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Evidence-based medicine (EBM) and evidence-based decision-making (EBDM) were intended to revolutionize health care and health policy. Thus far they have not. A great deal of research has demonstrated the persistent ubiquity of error in health care, wide and unjustifiable variations in practice and the minimal impact of decision aids such as clinical practice guidelines. This paper attempts to explain why EBM and EBDM have remained largely unrealized ambitions. It advances 10 propositions that together constitute a general theory of indifference to research-based evidence. Some of these propositions are conceptual (e.g. the epistemic resistance to the randomized trial), some are empirical (e.g. the impact of the corruption of science by industry), some are cognitive (e.g. human problems are holistic while science is typically fragmented and narrative free) and some are normative (e.g. the primary goal is not adherence to methods, but to make better decisions with better outcomes, irrespective of their origins). EBM and EBDM over-reached, and their failure was, as a consequence, inevitable. However, with corrective action on a number of fronts, research-based evidence can and should be more influential. The first step is to reconceive EBM and EBDM as habits of mind rather than a toolbox and to recognize that the sociology of knowledge is as important as its technical content. [ABSTRACT FROM AUTHOR]

Reports on health care in Canada as of October, 2001. History of Medicare which was founded on principles of universality, accessibility, comprehensiveness, portability, and public administration; View that the system has deteriorated from an icon of Canadian values and organisational know how to an apparent state of crisis; Proposed reasons for the deterioration, including less federal funding for the system; Impact of privatization.

Interpretation: Members of Saskatchewan district health boards supported the general goals of health care reform and believed that changes already undertaken had been positive. There were few major differences in views between appointed and elected members and between provider and nonprovider members. However, tensions related to authority and representation will require resolution. [ABSTRACT FROM AUTHOR]

Comments on the proper management of medical waiting lists. Importance of fairness or equity in the organization of waiting lists; Availability of information to determine priority of needs; Standardization of concepts and terms; Audit, evaluation and quality control; The meaning and value of waiting time; Preference for systemic solutions, rather than isolated solutions; View of public ownership of lists.

Argues that the Canadian medical profession has failed to provide adequate support for public medical care in relation to the Supreme Court decision of June 9, 2005. Comment on the support of the provision for single-tier health care; Areas in the Canadian health care system that need reform; Factors which contribute to the poor performance of organized medicine in the country.

The author comments on the article "Communicating Evidence-Based Information on Cancer Prevention to State-Level Policy Makers," by R. C. Brownson, E. A. Dodoson et al., published within the issue. He claims that the study did not fully achieve its aim of contributing to the understanding of how research affects policy makers. He notes that this is due to design issues such as choice of subject matter of the policy briefs and the definition of the word "use" in the study, as well as a lack of critical depth.

Looks at the status of the health care system in Canada. Allegation that the country's health care system as of 2004 is unsustainable; Identify the areas of the country's health care system that are performing excellent; Suggestion on how to tackle the problems or flaws of the country's health care system.

Argues that federalism in Canadian health care can improve the system. Belief of many politicians that federalism has failed; Suggestion of ways to improve federalism, including increased spending by Ottawa on health care; Perceived failure of provincial initiatives to unify health care.

Offers observations on studies of Canadian clinical practice guidelines (CPGs). Reference to an article by Graham et al in this issue; Use of the Appraisal Instrument for Clinical Guidelines to assess CPGs; Suggestion that all CPGs should be judged more on the basis of the quality of their recommendations than on the explicit processes of their creation; Conclusion that there should be one nationally-produced and federally-funded guideline for each area.

Editorial. Discusses research which studied international variations in medical practice. Research by Lavis et al in this issue; Why medical practice changes; Questions raised by study; Defining better health care; Cultural differences; Comparison between Canada and the United States; Distributive justice of Canadian health care; Health care growth in US; Health care payment systems; Future of small-area variation research.

Context: An evidence base that addresses issues of complexity and context is urgently needed for large-system transformation (LST) and health care reform. Fundamental conceptual and methodological challenges also must be addressed. The Saskatchewan Ministry of Health in Canada requested a six-month synthesis project to guide four major policy development and strategy initiatives focused on patient- and family-centered care, primary health care renewal, quality improvement, and surgical wait lists. The aims of the review were to analyze examples of successful and less successful transformation initiatives, to synthesize knowledge of the underlying mechanisms, to clarify the role of government, and to outline options for evaluation. Methods: We used realist review, whose working assumption is that a particular intervention triggers particular mechanisms of change. Mechanisms may be more or less effective in producing their intended outcomes, depending on their interaction with various contextual factors. We explain the variations in outcome as the interplay between context and mechanisms. We nested this analytic approach in a macro framing of complex adaptive systems (CAS). Findings: Our rapid realist review identified five 'simple rules' of LST that were likely to enhance the success of the target initiatives: (1) blend designated leadership with distributed leadership; (2) establish feedback loops; (3) attend to history; (4) engage physicians; and (5) include patients and families. These principles play out differently in different contexts affecting human behavior (and thereby contributing to change) through a wide range of different mechanisms. Conclusions: Realist review methodology can be applied in combination with a complex system lens on published literature to produce a knowledge synthesis that informs a prospective change effort in large-system transformation. A collaborative process engaging both research producers and research users contributes to local applications of universal principles and mid-range theories, as well as to a more robust knowledge base for applied research. We conclude with suggestions for the future development of synthesis and evaluation methods. [ABSTRACT FROM AUTHOR]