Systematic reviews in medicine generally focus on “does it work” or “what works best,” but answering such questions is difficult in summarizing research on complex interventions to which context is important, as in the application of information technology in organizations. That is just one of many important points made by Trisha Greenhalgh, Henry Potts, Geoff Wong, Pippa Bark, and Deborah Swinglehurst in the first article in this issue, “Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method.” As the authors explain, this method focuses on “systematically making sense of complex, heterogeneous, and conflicting bodies of literature” (see Greenhalgh et al. 2005), an approach that Greenhalgh and her colleagues also used in an article (2004) summarizing research about the diffusion of evidence in service-providing organizations.
This new systematic review is based on twenty-four previous systematic reviews of the vast literature on electronic patient records (EPRs), some of which are extensive—a recent one is about six hundred pages long (Car et al. 2008)—as well as ninety-four additional studies, many of which are from outside the biomedical literature. The research that Greenhalgh and her colleagues review varies on such matters as assumptions about the nature of reality (ontology), how reality can be known (epistemology), and preferred research approaches and study designs (methodology). The EPR research comes from four philosophical positions (interpretivist, critical, recursive, and positivist), has diverse historical roots (the authors identify eight), and is fit by the authors into nine “meta-narratives.”
The diversity of research questions and approaches defies a simple summation of findings, but Greenhalgh and colleagues draw seven key themes from the literature, each of which is characterized by inherent tensions. These themes pertain to the EPR itself, the user, the organizational context, clinical work and knowledge, the process of change, the impact of change and the definition of success, and complexity and scale. Greenhalgh and colleagues also discuss differences within the research literature as to how EPRs are thought of, the conflicting ways that success is defined, paths to problems and failures, and implications for successful implementation. In addition, they identify areas for which further research is needed and, somewhat unusually, several areas for which we need no more research. Stating that the goal of the review was to “illuminate and challenge the way that researchers think,” they conclude with the hope that their review will contribute to an “urgently needed” interdisciplinary debate on priorities for EPR research and policy.
The next three articles are of interest from the perspective of health reform debates in the United States, bearing on arguments commonly made about the role of government, strategies for increasing the effects of market forces, and future cost trends.
“Expensive Cancer Drugs: A Comparison between the United States and the United Kingdom,” by Ruth Faden, Kalipso Chalkidou, John Appleby, Hugh Waters, and Jonathon Leider, examines how the United States and the United Kingdom deal with difficult policy issues regarding very expensive technologies that offer only limited benefit to patients with serious diseases like cancer. Issues of fairness arise if only wealthy or well-insured patients can afford certain drugs, and the combination of high cost and modest-to-low benefit poses difficult questions for third-party payment systems, both governmental and private.
After describing the two countries’ current drug coverage, Faden and her colleagues examine the costs to patients for cancer drugs for which the annual expense of treatment is at least 50 percent greater than the country's per capita GDP (e.g., $47,000 in the United States). Patients in the United Kingdom have either full coverage (zero cost to patients) or no coverage, depending on whether a particular drug is covered by the National Health Service (NHS) (seven were, but four were not). In the United States, patients with Medicare Part D coverage face substantial costs in all cases (at least $6,766 per year). Their costs were higher than the British patients’ costs for drugs covered by the NHS but are substantially lower than British patients’ costs for drugs not covered by the NHS. American patients who lack drug coverage face the highest costs of all, even higher than British patients pay for drugs not covered by the NHS.
Faden and her colleagues then discuss three important questions: Which country's system is fairer? In which system are cancer patients better off? And what challenges are faced by both systems when presented with interventions that no system can provide in a sustained way to everyone for whom there might be a clinical indication?
In the next article, “Consumer-Oriented Health Care Reform Strategies: A Review of the Evidence on Managed Competition and Consumer-Directed Health Insurance,” Thomas Buchmueller reviews the two leading strategies to bring market forces to bear on cost containment in health care. Although the two strategies do not conflict (i.e., they both could be applied at the same time), they are based on different ideas about cost containment, and they have different targets. Managed competition seeks to use individuals’ choices from an array of health plans to exert downward pressure on costs, while consumer-directed plans seek to influence individuals’ decisions regarding whether to obtain particular medical services.
Buchmueller describes both approaches and summarizes the research evidence, which is largely based on employers’ experiences. This research has focused primarily on two different questions. For managed competition, the question concerns individuals’ price sensitivity to differences in cost across health plans. Their willingness to switch to less expensive plans can lead to cost savings. For consumer-oriented health plans, the question is whether medical spending is reduced and quality is maintained when enrollees in health plans have greater responsibility for paying for the cost of care. Buchmueller finds that the available research largely supports the managed competition approach (although he does not examine the possible effects on quality), whereas the evidence regarding consumer-oriented plans is both sparse and unsupportive.
The next article is concerned with a different aspect of the cost problem. Future changes in the life expectancy of the American population could have huge societal implications, including the costs of entitlement programs like Social Security and Medicare. New projections are provided by S. Jay Olshansky, Dana Goldman, Yuhui Zheng, and John Rowe in “Aging in America in the Twenty-first Century: Demographic Forecasts from the MacArthur Foundation Research Network on an Aging Society.” The authors believe that foreseeable advances in medical technology are likely to accelerate reductions in mortality, and they model how changes of various magnitudes would affect the number of older persons in the population. Their analysis suggests that official government forecasts may significantly underestimate the size of the aging population in 2030 and 2050, the years of their projections. Olshansky and his colleagues conclude that by the middle of the century, the cumulative outlay by Medicare and Social Security could be $3.2 trillion and $8.3 trillion higher than current governmental forecasts project.
The final two articles in this issue continue the Quarterly's focus on the relationship between research (and researchers) and policy (and policymakers) (Chalkidou et al. 2009; Exworthy et al. 2006; Greenhalgh et al. 2004; Jacobson, Butterill, and Goering 2005; Jewell and Bero 2008; Kilbourne et al. 2004; Lavis et al. 2003; Lavis et al. 2002; Lomas et al. 2003; Mitton et al. 2007; Tetroe et al. 2008; Walshe and Rundall 2001). First, in “Translating Medical Effectiveness Research into Policy,” Janet Coffman, Mi-Kyung Hong, Wade Aubry, Harold Luft, and Edward Yelin summarize lessons from the California Health Benefits Review Program. This program, based at the University of California, provides California's legislature with objective analyses of the medical, financial, and public health impacts of proposed health insurance benefit mandates and repeals.
The sharply different pace at which research progresses and policymakers work is a commonly cited barrier to applying research to policy, but the California program is given sixty days from the time of a legislative request to generate a report, have it reviewed, and submit it to the legislature. Coffman and her colleagues describe how the program works, and they discuss lessons learned about the limitations of available evidence, the importance of conveying the complexity of evidence to policymakers, and the need to keep expectations realistic.
The second article on the theme of research and policy is Jonathan Lomas and Adalsteinn Brown's “Research and Advice Giving: A Functional View of Evidence-Informed Policy Advice in a Canadian Ministry of Health.” Based on the authors’ personal experience in working with civil servants in the Ontario Ministry of Health and Long-Term Care, the article describes several steps that the ministry has taken to improve the evidence base for policymaking. The article's central contribution is distinguishing among three functions of research in policy: setting the agenda, developing policy, and monitoring and modifying existing policy. Lomas and Brown analyze how the research needs of civil servants differ among these three functional areas.