted at the First Global Symposium on Health Systems Research, held in Montreux, Switzerland, in November 2010. Health Systems Evidence (HSE) was developed as a one‐stop shop with an emphasis on policy‐ and management‐related systematic reviews and related products. While The Cochrane Library is the one‐stop shop for those with questions about clinical programmes and services or medicines, and health‐evidence.ca has emerged as the one‐stop shop for those with questions about public health programmes and services,[6] HSE is the only resource that answers questions about how to organise health systems in order to ensure that cost‐effective programmes and services get to those who need them. It first became available as a free online resource in late 2008. There are two key factors that drive the use of research evidence in policy‐making: timeliness, and interactions between policy‐makers and researchers.[7] HSE addresses the timeliness issue. With relevant reviews and review‐related products categorised and presented in an accessible format, HSE enables policy‐makers and stakeholders to find out quickly whether synthesised research evidence exists on a pressing issue and when the literature was last searched. HSE also provides information on the quality of the review and on the countries where the included studies were conducted, as well as links to structured, decision‐relevant summaries. The product of a collaboration between the McMaster Health Forum, McMaster University's Program in Policy Decision‐making, the Canadian Cochrane Centre, and Rx for Change, HSE is a continually updated, searchable repository of syntheses of research evidence, coded according to their relevance to governance, financial and delivery arrangements, and strategies for implementing change. Records contained in HSE are identified by: (1) annual searches of Medline; (2) review of each monthly issue of the Cochrane Database of Systematic Reviews; (3) review of each weekly update from the Database of Abstracts of Reviews of Effects; (4) review of each update of the Cochrane Qualitative Research Methods Group's database of qualitative reviews; and (5) regular scanning of listservs and websites. Each synthesis has links to user‐friendly summaries, abstracts and full‐text reports (when freely available), together with information about how recently the search for studies was conducted, the quality of the synthesis, and the countries in which the studies were conducted, helping policy‐makers and managers to assess the relevance of each record.[5] In keeping with the intent of one‐stop shops, HSE's online search interface has been designed to ensure that policy‐makers and stakeholders can easily retrieve the full spectrum of available synthesised research evidence related to their health system topic. An expandable 'closed dictionary' of health systems topics (governance, financial, delivery, implementation) can be used to retrieve available reviews. Ticking at the lowest level within the three‐tiered dictionary will retrieve the closest matches to one's area of interest. An open‐search function further enhances the specificity with which searches can be conducted within health systems topics (eg a particular financial arrangement for cancer care only). Specific types of synthesis (eg only Cochrane Reviews) and specific kinds of questions (eg only questions about effectiveness) can also enhance the specificity of a search. The Cochrane Collaboration is responsible for about a quarter of the reviews (304 of 1200) and nearly all of the protocols (154 of 155) currently in HSE. The Cochrane Effective Practice and Organisation of Care Review Group is responsible for 47 of the 304 Cochrane Reviews. The significant contributions of Cochrane reviewers reflect the importance of high‐quality reviews of effectiveness for policy‐making and management, especially when considering the potential benefits and harms of a particular policy or management option.[7] However, other types of reviews are needed for questions related to governance, finance, delivery and implementation. For example, reviews of process evaluations can provide vital information about how and why a particular programme works. This is useful when deciding how adaptations to a process will affect its benefits and harms.[8] Similarly, a qualitative review of evidence about perceptions of and experiences with a particular health system intervention may be essential for assessing the acceptability of an option, regardless of how effective it is. The Cochrane Qualitative Research Methods Group is contributing to advances in qualitative reviews, which we hope will be added to The Cochrane Library. HSE includes over 200 syntheses addressing questions that are not about the effectiveness of health system arrangements or implementation strategies. Instead, these syntheses focus on addressing issues such as whether a health system problem is getting better or worse over time and on understanding stakeholders' views about and experiences with a problem or with the options available for addressing it.[9] HSE also includes another 33 reviews that address a combination of effectiveness questions and complementary questions. As qualitative synthesis methods continue to develop and gain popularity, they will increasingly complement effectiveness reviews in efforts to link research evidence to policy and management decision‐making. This relationship has already been firmly established by the World Health Organization's EVIPNet policy briefs, which draw on a diverse range of review types to define health system problems, work up possible solutions, and outline implementation issues.[10] With growing support for linking research findings to policy and management decisions, there is a need for innovative and practical tools to assist in this process. HSE is one example of how specific challenges in this process – the need for timely, relevant, and optimally packaged research evidence – can be met through focused and collaborative efforts to help 'facilitate user‐pull' by drawing on extant resources to create a one‐stop shop for health policy‐makers and managers. HSE complements The Cochrane Library's reviews about effectiveness with reviews addressing other types of questions about health system arrangements and implementation strategies. We hope that HSE makes it easier for policy‐makers and other stakeholders to find and use evidence, but we still have much work ahead to support the use of this resource.[11]

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