Decision Making and Implementation: Is evidence based policydecision making possible

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Decision Making and Implementation Is evidence
based policy/decision making possible?

• Health Technology Assessment Executive Workshop
• Don Juzwishin, Director HTA AHFMR
• October 27 28, 2005
• St. Johns, Newfoundland Labrador

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Background to AHFMR

• Established by Legislative Act 25 years ago
• Endowed capital
• Independent
• supports biomedical and health research at
  Alberta universities, affiliated institutions,
  and other medical and technology-related
  institutions
• Programs HTA, RTNA, SEARCH

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Objectives

• Focus on decision making and implementation
• Using HTA to guide decision making
• Policy alternatives
• Consultation and education consensus building
• Stakeholder involvement

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Objectives

• Implementation
• Social demographic
• Technological
• Economic
• Ethical
• Political
• Legislation regulations
• Environment

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Objectives

• Follow-up and Evaluation
• Is the technology having the intended effect?
• Have there been unforeseen positive and negative
  impacts from the policy?

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How do we define evidence?

• Evidence is information that comes closest to the
  facts of a matter. The form it takes depends on
  context. The findings of high-quality,
  methodologically appropriate research are the
  most accurate evidence. Because research is often
  incomplete and sometimes contradictory or
  unavailable, other kinds of information are
  necessary supplements to or stand-ins for
  research. The evidence base for a decision is the
  multiple forms of evidence combined to balance
  rigour with expediencewhile privileging the
  former over the latter.
• Canadian Health Services Research Foundation

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What knowledge can we draw on?

• An analytical framework for immunization programs
  in Canada
• Erickson, De Wals, Farand
• Conceptualizing and combining evidence for health
  system guidance
• Lomas, Cuyler, McCutheon, McAuley, Law

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Types of Scientific Evidence for
Context-Sensitive Guidance
CHSRF Adapted from Davies, 2005
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Combining Scientific and Colloquial Evidence for
Context-Sensitive Guidance
CHSRF Adapted from Davies, 2005
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What are the barriers to using HTA or other form
of HQE in policy making?

• Politicians perspective
• Displacement of the important with the urgent
• Protection of interests or security
• HQE may not be comprehensible
• Evidence may not exist
• Evidence not contextual
• Separate the signal to noise ratio

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What are the barriers to using HTA or other form
of HQE in policy making?

• Policy maker perspective
• Paying lip service to HQE
• Timelines
• Differing incentives
• Multiple caveats
• Best practice in policy making?
• Speaking truth to power

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What are the barriers to using HTA or other form
of HQE in policy making?

• Researchers perspective
• Misaligned incentives
• No definition of best practice in policy making
• Data inaccessible from government
• Timing
• Focused problem statement

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Is best practice in policy making desirable?
Possible?

• Who thinks it is?
• Not?
• What are the issues?

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Framework for health regions to make optimal use
of HTA

• Structure and process embedded
• Sensitive to needs and priorities
• Integrated into accountability chain
• Figure 5 page 11

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Local HTA A guide

• HTA for RHAs
• Attributes of technologies
• Which technologies need to be assessed?
• Approaches to assessment
• Sources
• Quality of an HTA

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AHFMR Screening Procedure

• Screening process
• Prescreening needs assessment
• Evidence of effectiveness
• Impact on operations
• Financial assessment
• Executive summary

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Bridging the Gap

• Social, cultural system demographics
• Technology effects and effectiveness
• Economic
• Ethics
• Political
• Legislation regulations
• Environment

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Social and system demographics

• Patterns of illness
• population
• Burden of illness
• individual
• Patterns of care
• Cultural factors

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Technology effects and effectiveness

• Conditions
• Effects
• Program context
• Effectiveness

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Economic

• Rewards/costs
• Incentives/disincentives
• Multiplier effect
• Market effects
• Externalities
• Cost and utilization

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Ethics

• Values underlying the issue
• Value conflict
• Picking an alternative
• Identified values
• Common good
• Fairness equity
• Benefit/harm
• Patient choice

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Political

• Government policy
• Role of government
• Priorities for the province
• Health funding policy
• Cross jurisdictional (F/P/T) alignment

• Political analysis
• Problem definition
• Technology as solution
• Other influences
• Stakeholder analysis
• manufacturers
• Providers
• Groups
• Four R Analysis

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Legislation and regulations

• Relevant legislation regulations
• Enabling effects
• Constraining effects
• International agreements
• Emerging legislative constraints or facilitators

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Environment

• Compared to standard treatment
• Social externalities
• Safety issues
• Increased risk
• Energy consumption

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Build in tough challenges

• Relevant
• Timely
• Understandable
• Demonstrate magnitude of effect
• Show offsets to investment costs
• Illustrate budget impact
• Demonstrate patient outcomes
• Show system efficiencies
• Provide options for consideration
• Contextualize for health system realities
• Identify pressures and issues
• Demonstrate a high conversion rate from evidence
  based analysis to policy and
• Be transparent of stakeholder involvement.
• Ontario Health Technology Advisory Committee
  (HTPA)

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What are the lessons?

• The fact value distinction needs conciliation
  deal with it
• Not all evidence is created equal
• Examine standards of best practice in health care
  policy making

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Questions
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References

• L.J. Erickson, P. De Wals, L. Farand. An
  analytical framework for immunization programs in
  Canada.Vaccine. 2005 Mar 3123(19)2470-6.
• J. Lomas, T. Culyer, C. McCutcheon, L. McAuley,
  and S. Law, Conceptualizing and Combining
  Evidence for Health System Guidance, CHSRF, May
  2005.
• J. Brehaut, D. Juzwishin, Bridging the Gap The
  use of research evidence in policy development,
  AHFMR, September 2005.