This article by Kieran Walshe and Thomas G. Rundall, published in The Milbank Quarterly, serves as a critical examination of the concept of evidence-based health care (EBHC) and its relatively slow adoption within health care management compared to its more widespread application in clinical practice. While EBHC, rooted in ideas from as early as 1972, gained significant traction among clinicians, managers, policymakers, and researchers during the 1990s as a powerful response to health care system challenges, its principles have not been equally applied to managerial decision-making.
The authors highlight a persistent “research-practice gap” in health care, noting that research findings often fail to translate into actual clinical practice, leading to suboptimal care and avoidable harm. This gap manifests in three key problems:
- Overuse: Applying interventions where they are ineffective (e.g., prophylactic extractions of asymptomatic impacted wisdom teeth, prostate cancer screening).
- Underuse: Failing to apply known effective interventions (e.g., drug treatment for essential hypertension in older people, smoking cessation therapy).
- Misuse: Inconsistent application of interventions when evidence of effectiveness is ambiguous, leading to wide variations (e.g., use of pressure-relieving equipment, selection of hip prostheses).
Crucially, the article argues that these same problems of overuse, underuse, and misuse are equally prevalent in health care managerial practice (e.g., overusing organizational mergers, underusing physician replacement with other professionals, or varied adoption of total quality management initiatives), yet they have received far less attention.
The central premise of the article is to explore the reasons behind the slow progress of evidence-based management (EBM). It offers a comprehensive comparison between clinical practice and health care management across three key domains:
- Culture:
- Clinical culture is described as highly professionalized, with a formal, shared body of scientific knowledge and a strong value placed on scientific research. Clinicians are often trained in research methods, and a career path often combines practice, teaching, and research.
- Managerial culture, in contrast, is diverse, less professionalized, lacks a shared formal body of knowledge, and heavily values personal experience and pragmatism over formal research. Managers often have less understanding or even suspicion of research, with a notable divide between researchers and practitioners.
- Research and Evidence Base:
- Clinical research is characterized by a strong biomedical, empirical paradigm, prioritizing experimental methods like randomized controlled trials, quantitative data, and well-organized, indexed literature (e.g., Medline). There’s a presumption of high generalizability of findings across settings.
- Managerial research, stemming from social sciences, often uses qualitative methods, has less empiricism, and focuses more on theoretical development. Its literature is poorly organized, widely dispersed across various journals and “gray literature,” making systematic review and synthesis challenging. The transferability of findings is perceived as lower due to contextual factors.
- Decision-Making Processes:
- Clinical decisions are numerous, often made individually and quickly, focusing on specific patients. Clinicians frequently use decision support systems (e.g., guidelines, handbooks), which promote and are amenable to evidence-based approaches.
- Managerial decisions are fewer, larger, and have longer timeframes, often involving groups, negotiation, and significant organizational constraints (e.g., resources, politics). They are heterogeneous, less based on applying a general body of knowledge to similar circumstances, and traditionally lack formal decision support aids, relying more on intuition. The outcomes of managerial decisions are also often less immediately apparent and harder to trace back to the decision itself.
To bridge this gap, the article highlights the work of the Center for Health Management Research (CHMR) as an example of an “evidence-based management co-operative”. CHMR fosters collaboration between managers, clinicians, and researchers to develop research agendas, conduct studies, and disseminate action-oriented findings that address practical managerial questions.
Based on CHMR’s experience, the article outlines a vital agenda for action to promote EBM, stressing that implementation cannot simply mirror the clinical model:
- Cultivating an evidence-based culture: Organizations must support innovation, experimentation, data analysis, and critical appraisal skills among managers.
- Getting the evidence: Research questions must be specific, action-oriented, and important to the organization, involving collaborative input from managers.
- Changing decision-making processes: Research systems and products must fit existing managerial decision-making patterns, with timely results, succinct summaries, and broad, redundant dissemination efforts (e.g., research briefs, websites, liaison roles).
Ultimately, the authors assert that improving EBM requires significant changes in managers’ attitudes towards research—through training, involvement, and academic pursuits—and increased investment in a coherent, needs-related research and dissemination infrastructure by various stakeholders, including government agencies, funders, and academic centers. This transformation is crucial for enhancing the quality of health care management and supporting the broader development of evidence-based health care for the benefit of all stakeholders.
Reference:Walshe, K., & Rundall, T. G. (2001). Evidence-based management: From theory to practice in health care. The Milbank Quarterly, 79(3), 429–457.
