This issue of the Quarterly begins with “Knowledge Exchange Processes in Organizations and Policy Arenas: A Narrative Systematic Review of the Literature,” by Damien Contandriopoulos, Marc Lemire, Jean-Louis Denis, and Émile Tremblay. In recent years, the Quarterly has published several articles related to this topic (see appended table). Here these authors synthesize some 205 publications on the translation of knowledge into action. They identified these articles in a snowball sampling process that began with the identification of thirty-three seminal publications in several bodies of literature, including debates about the role of the social sciences in society, studies of the use of evaluation results, studies of the clinical use of evidence-based medicine, research on the use of information by interest groups in the policymaking process (lobbying), and work on networks and the circulation of information in policymaking processes.

The authors’ overall goal is to provide an integrated model to understand and analyze knowledge exchange processes in policy development. They discuss the forms of knowledge exchange, the nature of the knowledge that is exchanged, and what it means for knowledge to be used in a shared or collective fashion. Their argument is that the extent to which knowledge is translated into action—moving from an individual to a collective form—is influenced by three sets of contextual factors: the degree of political polarization related to the topic, the cost and value of the use of information, and institutionalized communication processes. They conclude that the effectiveness of knowledge exchange strategies depends heavily on contextual factors.

This article by Contandriopoulos and his colleagues provides a jumping off point for two commentaries, the first of which is entitled “History Matters for Understanding Knowledge Exchange” by Daniel M. Fox. Fox contends that knowledge workers and policy workers do not necessarily have different values or career paths. He suggests that historical accounts (primarily in the form of books) of policy development offer a much richer understanding than that gained from a systematic review of the largely article-based literature on knowledge transfer (see Fox 2010). However, such accounts do not lend themselves well to systematic review.

The second commentary, by Trisha Greenhalgh, addresses the question “What Is This Knowledge That We Seek to ‘Exchange’”? She analyzes how knowledge may differ from data, information, evidence, and experience, and she reminds us of seminal work on the nature of knowledge (and whether it is personal or collective) from philosophers such as Polanyi and Wittgenstein (Tsoukas and Vladimiros 2001). Calling knowledge “the capacity to exercise judgment,” Greenhalgh suggests that it involves the ability to draw distinctions and its location within a domain of action (e.g., a scholarly or policymaking context). She also calls attention to work by Van de Ven and Johnson (2006), who, in considering the relationship between theory and practice, proposed that knowledge “emerges dialectically when academics and practitioners or policymakers converge to address a problem.” Finally, Greenhalgh questions whether “translation” and “exchange” are the best metaphors for analyzing the evidence-practice challenge in health care.

The next article in this issue of the Quarterly is a systematic review entitled “The Influence of Context on Quality Improvement Success in Health Care.” Written by Heather Kaplan, Patrick Brady, Michele Dritz, David Hooper, W. Matthew Linam, Craig Froehle, and Peter Margolis, it focuses on forty-seven articles reporting on factors (more than 300) examined in quantitative studies as possible influences on whether quality improvement (QI) efforts have been successful. They found that sixty-six different contextual variables have had a statistically significant effect on at least one measure of QI. Kaplan and her colleagues grouped the evidence (both positive and negative) into several categories of contextual factors, including environmental (e.g., competitiveness of the market), organizational (e.g., leadership from top management or governing boards), the support and capacity for quality improvement (e.g., funding and the presence of a data infrastructure), microsystem factors (e.g., physician leadership), and aspects of the QI team itself. After summarizing the strength of support for the different contextual factors studied, Kaplan and colleagues assess the methodological quality of the research that they reviewed, and they point to the need for better and more consistent definitions of contextual factors, research designs that incorporate qualitative as well as quantitative approaches, and the use of theory-based conceptual models.

New research on the much-studied question of the extent to which greater medical spending is associated with positive health outcomes is the subject of the next article. In “Evidence on the Efficacy of Inpatient Spending on Medicare Patients,” Robert Kaestner and Jeffrey Silber look at hospital-level data to examine the effect of spending on the thirty-day mortality of Medicare patients who were admitted to the hospital for any of several medical conditions (acute myocardial infarction [AMI], congestive heart failure, stroke, and gastrointestinal bleeding) or who experienced an in-hospital complication after surgery (general, orthopedic, or vascular). They use an instrumental variable approach to overcome the confounding likelihood that spending should be higher for patients who are sicker, thereby creating a negative relationship between spending and outcomes. Then, framing their analysis in terms of Victor Fuchs’s (1966) conceptualization of flat-of-the-curve medicine, they ask whether additional spending had produced additional health benefits. They find that in most of the conditions studied (AMI was the exception), more hospital spending was associated with lower mortality. Although a study showing that higher spending is associated with better patient outcomes for certain services does not tell us that we can reduce health care spending without adverse consequences, it does sound a cautionary note for arguments that do suggest that.

“Demand and Supply–Based Operating Modes—A Framework for Analyzing Health Care Service Production,” by Paul Lillrank, P. Johan Groop, and Tomi Malmström, uses ideas from operations management that hold that tasks are best managed if they have similar requirements regarding integration, coordination, and control. Malmström and colleagues believe that in health care, the operating modes should reflect both the available supply of services and the demand that arises from the patients’ characteristics and the services they require. Using five classificatory variables—urgency, severity, clarity, continuity, and risk—they propose that seven “demand and supply–based operating modes” should exist in health care. Their terms for these modes are prevention, emergency, one visit, project, elective process, cure process, and care process. Each has its own pattern of managerial issues regarding integration, coordination, and control. The authors’ hope is that this set of demand and supply–based operating modes will be useful in improving both the management of and research on health care organizations.

This issue of the Quarterly concludes with a commentary on the article entitled “Implicit Value Judgments in the Measurement of Health Inequalities,” by Sam Harper and colleagues, which was published in the March 2010 issue (Harper et al. 2010). First, Yukiko Asada, in “On the Choice of Absolute or Relative Inequality Measures,” raises questions about Harper and colleagues’ conclusions about researchers’ choice between absolute and relative measures of inequality. Then, in “We’ll Take the Red Pill,” the authors clarify and reiterate the points made in their original publication.

Bradford H. Gray
Editor, The Milbank Quarterly


Fox, D.M. 2010. The Convergence of Science and Governance: Research, Health Policy, and American States. Berkeley: University of California Press.

Fuchs, V.R. 1966. The Contribution of Health Services to the American Economy. The Milbank Memorial Fund Quarterly 44(4):65–103, Part 2.

Harper, S., N.B. King, S.C. Meersman, M.E. Reichman, N. Breen, and J. Lynch. 2010. Implicit Value Judgments in the Measurement of Health Inequalities. The Milbank Quarterly 88(1):4–29. Available at (accessed October 15, 2010).

Tsoukas, H., and E. Vladimiros. 2001. Organizational Knowledge. Journal of Management Studies 38(7):973–93.

Van de Ven, A., and P.E. Johnson. 2006. Knowledge for Theory and Practice. Academy of Management Review 31(4):802–21.

Recent Milbank Quarterly Articles Related to the Use in Policy of Research-Based Knowledge

1 Chalkidou, K., S. Tunis, R. Lopert, L. Rochaix, P.T. Sawicki, M. Nasser, and B. Xerri. 2009. Comparative Effectiveness Research and Evidence-Based Health Policy: Experience from Four Countries. Milbank Quarterly 87(2):339–67.

2 Coffman, J.M., M.K. Hong, W.M. Aubry, H.S. Luft, and E. Yelin. 2009. Translating Medical Effectiveness Research into Policy: Lessons from the California Health Benefits Review Program. Milbank Quarterly 87(4):863–902.

3 Exworthy, M., A. Bindman, H. Davies, and A.E. Washington. 2006. Evidence into Policy and Practice? Measuring the Progress of U.S. and U.K. Policies to Tackle Disparities and Inequalities in U.S. and U.K. Health and Health Care. Milbank Quarterly 84(1):75–109.

4 Greenhalgh, T., G. Robert, F. Macfarlane, P. Bate, and O. Kyriakidou. 2004. Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. Milbank Quarterly 82(4):581–629.

5 Jacobson, N., D. Butterill, and P. Goering. 2005. Consulting as a Strategy for Knowledge Transfer. Milbank Quarterly 83(2):299–321.

6 Jewell, C.J., and L.A. Bero. 2008. “Developing Good Taste in Evidence”: Facilitators of and Hindrances to Evidence-Informed Health Policymaking in State Government. Milbank Quarterly 86(2):177–208.

7 Kilbourne, A.M., H.C. Schulberg, E.P. Post, B.L. Rollman, B.H. Belnap, and H.A. Pincus. 2004. Translating Evidence-Based Depression Management Services to Community-Based Primary Care Practices. Milbank Quarterly 82(4):631–59.

8 Lavis, J.N., D. Robertson, J.M. Woodside, C.B. McLeod, J. Abelson, and the Knowledge Transfer Study Group. 2003. How Can Research Organizations More Effectively Transfer Research Knowledge to Decision Makers? Milbank Quarterly 81(2):221–48.

9 Lavis, J.N., S.E. Ross, and J.E. Hurley. 2002. Examining the Role of Health Services Research in Public Policymaking. Milbank Quarterly80(1):125–54.

10 Lomas, J., and A.D. Brown. 2009. Research and Advice Giving: A Functional View of Evidence-Informed Policy Advice in a Canadian Ministry of Health. Milbank Quarterly 87(4):903–26.

11 Lomas, J., N. Fulop, D. Gagnon, and P. Allen. 2003. On Being a Good Listener: Setting Priorities for Applied Health Services Research. Milbank Quarterly 81(3):363–88.

12 Mitton, C., C.E. Adair, E. McKenzie, S.B. Patten, and B.W. Perry. 2007. Knowledge Transfer and Exchange: Review and Synthesis of the Literature. Milbank Quarterly 85(4):729–68.

13 Tetroe, J.M., I.D. Graham, R. Foy, N. Robinson, M.P. Eccles, M. Wensing, P. Durieux, et al. 2008. Health Research Funding Agencies’ Support and Promotion of Knowledge Translation: An International Study. Milbank Quarterly 86(1):125–55.

14 Walshe, K., and T.G. Rundall. 2001. Evidence-Based Management: From Theory to Practice in Health Care. Milbank Quarterly79(3):429–57.

15 Whicher, D.M., K. Chalkidou, I.A. Dhalla, L. Levin, and S. Tunis. 2009. Comparative Effectiveness Research in Ontario, Canada: Producing Relevant and Timely Information for Health Care Decision Makers. Milbank Quarterly 87(3):585–606.

Author(s): Bradford H. Gray

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Volume 88, Issue 4 (pages 439–443)
DOI: 10.1111/j.1468-0009.2010.00607.x
Published in 2010