Managing complexity:
Evidence and real world impact
Soo Downe
Health Research With Real Impact
Conference
UCLan
Wednesday 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 1.231.61) 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.
EFM practice: Switzerland
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
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 counts
Jordon 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 evidence
Episteme
Science:
what is:
(theōria)
Ways of knowing: Clinical expertise
Téchnē
Art/technology:
bringing into being:
production
(poiēsis)
Ways of knowing: Values
Phronēsis
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
…Lessons for complex real world
research from Francis….
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