Abstract
Three fundamental resources to promote and support evidence were published at the end of 2021 and the start of 2022. The purpose of these contributions was to emphasize one of the main lessons learned from the COVID-19 pandemic and specifically its impact on medicine: the importance of using evidence to make decisions. These initiatives captured the attention of Nature 1 , with an editorial that focused on the impact that evidence could and should have beyond health, informing decisions relevant to global challenges, using the best available up-to-date or “living” evidence. The Nature editorial pointed out the low quality of many publications dedicated to COVID-19 during the pandemic, an opinion shared by editors of rehabilitation journals, who also noticed an increase in the incidents of misconduct, in particular attempts of duplicate publications. In this paper, we summarize for the rehabilitation audience the main recommendations of the 3 groups that worked simultaneously but independently on the use of evidence in health decision- making. The conclusions were similar, a finding that reinforces their importance.
The World Health Organization (WHO) Evidence-informed Policy Network (EVIPNet) published the document “Together on the road to evidence-informed decision-making for health in the post-pandemic era: a call for action” 2 . The document recommends 4 main actions (Table 1), mainly directed to governments and policy decision-makers: 1) institutionalize structures and processes to support evidence-informed decision-making; 2) use high-quality norms, standards and tools promoting evidence-informed decision-making; 3) strive to ensure national and international capacity for the translation and use of evidence in decision-making; and 4) strive to ensure that evidence is accessible, timely and relevant for policymaking, especially in emergencies. Each action is supported by enabling strategies that provide a practical way forward for implementation. As stakeholders in health and social systems and as part of the evidence ecosystem, readers can promote, support and implement these actions.
Recommendations by the World Health Organization Evidence-informed Policy Network (EVIPNet) in the document “Together on the road to evidence-informed decision-making for health in the post-pandemic era: a call for action” (2).
The COVID-19 Evidence Network to support Decision-making (COVID-END) 3 is a global organization launched by McMaster University in Canada at the start of the pandemic to cope with COVID-19 by using the best available evidence. COVID-END includes most organizations active in the prevention and management of COVID-19, including Cochrane 4 and Cochrane Rehabilitation 5 . In 2021, COVID- END convened the Global Commission on Evidence to Address Societal Challenges to change the global panorama on evidence generation beginning with the lessons learned during the COVID-19 pandemic. The commission published a report titled “A wake-up call and path forward for decision-makers, evidence intermediaries, and impact-oriented evidence producers” 6 . The title flags the need for immediate, targeted action to ensure high-quality, timely, relevant and feasible decision-making in systems affecting individual, family, community and societal well-being. Core to the report is the concept of the best available research evidence. The report preamble explains “now is the time. . . [for] creating the capacities, opportunities and motivation to use evidence to address societal challenge, and putting in place the structures and processes to sustain them”. The commission explored the levels, sectors and complexity of societal challenges needing evidence; decision-making processes and who decision-makers are; forms of evidence encountered in decision-making; how forms of evidence can be mapped to decisions; the need for high quality local and global evidence; the critical role of system infrastructure for evidence-based decision-making; and the role of evidence intermediaries, public goods and distributed capacity. The report presents recommendations that encompass the framing/approach, structures and processes, accountabilities and funding, together with actions that emerge from these foundations. The document includes 8 main and 24 total recommendations clearly presented in short-form in the executive summary of the report (Table 2). As stakeholders in health in roles that encompass decision-makers, evidence intermediaries and evidence producers, readers may appreciate this report recommendation to all stakeholders: “Citizens should consider making decisions about their and their families’ well-being based on best evidence; spending their money on products and services that are backed by best evidence; volunteering their time and donating money to initiatives that use evidence to make decisions about what they do and how they do it; and supporting politicians who commit to using best evidence to address societal challenges and who commit (along with others) to supporting the use of evidence in everyday life” 6 .
Recommendations by the Global Commission on Evidence promoted by the COVID-19 Evidence Network to support Decision-making (COVID-END) (6). In bold are the eight main recommendations.
Finally, Cochrane 4 published “Cochrane Convenes: Preparing for and responding to global health emergencies. Learnings from the COVID-19 evidence response and recommendations for the future” 7 . This incisive and extensive work captures 3 over-arching reflections that should jolt us all to action: the pandemic-exacerbated pre-existing inequities in society, including social determinants of health, and the evidence response has been globally unequal; the rapidly changing context and rapidly evolving evidence of mixed quality led to particularly challenging communication of the certain and uncertain; and strategies to prevent or disarm misinformation and disinformation were ineffective or insufficient. Three areas for action arise from these lessons learned: the need to incentivise and encourage change at the system level; produce and share research and evidence synthesis; and reflect on communicating uncertainty as well as understand misinformation/disinformation and do something about it (Table 3). Each area has specific strategies that can be implemented by stakeholders. Although the document is more specific about the evidence production and dissemination process, it also takes into account policymaking.
Key recommendations by “Cochrane Convenes (2022): Preparing for and responding to global health emergencies: Learnings from the COVID-19 evidence response and recommendations for the future. ” (7).
Evidence-based medicine (EBM) and evidence-based practice in health are only a few decades old and combine the 3 components of research-based evidence: the clinician’s expertise and the patient’s values and preferences 8 . An essential role of EBM is to strengthen the importance of scientific data in decision-making in medicine, which is increasingly complex given the exponential growth of research and information. How do we identify the best available information? How do we make decisions about the care of individual patients and populations? These are some of the fundamental questions that EBM answers. In this paper, we focus on the first component of the triad: research-based evidence. For all professionals working in health care, EBM makes the basic assertion that we cannot provide quality patient care without evidence. EBM is, arguably, the best way forward for medicine. The importance of evidence is also noted, for example, in the social sciences with the Campbell Collaboration, the social science research network. The documents mentioned above emphasize the need to extend and establish the use of evidence in the process of making policy decisions, particularly, but not limited to, health policy.
EBM in rehabilitation has not always been accepted as the best way forward 9 . Rehabilitation focuses on functioning and is based on conceptual models that are close to the complex bio-psycho-social paradigm. Evidence gathering is complicated, and the conduct of a classical randomized controlled trial (RCT), the gold standard study design for generating evidence in many areas of medicine, may be challenging and in fact unfeasible for many questions in rehabilitation science. Indeed, the RCT is less appropriate when complex interventions and multiple interactions are studied 10 . Additionally, heterogeneity in patient populations can pose difficulties in obtaining a sufficiently powered sample size for an RCT, and recruitment to traditional no-treatment control conditions can be challenging and present ethical concerns. A narrow approach to evidence, based on only RCTs and confusion between the means and the aim, has contributed significantly to the diffidence in rehabilitation science to accept EBM. Other reasons include challenging methodological research issues in our field 11 and the difficulties associated with the reporting of results 12 . Nevertheless, it has become clear that the practice of rehabilitation benefits from and is in need of an EBM approach.
The documents highlighted in this paper call for evidence as the main tool to make decisions about the treatment of health conditions in individuals and populations. This approach to decision-making is becoming clearer to policymakers, too. The documents call us to action or provide the resources to support action for evidence-based decision making in health and in societal challenges that face us locally and globally. We are stakeholders in health and human systems and in the evidence-ecology that have the opportunity to feed into decision-making systems that affect us all. We have to enhance evidence-informed decision-making in our own practice and in the systems in which we live and work. We can be decision-makers or decision intermediaries, adopting or advocating for the specific strategies outlined in sources presented here in practice, policy and education. We can be evidence-producers, advancing the strength and quality of research by asking questions suited to answers that use well-designed randomised controlled designs, primarily because these provide the greatest opportunity for synthesis and uptake in clinical guidelines. When other questions are asked and other research designs are used, we can build capacity to ensure the appropriate interpretation and application of less rigorous findings. Beyond intervention research, rehabilitation systems and services need high-quality evidence to inform the managerial and administrative decision-makers who ultimately control access to and provision of human and infrastructure resources.
The world of rehabilitation cannot afford to do without evidence, nor to remain diffident and passive on this issue. Our campaign to improve evidence in rehabilitation is fundamental to the future of the field, and we need to identify the optimal approach to the generation and utilization of evidence appropriate for rehabilitation. First, wherever appropriate and possible, we need to conduct well-designed RCTs. When RCTs are not appropriate or possible, other types of study designs such as rigorous quasi-experimental and n-of-1 designs can be used depending on the nature of the research question. Second, the 3 documents summarized in this editorial repeatedly stress the need for collaboration. To implement the many strategies and work toward achievement of the many recommendations, we need to champion rehabilitation as an essential, multidisciplinary, collaborative field. In rehabilitation, collaboration is particularly required, and divisions of any type (cultural, professional, and other) interfere with efforts to generate the best evidence and strengthen the field. This emphasis on collaboration includes other fields of inquiry because it facilitates a supportive environment, with evidence guiding discussions and decisions beyond healthcare systems to health policy and other areas important to society.
Rehabilitation as a field and the community of rehabilitation journals are not new to collaborations. Rehabilitation journals have co-published several important papers during the last decade on various topics, including implementation of reporting guidelines 13 and trial repositories 14 , the WHO “Rehabilitation 2030: a call for action” 15 and specific relevant research initiatives 12 . Cochrane Rehabilitation and rehabilitation journals are committed to “collaborate [as] groups that have complementary comparative advantages, and help to build a better evidence-support system . . . and architecture”, “improve the ways in which [we] support the use of best evidence” and to “prepare derivate products communicating what we know in ways that make sense to their target audiences” 5 . Finally, we are also committed to “investing time and resources in science communications on an ongoing basis”, “being alert to – and communicating about – fraudulent trials and studies”, “reducing duplication and research waste”, and “engaging with evidence users to help communicate uncertainty and the evolving nature of the evidence 6 .
This paper is supported and co-published by the following journals, and their Editors in Chief:
Annals of Physical and Rehabilitation Medicine – Dominic Pérennou
American Journal of Physical Medicine & Rehabilitation – Walter Frontera
Developmental Neurorehabilitation – Wendy Machalicek
European Journal of Physical and Rehabilitation Medicine – Stefano Negrini and Giorgio Ferriero
Journal of Occupational Rehabilitation – Douglas Gross
Journal of Rehabilitation Medicine – Kristian Borg and Henk Stam
Musculoskeletal Science & Practice – Ann Moore
Neurorehabilitation and Neural Repair – Randolph Nudo