INFORMED DECISION-MAKING :

1. INFORMED DECISION-MAKING: FROM KNOWLEDGE TO WISDOM IN POLICY Stephen Birch McMaster University Hamilton, Ontario.

2. KNOWLEDGE TRANSFER Positive analysis: Do decision-makers use knowledge derived from scientific research? Do scientific researchers address questions that decision-makers face? Normative analysis: Should decision-makers use knowledge derived from scientific research? Should scientific researchers addresses questions that decision-makers face?

3. RESEARCH-POLICY INTERFACE • Emphasizes how to transfer not what to transfer Driven by intellectual curiosity of researcher Is this effective (on average in study subjects) • Decision-maker’s needs Determinants of effectiveness Under what conditions is policy more likely to work What policies work under particular conditions • Conditions, circumstances, contexts noise or confounding to researchers substance to decision-makers • Behaviour change need knowledge on what determines behaviour and role of information on behaviour change

4. KNOWLEDGE FROM SCIENTIFIC RESEARCH • Is it relevant to decision-maker’s problem? Is the research question the same as the policy question the decision-maker needs answered? • Is it understood by decision-maker? • Is it considered in decision-making process? • Is it used to determine decisions? Relationship between knowledge and behaviour Role of values

5. RESEARCHER INTERESTS, RESEARCH PARADIGMS AND VALUES • Measuring effectiveness: 5 year survival surviving one day or 4 years and 364 days makes no difference surviving 5 years and surviving 20 years makes no difference • Comparison of survival on average in two groups with similar distributions of characteristics Relative survival among people like me? Simpson’s Paradox • Choose to study what we are paid to study The amazing success of the Beta blocker

6. SIMPSON’S PARADOX: EFFECTIVENESS REVERSAL Condition A Condition B Subjects 200 200 rich (n/treatment/control) 40/20/20 160/80/80 poor 160/80/80 40/20/20 Outcomes (years of survival) 900 880 rich 100 640 poor 800 240 Effectiveness (years/n) 9 8.8 rich 5 8 poor 10 12

7. EFFECTIVENESS OF PROPANALOL: FINDINGS OF AN RCT (Ruberman et al NEJM 1984) Outcome 3 year mortality post myocardial infarction Clinical: Propanolol 9% Placebo 12% (p<0.05) Education: High 6% Low 13% (p<0.05) Stress and social isolation: Low 2% High 14% (p<0.05)

8. DO PRACTICE GUIDELINES GUIDE PRACTICE?(Lomas et al NEJM 1989) Evidence-based guidelines: repeat cesarean section: Clinicians survey: 90% received and 85% agreed with guidelines 33% would change practice, rest already in line Clinical audit: Baseline cesarean rates higher than self reports No significant reduction post guidelines Knowledge transfer focussed on effectiveness of procedure not behaviour change of provider

9. KNOWLEDGE TRANSFER IN THE ROMANOW COMMISSION: HOSPITAL OWNERSHIP • 95% hospitals in Canada private not for profit (PNFP) but publicly funded • Provinces considering private for profit (PFP) • Devereaux et al (CMAJ 2002): Effect of PFP (cf PNFP) on patient mortality • Meta analysis (n=15) RR death PFP = 1.02 • “PFP results in higher risk of death” • “Policy makers should take this into account”

10. KNOWLEDGE TRANSFER IN THE ROMANOW COMMISSION: HOSPITAL OWNERSHIP Informing decisions or supporting ideology? • All 15 studies from USA • PNFP hospitals in US and Canada differ Excludes public hospitals in US PNFP in Canada are ‘private’ in name only Purchaser-funding arrangements differ Knowledge acquired: For a population like the US, with access to care based on ability and willingness to pay, and three distinct types of hospital ownership, for those with access to private hospitals, patient mortality is higher in for profit hospitals

11. PHYSICIAN PAYMENT REFORM IN CANADA(Birch et al. 1994, Hutchison et al 1996) • KT: Lower rates of patient hospitalisation among family physicians paid capitation compared to Fee for Service (FFS) • Action: Ontario committed to shifting physician off FFS for Service to reduce hospital costs Decision-maker needs: How does switching from FFS to capitation lower a physicians practice style? Physician selection explained observed rates No change in hospitalisation rates Findings specific to levels of capitation and FFS

12. HEALTH INEQUALITIES IN UK(Birch 2000) KT: Acheson et al. (1998) presented 39 evidence- based policies for reducing inequalities • None of the evidence reported on impact of policy on inequalities in health • Information related (at best) to impact on individual health • Health impacts based on studies of non-poor populations Marmot (2010) found inequalities in health haven’t reduced

13. EVIDENCE-BASED DECISION MAKING FOR DRUG FORMULARIES (Birch and Gafni 2006) KT: Cost-effectiveness ratios for new drugs - compares new drug with existing drug for same patient group • New drug costs more than existing drug so decision maker does not face choice between new and old drug • Evidence ignores opportunity cost of new drug • By calculating ratio ‘evidence’ discards information relevant to decision maker (total costs and effects) • Using ‘knowledge’ has led to increased costs and no evidence of increased health gains

14. ENDARTERECTOMY FOR CAROTID STENOSIS:THE NASCET TRIAL (Haynes et al JAMA 1994) • KT: Structured abstract: “Carotid endarterectomy reduced the risk of stroke” • No qualifications to this statement • One sixth of the main text devoted to the ‘special circumstances’ (highly selected patients, providers, centres) associated with the trial

15. KEY MESSAGES FOR KT • Research focused on how to transfer as opposed to what to transfer Decision-makers ought to use the information generated by scientific research • Information is just one of many determinants of behaviour Role of information in behaviour change So what constitutes effective KT? • Reflects the intellectual curiosity of researchers as opposed to the needs of the decision maker What works on average in setting/population versus what works best for my setting/population