Matrix Evidence

Big Society has become a signature policy of the current administration. While simple definitions are elusive, David Cameron has variously described it in terms of liberalism, empowerment, freedom and responsibility. In the context of delivering health and social care, an Institute for Government seminar concluded that health professionals will have to accept the public’s growing role in determining their own service needs.

But what is the evidence for greater public involvement improving services? Two recent papers provide some interesting insights.

Martin Marshall and Vin McLoughlin of the Health Foundation claim the available evidence does not unequivocally support the assumption that patient choice is a significant driver of quality improvements. Because patients typically do not behave like rational consumers when it comes to their healthcare, current mechanisms for providing them with information on care quality is not proving to be a strong lever for change. Marshall and McLoghlin suggest that changing the way information is presented to the public could change relationships between patients and providers for the better, but is unlikely to lead to improvements in quality of care in the short term.

A systematic review from the RAND Corporation found that while it may have some intrinsic value, there is little evidence to suggest public involvement in healthcare activities has had any positive impact on decision-making or policy. The report suggests that greater public involvement in health decisions may even threaten equitable access to services. It concludes that we in fact know too little about how people become involved as active service users, how the healthcare system influences patient expectations, and the impact of social and political values.

While the rhetoric may be popular, it would appear there is still work to be done in building evidence of effective practice when it comes to involving the public in policy and practice in the healthcare field.

Tags: evidence-based policy, healthcare, medicine, public involvement in policy
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A symposium of the Fifth Annual Scientific Session of the Surgical Outcomes Club in Chicago, Illinois, in October of last year, was dedicated to the topic of comparative effectiveness research in surgery. The symposium served to clarify current thinking about what comparative effectiveness research is, particularly its objectives and methods.

The definition of comparative effectiveness research has evolved with the input of a variety of parties, including the Congressional Budget Office, Office of Management and Budget, and the White House. A working definition has been produced by the Federal Coordinating Council for Comparative Effectiveness Research that you can find here. Briefly, the definition talks about improving health outcomes by ‘developing and disseminating evidence-based information to patients, clinicians, and other decision-makers, responding to their expressed needs, about which interventions are most effective for which patients under specific circumstances’.

Comparative effectiveness research is currently being used in some jurisdictions to make policy and coverage decisions. While policy making and coverage decisions are increasingly made on the basis of research evidence, the evidence on which decisions are made is typically very weak.

Tags: evidence-based policy, medicine, USA
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If you don’t know where you are going, any road will take you there. If you don’t know where you are, you may already be there. Or you may not. – Alice in Wonderland

A great quote that comes from a presentation to the Prince Mahidol Award Conference in January by Dr Téa Collins. In her presentation entitled, ‘Measuring Health Systems Performance: Challenges and the need for more research’, Dr Collins set out the challenges that face researchers in estimating the impact of health systems, including the difficulty of establishing specific contribution of health systems to public health, the long-term nature of some clinical outcomes, and problems of collecting adequately robust data. You can download her slide presentation at the global forum for health website.

Tags: evidence-based policy, medicine
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On 11 June 2009, Dr Margaret Chan, the World Health Organisation (WHO) Director-General, raised the current level of influenza pandemic alert from phase 5 to phase 6, thereby declaring the pandemic (H1N1) 2009.

A Cochrane review published in the British Medical Journal has failed to find robust evidence to support the benefits of making Tamiflu available to healthy adults as a means of reducing the impact of seasonal flu, including swine flu. The findings are particularly germane to the policy adopted by the UK and other governments in relation to widespread vaccination of otherwise healthy adults.

The WHO recommends that the drug be used in groups at risk of complications. These include pregnant women, the elderly, children and those with underlying medical problems. However, both the Cochrane team and the WHO have concluded that there is little evidence to support the policy of mass vaccination of health adults.

Tags: evidence-based policy, medicine
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The Commons Science and Technology Committee held the first evidence session of its inquiry into how the government uses evidence to formulate its policy on homeopathy on Wednesday 25th November 2009.

The Committee exists to ensure that Government policy and decision-making are based on good scientific and engineering advice and evidence.

The inquiry is looking at:
• government policy on licensing of homeopathic products
• government policy on the funding of homeopathy through the NHS
• the evidence base on homeopathic products and services

Witnesses included Professor Jayne Lawrence, Chief Scientific Adviser, Royal Pharmaceutical Society of Great Britain, Robert Wilson, Chairman, British Association of Homeopathic Manufacturers, and Dr Ben Goldacre.

You can watch a video of the proceedings here. It really is gripping viewing for anyone interested in evidence-based practice, and of course exposes the lack of any evidence supporting the efficacy of homeopathic treatments.

Keep an eye out for key points concerning systematic reviews and meta-analyses on about 13 minutes; and some really awful examples of pseudo science presented by representatives of the homeopathy industry.

Tags: evidence-based policy, medicine
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U.S. Preventive Services Task Force have published a report suggesting the policy of recommending routine screening for women aged between 40 and 50 may not be entirely consistent with the available evidence. Their report cited evidence that the potential harm to women having annual screenings beginning at age 40 outweighs the benefits.

“We’re not saying women shouldn’t get screened. Screening does saves lives,” said Diana Petitti, vice chairman of the, which released the recommendations in a paper being published in the Annals of Internal Medicine. “But we are recommending against routine screening. There are important and serious negatives or harms that need to be considered carefully.”

A review of several major studies and a new statistical analysis showed that mammograms produce false-positive results in about 10 percent of cases, causing anxiety and often prompting women to undergo unnecessary follow-up tests, sometimes disfiguring biopsies and unneeded treatment, including surgery, radiation and chemotherapy. Women who have a family history of breast cancer or other risk factors should continue to seek annual screening, doctors said.

However, the findings were not well received by politicians in Washington. The White House responded by saying that despite the evidence cited in the report, the findings were not binding on either physicians or insurers; government insurance programs would continue to cover mammograms for women starting at age 40.
Republicans argued that the recommendations illustrated the dangers of an expanded government role in medical decision making.

The report has brought into sharp focus the sometimes uneasy relationship between evidence and politics, especially when it comes to healthcare in the US. The secretary of health and human services, acknowledged in a statement that the recommendations, had “caused a great deal of confusion and worry.” stressing that the task force “is an outside independent panel of doctors and scientists who make recommendations” and who neither “set federal policy” nor “determine what services are covered by the federal government.”

Tags: evidence-based policy, medicine, USA
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A report from the African Science Academy Development Initiative (ASADI) claims that nearly 4 million deaths among women and children in sub-Saharan Africa could be prevented annually if relatively inexpensive, “science-based health policies” reached 90 percent of families.

The report divides African countries into three categories based on the percentage of births that are overseen by a skilled person, such as a midwife or health worker:

(1) less than 30%;
(2) 30–60%; and
(3) more than 60%.

Improving infectious disease care for children younger than age 5 would save the most lives across all of the categories.

In countries where fewer than 30% of mothers have access to a skilled person to plan their pregnancies, the potential to save lives is considerable. Where levels of skilled attendance at birth are higher, access to emergency obstetric care, such as Caesarean sections and blood transfusions, would make real differences.

And the cost of implementing the recommended policies? From $0.50–$3 per person according to the report’s authors.

This is the first joint policy briefing produced by the initiative. Funded by the Bill & Melinda Gates Foundation, ASADI brings together the science academies of Nigeria, South Africa, Senegal, Ghana, Kenya, Uganda and Cameroon. Roseanne Diab, executive officer of the Academy of Science of South Africa, is quoted as saying “This is a product of Africa, produced by its best and brightest minds”.

Tags: evidence-based policy, medicine
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The sales of antidepressant drugs are rising in most Western countries. The proportion of Americans taking antidepressants in any given year nearly doubled from 1996 to 2005. The figures on volume of sales are similar in the UK. Received wisdom has been that the figures reflect a rise in the number of people diagnosed with depressive illness.

However, a recent paper published in the British Medical Journal suggests that not to be the case. The authors examined medical records from 1.7 million British patients that had visited their family doctors. They found that antidepressant sales rose strongly between 1993 and 2005. However, the rise was not because more people are taking these drugs, but because of an increase in the duration of treatment amongst the antidepressant users. It’s not that more people are taking them, it’s that people are taking them for longer.

The research showed that the rate of diagnosed depression remained steady from 1993 to about 2001, but then fell by about a third in the period to 2005.

Tags: Add new tag, evidence-based policy, medicine
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Health reform is one of the hottest policy debates currently raging in the US. In a recent contribution, Lara Shore-Sheppard argues that which ever side of the debate you favour, one thing is clear: “doing nothing is definitely worse than doing something”.

In a paper published by the National Bureau of Economic Research, Shore-Sheppard looks at the effects of recent Medicaid expansion on a range of factors including the private health insurance market and children’s visits to the doctors.

The paper concludes that so-called ‘crowd out’ effects on the private market are small, and that whilst children with Medicaid cover are more likely to seek medical attention, expanding coverage is no silver bullet.

Shore-Sheppard is clear that research must feed into the policy development process. “It’s not always a seamless transition from research to policy” she says, “but good policy will be based on the evidence that exists.”

Tags: Add new tag, evidence-based policy, medicine
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The death of a pregnant teenager in Scotland from swine flu has brought the issue of policy options to deal with a possible pandemic into sharp relief. This latest death comes as estimates for the number of people contracting swine flu in Scotland suggest cases have risen from 7000 to 12,500 over recent weeks.

Timely then that Carl Heneghan, Deputy Director of the Centre for Evidence Based Medicine, GP and clinical lecturer at the University of Oxford should set out the evidence for policy interventions designed to deal with the possibility of a swine flu pandemic. In brief, the evidence suggests: DO wash your hands regularly, DON’T rely on mass vaccinations or distribution of antivirals; DO extend GP hours to provide daytime emergency cover; DON’T go for mass school closures.

Tags: evidence-based policy, medicine
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