Finding the Sweet Spot

When you are trying to solve a problem, how do you know what will work? And if the answer isn’t clear, how do you decide what to do? Those questions were asked a lot last week at the 14^thRocky Mountain Workshop on How to Practice Evidence-Based Health Care. And Dr. Tim Byers helped out those of us who were discussing evidence-based public health by drawing a picture. That’s it on the right. (Click on the image to get a closer look.)

Each circle is an approach to solving the same problem - poor oral health, for example, or any other public health problem you want to think about. So the circles might be community programs, or policies, or other activities – anything done to try to solve that problem. Some of these potential solutions have things in common, so the circles overlap. Some are a subset of a broader effort, so they look like a tiny circle inside a big one.

The question is this: which approach works best? The annual workshop provides training on how to find and use evidence to answer that question. It is presented by the Colorado School of Public Health Center for Public Health Practice, and this year nearly 50 people came from across the country to participate in this intensive, hands-on training led by more than 20 tutors who are leaders in the field of evidence-based health care.  Participants included clinical care providers, public health practitioners, research librarians, policy makers, health journalists and others interested in understanding how evidence-based decision making can be used in various health care settings. In broad terms, there are four steps to evidence-based decision making:

• Ask: Frame the question as clearly and specifically as possible so you can identify research evidence that can help answer that question.
• Acquire: Use efficient and systematic search strategies to find evidence that is relevant to your question. (And never underestimate the talents of a librarian!)
• Appraise: Is the evidence strong, or are there reasons to doubt it such as weak study design or high risk of bias? Sometimes there just isn’t very much evidence, or the quality isn’t very good.
• Apply: This is where you use the evidence you did find, and the strength of that evidence, to make your decision. The evidence is only part of the decision, but it is an important part.

And this brings us back to finding the sweet spot in the picture. The evidence might show that some of these approaches don’t work so it won’t be useful to put time and money into those. They are crossed out in green. And even if the evidence isn’t conclusive, it might suggest that some approaches – or combinations of approaches – are particularly promising. That is the sweet spot. There are three of those in the picture, colored in blue. (If you click on the photo to the right you can click through to an annotated version.)

Health topics are usually complicated, and sometimes there is not as much evidence as we would like. But to find the sweet spot, we need to use all the relevant evidence available.