From Research to Public Policy: An Essential Extension of the Translation Research Agenda

Abstract

Research translation typically includes translation from basic science into clinical research and from clinical research into everyday clinical practice. In this essay, we propose a greater emphasis on applying research findings, both basic and clinical, into effective public policies that promote health. Research can have important influences on policy by providing a scholarly basis for action research, and translation science units within academic health centers are in powerful positions to build bridges between the research and policy making communities to promote the development of evidence based policy. The results will benefit the researcher and the decision maker, as well as the research itself.

Introduction

Facilitating the translation of basic and clinical research into clinical practice and improved population health has become a major goal of the health‐related research enterprise. The original emphasis on supporting “bench to bedside” translation has been expanded to include facilitating applications of basic and clinical research into practice settings and into broader community environments. ¹

In this essay, we emphasize the additional, critical role of public policy in achieving the overall goal of improving the health of individuals and populations by the more effective and efficient application of new knowledge. We suggest that the importance of this effort applies across the full spectrum of research from basic to clinical research, from controlled clinical trials to practice settings, and from clinical practice settings to efforts in the broader community. Although the role of policy has been sporadically included in the translation process, we suggest that its importance mandates greater attention and emphasis.

Why Is Public Policy Relevant to Researchers?

Public policies can be impacted by basic and clinical research findings, and research can be impacted by public policy. Informing public policy is a critical and powerful way of improving the health of individuals and of populations. Lawrence Brown, ² among others, has identified several ways in which research can impact health‐related policy making. These include accurately and objectively documenting the existence, quantifying the extent, and demonstrating the correlates of a problem; analyzing the problem to identify what interventions work and which do not, and identifying undesired and unintended consequences of policy decisions; suggesting or prescribing options to address the problem; and, perhaps most importantly, raising the quality of the debate about health issues to include scholarly evidence as well as anecdotes and biases. ³

The net effect is the promotion of “evidence‐based policy making” ⁴ as a direct analogy to evidence‐based clinical practice. In one survey, ⁵ almost 90% of policy makers and their staff valued researchers’ thoughts on the policy implications of their work. Numerous examples of the meaningful translation of basic, clinical, and health services research into public policy may be cited as indications of the potential of this approach. These include adding measures of the use of angiotensin converting enzyme inhibitors for treating heart failure in pay‐for‐performance physician payment reform models and implementing state mandates for human papilloma virus (HPV) vaccination.

The need for this input will continue to grow at the state and federal levels as new discoveries from translational efforts introduce new challenges to policy and regulation. Policy debates will follow advances in, for example, pharmacogenomics and individualized medicine, ⁶ as well as around efforts to expand access to new and established treatments for, for example, asthma and obesity to improve population health. ¹

On the other hand, public policy can have substantial impacts on the research enterprise. The most direct impact is on financial support from public sources. The level of support is influenced by the general value that policy makers place on research as well as by political forces related to specific topics and proposals. ⁷ Other effects relate to specific areas of research. Recent examples include governmental limits on politically sensitive topics such as stem cell research, on applying results of clinical effectiveness research to health care financing, and on other issues opposed by powerful advocacy groups. ⁸ , ⁹

New policy initiatives can also spur major areas of research, as Medicare and Medicaid programs did for the growth of health systems research and health economics, ² while political controversies can steer investigators away from some topics. ¹⁰ Finally, political forces can use or misuse research results to support policy decisions in unintended or inappropriate ways. ³ , ¹¹ Thus, there is much at stake for all parties.

The Role of Academia

Academic institutions can have a major role in influencing public policy. They have much to gain from public support of research and they have the expertise to promote evidence‐based policy making. They also have the advantage of being generally viewed as well‐informed, objective advisors or “honest brokers,” without a vested interest in the outcomes of a debate as do most other knowledge sources in a political environment. ¹²

Despite the potential values of the linkage between research and the policy making process, research is uncommonly used in making policy decisions. As summarized by Brown, ² “… it must be a very good and rare day indeed when policymakers take their cues mainly from scientific knowledge about the state of the world they hope to change or protect.” The breadth and depth of the gap has been demonstrated by, for example, Soumerai and associates ¹³ in an analysis of the scant use of research data in state Medicaid policy making. Jonathan Lomas ¹⁴ likened the disconnect between research and policy making to the “sound of one hand clapping.”

This disconnect results from factors within universities as well as differences between the “two communities” of researchers and public policy makers. Within many academic health centers, the translation of basic and clinical research into policy has been constrained by the limited value placed on policy analysis and research. It often does not result in the same valued outputs as other forms of scholarship, that is, fewer manuscripts in traditionally accepted journals, fewer grants from established sources, etc., that impact promotion and tenure decisions. ¹⁵ Also, and substantially as a result of the first constraint, faculties commonly do not have the needed skills and knowledge of policy content, the political context in which policies are made, and approaches needed to effectively inform policy makers.

Differences between the goals, needs, and cultures of academia and public policy are also major obstacles to the meaningful use of research in policy making. ¹⁴ , ¹⁶ Policy makers function in a complex environment in which decisions are based on many factors including political and pragmatic pressures, competing priorities, prior commitments to stakeholders, ideologies, values, and economics in addition to the best objective evidence. Policy makers require straight‐forward, practical, and “actionable” results that focus on a specific issue within a short time frame and tthat consider contextual factors such as local relevance, cost, and political acceptability, and they may be forced to act even if the evidence is poor. Researchers, on the other hand, seek to study an intellectually challenging problem thoroughly and examine the complexity of issues without preset time frames to provide rigorous results and creative new approaches to solving problems that withstand the critique of peers. Research findings are commonly not easily accessed by policy makers and, when available, are suffused with technical jargon, statistical estimations, and cautions rather than the clear conclusions and specific recommendations needed by policy makers.

The net effect has been described by Lomas ¹⁷ as “finger pointing,” as policy makers argue that researchers produce an irrelevant and poorly communicated product that is “often the wrong size, needs some assembly, is on back order, and comes in last year's fashion line.” Researchers, in turn, complain that policy makers act on political expediency to produce irrational decisions.

What Can Clinical Translation Science Centers Do?

The National Institutes of Health has, in the past several years, invested heavily in a substantial number of programs within academic health science centers dedicated to the translation effort. These academic units focusing on translational science are in ideal positions to mitigate these deficiencies.

As a central and highly visible group within an academic health center, they can provide a focal point for conducting or proactively supporting, both intellectually and financially, policy‐related activities and developing or providing the requisite skills. And because they bridge, by design, many organizational units, they can harness the expertise of many disciplines with broad perspectives that cross basic, clinical, and health systems research domains to examine a policy issue from many angles. This includes both direct studies of specific issues as well as encouraging the broader exploration of the policy implications of other ongoing basic and clinical research. ³ Many of the barriers within academic institutions related to valuing policy‐related scholarship are similar to those that inhibit other forms of translational efforts such as community‐based research ¹⁵ and that translational science units are intended to address.

While some barriers in the policy community are institutional and may be immutable, others can be approached. Clinical translational units can serve as an institutional form of what has been referred to as a “knowledge broker.” ¹⁷ , ¹⁸ Knowledge brokers act to facilitate the exchange and sharing of knowledge between the producers and the users of research by promoting a better understanding of the goals and cultures of the different groups and by facilitating meaningful interaction between them. They serve as “policy entrepreneurs,” with “sufficient research backgrounds and credentials to understand the culture and methods of the university research organization but who also understand the policy process and can communicate effectively with state policymakers.” ¹⁹

This interaction may take many forms including the role of a cross‐pollinator who has knowledge of many sectors and who can identify opportunities for linkages; a matchmaker who brings knowledge creators and users together; a translator who adapts information for use in other settings; and an articulator of user perspectives who provides feedback about the needs of users to the research community. ²⁰ The units may serve to actively inform policy makers of information relevant to current policy issues, provide “one stop shopping” sites for policy makers with information needs and develop ongoing relationships between groups. The net effect, as described by Lavis, ²¹ is to “collectively create music, not noise, for the select ears of research users.”

Several specific actions have been shown to be successful. ¹⁴ , ¹⁶ , ¹⁷ , ²⁰ , ²² These include, most importantly, building sustained relationships and trust between researchers and policy makers. These relationships include the early and continuous engagement of policy makers in research process from project design through the dissemination of results. Other activities promoting success include developing processes for providing timely, relevant information; synthesizing and disseminating findings into (multiple) formats that are accessible and understandable by policy makers and the broad range of other stakeholders; demonstrating the local applicability of results; and building the capacity of policy makers and staff and media to better use research findings.

Translation units can also promote research on methods to develop evidence‐based policy. That is, they can be involved not only in the translation of science but also in the science of translation. Research on how policy makers make decisions is limited and represents an area for expanded study that can have meaningful implications. ²³ Areas of interest might include developing effective ways to synthesize research findings with the contextual forces relevant to policy makers.

Finally, these academic units can help assure that the university's programs in the policy arena remain academic, that is, based on scholarly approaches to studying public policy issues. ¹⁷ Providing valid data is, as noted above, one of tthe main values of an academic‐policy linkage. And because of the impact that the information may have on policy, accuracy and objectivity is critical. ²⁴

The proposed interaction between researchers and policy makers is not, however, without hazards that must be recognized and minimized. It does require time and effort. Policy‐relevant findings may arouse political sensitivities that conflict with academic freedom and the need for widespread publication, and researchers may fear distorting their research agenda based on short‐term political interests. Thus, the independence of the academic unit government must be maintained. ²⁵ Similarly, the knowledge sharing effort must remain separate from the specific political agendas of the institution related to funding, etc.

Examples exist of successful interactions in which academic health services research centers provide useful information within the United States ¹⁹ and in Canada. ²⁰ , ²⁴ Benefits have accrued to both the researcher and to the decision maker, as well as to the research itself. ²⁴ Clinical translation science units are poised, once they decide to do so, to expand the breadth and scope of this function to the full range of basic and clinical research. The result will be a win‐win solution for both research and health.