Managing complexity: Evidence and real world impact

Soo Downe

Health Research With Real Impact ConferenceUCLanWednesday 15th May, 2013 With thanks to women and families for permission to use the photographs

What complexity is not…• Random

• Complicated

• Chaotic

• Predictable

• Linear

The nature of linear evidence….

• Theory-practice gap

• ‘Ivory towers’ and real life…

On the high ground, manageable problems lend themselves to solution through the application of research method and theory…

In the swampy lowland, messy confusing problems defy technical solution.. [these are]…the problems of greatest human concern’

Schon 1983 p14

… a tale of two techniques

•Routine electronic fetal monitoring, low risk women

•Vaginal Breech Birth

Electronic Fetal Monitoring

Date of introduction: 1960s

Dates of trials: 1976-1993

Nine trials (of 13), 18,561 pregnant women, 18,695 infants in both high- and low-risk pregnancies, seven clinical centers in the United States, Europe, and Australia

Electronic Fetal Monitoring

Findings: Statistically significant decrease in neonatal seizures (relative risk

(RR) 0.51, 95% confidence interval (CI) 0.32-0.82), no decrease in cerebral palsy

An increase in the rate of cesarean delivery (RR 1.41, 95% CI 1.23-1.61) and operative vaginal delivery (RR 1.20, 95% CI 1.11-1.30).

NICE 2001

For a woman who is healthy and has had an otherwise uncomplicated pregnancy, intermittent auscultation should be offered and recommended in labour to monitor fetal wellbeing.

…In the active stages of labour, intermittent auscultation should occur after a contraction, for a minimum of 60 seconds, and at least:

Every 15 minutes in the first stage. Every 5 minutes in the second stage.

Although the skills necessary to implement

evidence into obstetrical practice are still

available, evidence based research results do

not seem to be of great importance, when

midwives decide which method to use for

intrapartum FHR monitoring. Hospital

policies and the professional training

received were more important factors.

Luyben AG, Gross MM.2001

EFM practice: Switzerland

Term breech presentation

First trial: 1980, second 1983, same centre

Main trial 2088 women 121 centres 26 countries (Hannah et al 2000)

Three trials (2396 participants) included

Primary outcome, term breech trial

Media spin

Evidence based real world impact?(mindlines… illness scripts…chunking…)

• 80 centres, 23 countries. 92.5% changed clinical practice to planned CS for most or all term breech babies.

• 66.3% had no difficulties or concerns with implementing a policy of planned Caesarean section for term breech babies.

• 85.0% indicated that an analysis of relative costs would not affect clinical practice in their setting.

Hogle KL et al 2003

…counter stories

• Local studies of consecutive cases varied:

• from evidence that CS confers benefit (eg Rietberg et al 2003)

• to evidence of no difference (Hellsten et al 2003)

• to evidence of benefit for vaginal breech birth (Sibony et al 2003).

2 year follow up:death or serious morbidity

How these sources interact:the reification of knowledge…

The power of authoritative

knowledge is not that it is

correct, but that it countsJordon B 1997 In: Davis-Floyd and Sargent (eds) Childbirth and Authoritative Knowledge,

University of California Press.

Research with real world impact..

Initial conditions, tipping points and simple rules

• separation– don’t collide with

your flockmates

• alignment– go where most of

the others are going

• cohesion:– move towards the

middle

Explanatory theories…

• Diffusion of innovation

• Theory of planned behaviour

• Technology adoption theory

• Baysian theory…

• &etc

Simple rules for evidence based medicine?

Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise and patient value… when these three elements are integrated, clinicians and patients form (an)…alliance which optimises clinical

outcomes and quality of life…’

Sackett et al 2000

Ways of knowing: Best evidenceEpisteme

Science: what is: (theōria)

Ways of knowing: Clinical expertiseTéchnē

Art/technology: bringing into being:

production (poiēsis)

Ways of knowing: ValuesPhronēsis

Practical wisdom:ethics, values

action (praxis)

Evidence that takes account of real world complexity

• Mixed methods

• Participatory Action Research

• Experience based co-design

• Realist research

‘what works, for who, in what context’?

Context + mechanism = outcome

Pawson and Tilley 1997

‘good’ evidence – accounting for ‘initial conditions’: how, when, where, who, as well as ‘what works’

Expertise in complex real world context..

• no longer relies on an analytic principle (rule, guideline, maxim)

• intuitive grasp of each situation - zeroes in on the accurate region of the problem without wasteful consideration of a large range of unfruitful, alternative diagnoses and solutions.

• deep understanding of the total situation. • performance fluid, flexible and highly

proficient.• Uses analytic problem solving where

necessary.

Stories as evidence of values in complex real life practice

‘hearing the moral impulse

in others’ stories enables

us to become part of their

struggle to re-enchant a

disenchanted world’. Sylvia Barton p18

Where Bacons origin story

for science spoke of the

intimate connection of

knowledge and power, the

feminist critique of science

…has spoken of the danger

of knowledge without love… Hilary Rose 1994 Love power and knowledge towards a feminist transformation of the sciences. polity press

…Lessons for complex real world research from Francis….