John Øvretveit's latest book offers a clear and comprehensive introduction to health care evaluation. While it is certainly a book you will want to keep on your shelf and dip in and out of frequently, it is important to first carefully digest the text in its entirety. As Øvretveit points out, what author would agree that you only need to read part of what he has written?
Part 1 introduces the reader to the concept of health care evaluation. Topics such as why do evaluations, tools for evaluation, how to plan and carry out an evaluation are all covered in this section. A final chapter on design explains the differences between types of research, breaking these down into the three broad categories of experimental and quasi-experimental, observational and action. These are explained in some detail that includes the benefits and detriments of each category.
Part 2 provides examples of evaluations and asks the question “Does it work?” Øvretveit reminds us that there are many outcomes to any intervention, some intended and some not. These may be either beneficial, or detrimental but need to be considered when evaluating health care interventions. Chapters in this section discuss evaluations to service users, to health professionals, to health institutions and to whole health care systems. Examples are given and the evaluations themselves are evaluated or critiqued. An example is the Guatemalan doll therapy (GDT) for insomnia. The precept is that telling one's troubles to a tiny doll before bed, and then placing the doll under one's pillow can improve length of uninterrupted sleep. A trial was set up in which 17 people experiencing insomnia participated. Participants followed instructions and results were measured in the fifth week of the trial. Totally, seven out of 17 participants, or roughly 41 percent reported an improved length of uninterrupted sleep. While this might seem to be a moderately successful result, the author explains how this trial could have been improved. Identifying a clear hypothesis, setting stricter parameters for sleep improvement, exploring how the treatment worked, are all aspects that would have created a more robust evaluation.
Part 3 tackles the problems of implementation. Evaluation of interventions is all well and good; however, it is the implementation of interventions that have been evaluated as beneficial that actually changes health outcomes. Three major factors in implementation are identified. The first of these is how to enable change. We might know, for instance, that people who exercise have better long-term health outcomes. The question is how do health professionals actually motivate people assessed as needing exercise to participate? The second factor is the digital revolution. People now Google information about their health care concerns. Digital records alleviate the need for paper files. Medical devices are “smart” and require less human intervention to function efficiently (dependent on correct programming). Digital health technologies (DHT) continue to affect the way health care is perceived, accessed, delivered and evaluated. The final factor affecting health implementation is money. Scarce resources often limit the type and scope of interventions available and this can vary widely from location to location. Some interventions designed to save money for health care providers might demonstrate theoretical budgetary improvements, but do these translate to real-time savings? For instance, an intervention designed to send patients home early might be cost effective in terms of freeing up blocked beds, but might there be other long-term consequences that are more costly? Øvretveit explores how these different aspects can be evaluated to determine the true costs of health interventions.
This book belongs on the bookshelf of every health professional and health care manager. More importantly, it should be taken off the shelf frequently and referred to whenever health interventions are being planned or evaluated. I will certainly introduce this text into my pre-registration and post-graduate health professional teaching as I predict that Evaluating Improvement and Implementation for Health will become a seminal text on the topic and will be used as reference material for years to come.
