Responsibility and accountability for well informed health-care decisions: a global challenge

Despite large investments during past decades in health-care research, evidence synthesis, and clinical practice guidelines, too much research is wasted and too many decisions are still not well informed. Why is this, and what can we do about it? The following four conditions must be met. First, relevant and reliable health-care research must exist and be disseminated. Often research is lacking— eg, there is no substantial research for between 2% and 53% (median 19%) of treatments off ered to patients (summarised in the appendix). At the same time, resources are used on unnecessary research, which does not address the right questions, nor use the right methods or provide suffi cient description of interventions. Research is sometimes also inapplicable because it does not address multimorbidity. Second, decision makers and patients must have access to reliable and relevant evidence synthesis. The over whelming volume of primary clinical research and the temptation to rely on single studies makes systematic reviews and health technology assessments (HTAs) prerequisites for well informed decisions (appendix). Epistemonikos, a database of all systematic reviews, contains more than 58 000 reviews, and although some independent replication of synthesis might be useful there are unnecessary duplications. As many as 11 meta-analyses for statins in the prevention of atrial fi brillation after cardiac surgery including almost the same primary studies have been published, and several HTAs were produced across Europe when human papillomavirus vaccination was introduced. At the same time, reviews addressing important questions are missing, and reviews are misleading because they are not updated when new trials are published. Access to reliable knowledge is often restricted for economic reasons. Third, patients, clinicians, and policy makers must be encouraged to ask for and use evidence synthesis. On average, clinicians have one question for every two patients they see, pursue only half of those questions, and fi nd answers to about 80%. Despite improved availability of online resources, this situation has changed little in the past 20 years. Patients frequently seek health information online. Worldwide, about 4·5% of all internet searches are for health-related information. However, patients’ search and evaluation skills are limited, and relevant and evidence-based health information is often not accessible to patients. Among policy makers, frequently reported barriers to evidence use are scarcity of timely, relevant research and poor access. Fourth, to improve patient outcomes, recommendations and decisions must be put into action and be implemented in policy and practice. Studies of the implementation of evidence-based recommendations indicate large gaps between the care that patients should receive and the care they do receive. Medical practice in Organisation for Economic Co-operation and Development countries varies widely across regions, hospitals, and physicians for almost every disorder. This situation indicates that many patients do not receive optimum care. Production of trustworthy guidelines is not in itself a solution. Health decisions are complex and many eff orts are needed to ensure that they are well informed. Clinicians and patients need to develop attitudes and skills to use evidence synthesis and resources for shared decision making. However, although indiv iduals, patients, and clinicians can address some barriers to well informed decisions, collective action is needed in many, if not most, cases. This statement is particularly true for low-income and middle-income settings where fi nancial barriers restrict people’s access to eff ective health care. Many stakeholders have responsibilities and they are accountable for a range of groups (appendix). Researchers and research organisations are responsible for using systematic reviews to inform their research, only doing research that is relevant, reliable, and needed, engaging stakeholders (including patients and health professionals) in their research, publishing all studies, and contributing to systematic reviews, HTAs, and guidelines production. They are accountable to patients, research participants, research funders, and peers for their use of resources and the quality of their research. Systematic review authors and editors, HTA agencies, and guideline developers are responsible for producing relevant, reliable, transparent, and up-to-date evidence synthesis and recommendations, avoiding unnecessary duplication, making their work accessible to decision makers, and engaging stakeholders. The academic community and journal editors must acknowledge the importance of evidence synthesis and open access. They are accountable to their funders and decision makers who use their products. Health-care professionals and managers are responsible for seeking reliable information and learning suffi cient skills to use evidence-based resources appropriately to provide optimum patient care, and to participate in research and guideline development. They are accountable to their patients, governments, and third party payers (as public representatives) for their use of health-care resources. Lancet 2015; 386: 826–28