Table 1 Critical Analysis of Tools

Audience

Clinical decision makers/practitioners/policy makers/health consumers

Health care consumers and clinicians providing decision support

Decision makers at provincial, regional and national levels

Local policy makers, community agencies, schools, and non-government organizations

Health professionals, policy makers and health system planners

Objectives

They aim to help people make well informed decisions about health care by preparing, maintaining and disseminating systematic reviews.

Prepare individuals for decision making: help them understand the probable benefits and risks of options, consider the value they place on the benefits and risks, & participate actively with their practitioners in deciding about options

Bring scientific research methods to local government and community levels; build the community voice into planning and good governance

To bridge the gap from evidence to action in reducing health inequalities

To assist in the efficient and effective allocation of health care resources

Strengths

The Cochrane Library now has over 2000 reviews providing high quality, up to date summaries of evidence obtained through a transparent process aimed at avoiding bias.

Improved decision making outcomes (see 'Success')

Representative, community-based cross-design combines qualitative and quantitative data; emphasis on training and capacity building; methods adapted for a wide variety of issues

Actions are based on the best-evidence of interventions

The toolkit is based on a systematic and comprehensive framework for assembling the information on which clinical and health policy decisions about technologies can be based. It is needs-based according to clinical and population health status needs, and therefore not "wants-based" nor driven by the vested interests of health professions, industry, or government

Limitations

Many estimates are of efficacy in ideal situations, not effectiveness in a community setting. Also, only limited numbers of less rigorous non-controlled studies are included.

Most decision aids are web-based which increases universal access, but may limit access for some groups

CIET methods are less useful for rare conditions (cancers, maternal mortality) than for common risk factors or outcomes. Methods require considerable epidemiological analysis skills.

The process of engaging such a diverse range of stakeholders has presented a number of difficulties

The toolkit provides only a selected set of tools. Users must decide whether these tools can be adapted to their own settings and needs.

Success

Examples where Cochrane has been used, including in the policy environment http://www.cochrane.org/reviews/impact/dissemination.htm. For example, a patient directed handout containing information from a Cochrane review of antibiotics and acute otitis media changed prescription rates in a general practice population in south London.

Research shows that DA's: increase patient participation in decision making (without increasing anxiety); improve decision quality (improved knowledge, more realistic expectations, better match between values and choices, lower decisional conflict, fewer undecided, reduce uptake of options patients do not value.

Methods have been used in 48 countries worldwide since 1985; research topics have included corruption in public services, Aboriginal health, prenatal care, landmine awareness and health, and HIV/AIDS and sexual violence.

The Ottawa Equity Gauge iis only 5 years old, but has successfully conducted a study of food security which is being used for advocacy and has recently obtained support for a study of geographic inequalities in food security in Ottawa. There have however been a number of identified successes of the Equity Gauge strategy in other countries where it has been implemented. (McCoy et al 2003

The project's main activity has been dissemination, training and policy dialogue. It is expected that developmental impact will be more apparent in the future because there was and continues to be sustained institutional support for those health professionals who completed their fellowships in Ottawa with the WHO Collaborating Centre for Health Technology. The Tool Kit is incorporated into graduate curricula and course materials. Usability and usefulness for policy-makers is being assessed by focus groups with policy-makers at local and international conferences (2004–2005)

Challenges

Challenges facing the Cochrane Collaboration include its future sustainability, its ability to prioritize reviews, and to further influence consumers, practitioners and policy makers.

Integration into the process of care

Building epidemiology skills. Communicating evidence to decision makers in a way they can understand; logistics of fieldwork in difficult and sometimes dangerous conditions.

Building relationships with community, grass-roots groups and policy and decision-makers is challenging. Also, it is difficult to ensure that community needs remain the main driver of the Ottawa Equity Gauge

Ensuring that the toolkit is updated to reflect new tools available for Health Technology Assessment. Evaluation of the impact of the toolkit.