This book represents a now historical ethnographic account of a particular time in which the Ontario Stroke Strategy (OSS) was being implemented in Ontario, Canada, with the explicit aim of âimproving best practice care across the continuumâ.1 It offers an explication of how the discourses of both evidence-based medicine (EBM) and knowledge translation (KT) were institutionalized in the OSS. At the time, the rising emphasis on knowledge translation was relatively new. It has since become firmly enshrined across all aspects of health research funding, clinical care guidelines and government policy. While the terms used to describe KT have multiplied and evolved, many of its key features arguably remain the same in the more contemporary practices of EBM. I theorize it then and now as a text that is the managerial arm of EBM.
Health care in Canada, at the time of this study, was in a particular era of emphasis on change and improvement (Health Canada, 2003; Health Council of Canada, 2008). The concurrent sense of urgency around implementing best evidence care could be read in both medical and media accounts calling for greater investment by governments in health care research (Rosenberg, 2003). There was a growing accumulation of scientific and medical evidence and information technologies to help both spread and monitor new evidence, and a focus on developing strategies to urge physicians to implement research findings in their practice. Some critical scholars have argued that inherent in this movement was the implicit idea that science can perfect the delivery of medicine through ever more sophisticated drugs and treatments (Traynor, 2002; Walker, 2003).
This focus on change and improvement arose at least in part from the rise of evidence-based medicine. For the past several decades, the field of medicine has been dominated by what has been commonly referred to as the Evidence-based Medicine (EBM) movement. The basic premise of EBM is that by using methods of scientific and epidemiological inquiry, clinicians can deliver best practice medicine. Best practice refers to interventions that are based on results from research that range in hierarchy from meta-analyses of double-blinded randomized controlled trials (RCTs), considered to produce gold standard evidence, to anecdotal or clinical experience. However, as one author has noted, âThe term hierarchy of evidence is a misnomer; the hierarchy is actually a hierarchy of methodologies. That is, it focuses not on the actual results of a particular study or group of studiesâin other words, on the evidence they provide for the efficacy of a treatmentâbut on how that evidence was obtainedâ (Bluhm, 2005, p. 536). The promise of evidence-based medicine is that it will improve health outcomes for patients. As defined in the literature, the problem arises when individual physicians do not implement best practices in their delivery of care (Cabana et al., 1999; Davis et al., 2003; Graham et al., 2006).
Further, patients and their families are said to have a right to this best evidence treatment (Rosenberg, 2003). To withhold best practice care is considered unethical and uncaring (Davis, 2006; Graham et al., 2006; Grimshaw, Santesso, Cumpston, Mayhew, & McGowan, 2006). Strategies developed with a clear aim to change individual physician behaviour (Armstrong, 2002). Some of these studies focused on physician compliance (Cass, Smith, Unthank, Starling, & Collins, 2003) or adherence (Gifford et al., 1999) and discussed the dilemma of how to change physician behaviour (Lucas et al., 2004). These efforts uncritically accepted that physicians should change their practice based on evidence.
Added to this, there was and is pressure on cliniciansâphysicians, nurses, physiotherapists and other allied health professionalsâto also become scientists, to become involved in the production and implementation of new and even better knowledge. The notion that research plays a key role in improving the health of Canadians became increasingly accepted. Rarely were questions asked regarding how patientâs participation in clinical research affects their care. As Mykhalovskiy and Weir note, âEvidence -based medicine creates a demand for clinical trials and thus the recruitment of patients into these trials. What are the effects of the evidence-based market in clinical trials on patients, on physicians and on health care?â (Mykhalovskiy & Weir, 2004, p. 1066).
Although there have been many social science critiques of EBM,2 and many excellent ones since the time when this study was originally conducted (e.g., Greenhalgh, Howick, & Maskrey, 2014), few studies had empirically studied the social organization of best practice care from a physician standpoint. Through my work, I introduce the Ontario Stroke Strategy3 as formal medical policy that has been realized in varying institutional and regional settings. What I discovered provides something beyond dichotomous arguments for and against the uses of evidence and beyond abstract theories about how to disseminate evidence to physicians or encourage them to change; instead, I examine what physicians actually do in the everyday worlds of delivering care and making decisions. I began to understand the forms of coordination across different sites that produced variation in care. What emerged consistently from the accounts I gathered is that stroke care was coordinated in ways that often overlooked the everyday conditions under which the individual physician was working. And this coordination masked particular institutional interests that determined the delivery of this acute treatment rather than individual decision-making.
Eccles and Mittman (2006) have described Implementation Science as âthe scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health servicesâ. Yet this definition overlooks how health care is coordinated in such a way that, despite many cliniciansâ commitment to prevention and better integration with public health , the majority of funds are directed towards acute care and post-event pharmaceutical therapies. In my work, variation in practice and local context become more than just problems to be solved, but reflected that the narrow band of strategies for which we have evidence does not align with the full range of work that is being provided, or needs to be provided, in hospitals and in the community on an everyday basis. It also begins to identify priorities at the level of hospitals, governments and health charities that are not visible within the stated public claims of âimproving equitable access to care across the continuumâ.
Stroke care was the case through which I studied the complex regime that organizes physicianâs practices in relation to best practice care. Since 1995, the use of a drug known as rt-PA has been defined as best practice for acute stroke treatment. Prior to this, little could be done on an emergency basis to assist the recovery of patients who had suffered an acute stroke. This changed when a drug study produced gold standard evidence that when thrombolytic therapy (rt-PA) was administered to ischemic stroke patients, a benefit could be seen.4 Experimental results showed that this therapy potentially had the power to halt and even reverse the life-altering neurological damage caused by ischemic stroke. Occasionally it produced an immediate benefit; more usually, this benefit takes place over time. Nevertheless, its potentially transformative effect continues to be likened to the Lazarus Effect by some stroke specialists.5 There are, however, risks involved in administering it: it carries a 6 per cent fatality rate. In 1999, when rt-PA became established as best practice care for acute stroke in Canada, an infrastructure was created in Ontario to bring it into practice. Promotion of the utilization of rt-PA for acute stroke was accomplished through the development of the Ontario Stroke Strategy, a joint initiative between the Ontario Ministry of Health and Long-Term Care (MoHLTC) and the Heart and Stroke Foundation of Ontario. Through a model that involved creating Regional and District Stroke Centres, best practice care was to be standardized across the province.
A distinctive feature of rt-PA is that eligibility for treatment is determined in relation to the time between possible treatment and the onset of stroke. In addition, only patients with ischemic (rather than haemorrhagic) stroke can be treated, since rt-PA can cause fatal bleeds. A computed tomography (CT) scan must be takenâand professionally readâin order to determine the patientâs type of stroke. This involves both technology (the scan itself must be available 24/7) and human resources (radiologist to read the scan). At the time of my study, a core criterion for treatment was stroke onset of less than 3 hours before rt-PA was administered (this time window has been increased to 4.5 hours on the basis of tw...