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eCAM Advance Access originally published online on December 1, 2006
eCAM 2007 4(3):279-285; doi:10.1093/ecam/nel079
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© 2006 The Author(s).
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.0/uk/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Commentary

Evaluating Complex Healthcare Systems: A Critique of Four Approaches

Heather Boon1, Hugh MacPherson2, Sue Fleishman3, Sameline Grimsgaard4, Mary Koithan5, Arne Johan Norheim6 and Harald Walach7

1University of Toronto Canada, 2University of York UK, 3Oregon College of Oriental Medicine USA, 4University Hospital of North Norway Norway, 5University of Arizona USA, 6National Research Center in Complementary and Alternative Medicine, University of Tromsø Norway and 7University of Northampton UK

The purpose of this paper is to bring clarity to the emerging conceptual and methodological literature that focuses on understanding and evaluating complex or ‘whole’ systems of healthcare. An international working group reviewed literature from interdisciplinary or interprofessional groups describing approaches to the evaluation of complex systems of healthcare. The following four key approaches were identified: a framework from the MRC (UK), whole systems research, whole medical systems research described by NCCAM (USA) and a model from NAFKAM (Norway). Main areas of congruence include acknowledgment of the inherent complexity of many healthcare interventions and the need to find new ways to evaluate these; the need to describe and understand the components of complex interventions in context (as they are actually practiced); the necessity of using mixed methods including randomized clinical trials (RCTs) (explanatory and pragmatic) and qualitative approaches; the perceived benefits of a multidisciplinary team approach to research; and the understanding that methodological developments in this field can be applied to both complementary and alternative medicine (CAM) as well as conventional therapies. In contrast, the approaches differ in the following ways: terminology used, the extent to which the approach attempts to be applicable to both CAM and conventional medical interventions; the prioritization of research questions (in order of what should be done first) especially with respect to how the ‘definitive’ RCT fits into the process of assessing complex healthcare systems; and the need for a staged approach. There appears to be a growing international understanding of the need for a new perspective on assessing complex healthcare systems.

Keywords: complex interventions – research methods – whole systems research

For reprints and all correspondence: Heather Boon, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, Canada M5S 3M2. Tel: +1-416-946-5859; Fax: +1-416-978-1833; E-mail: heather.boon{at}utoronto.ca

Received January 16, 2006; accepted September 25, 2006


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