Le rôle de l’évaluation économique dans la pratique des médecins de famille = The role of economic evaluation in the practice of family physicians

L’évaluation économique en santé consiste en l’analyse comparative d’alternatives de services en regard à la fois de leurs coûts et de leurs conséquences. Elle est un outil d’aide à la décision. La grande majorité des décisions concernant l’allocation des ressources sont prises en clinique; particulièrement au niveau des soins primaires. Puisque chaque décision est associée à un coût d’opportunité, la non-prise en compte des considérations économiques dans les pratiques des médecins de famille peut avoir un impact important sur l’efficience du système de santé. Il existe peu de connaissances quant à l’influence des évaluations économiques sur la pratique clinique. L’objet de la thèse est de comprendre le rôle de l’évaluation économique dans la pratique des médecins de famille. Ses contributions font l’objet de quatre articles originaux (philosophique, théorique, méthodologique et empirique). L’article philosophique suggère l’importance des questions de complexité et de réflexivité en évaluation économique. La complexité est la perspective philosophique, (approche générale épistémologique) qui sous-tend la thèse. Cette vision du monde met l’attention sur l’explication et la compréhension et sur les relations et les interactions (causalité interactive). Cet accent sur le contexte et le processus de production des données souligne l’importance de la réflexivité dans le processus de recherche. L’article théorique développe une conception nouvelle et différente du problème de recherche. L’originalité de la thèse réside également dans son approche qui s’appuie sur la perspective de la théorie sociologique de Pierre Bourdieu; une approche théorique cohérente avec la complexité. Opposé aux modèles individualistes de l’action rationnelle, Bourdieu préconise une approche sociologique qui s’inscrit dans la recherche d’une compréhension plus complète et plus complexe des phénomènes sociaux en mettant en lumière les influences souvent implicites qui viennent chaque jour exercer des pressions sur les individus et leurs pratiques. L’article méthodologique présente le protocole d’une étude qualitative de cas multiples avec niveaux d’analyse imbriqués : les médecins de famille (niveau micro-individuel) et le champ de la médecine familiale (niveau macro-structurel). Huit études de cas furent réalisées avec le médecin de famille comme unité principale d’analyse. Pour le niveau micro, la collecte des informations fut réalisée à l’aide d’entrevues de type histoire de vie, de documents et d’observation. Pour le niveau macro, la collecte des informations fut réalisée à l’aide de documents, et d’entrevues de type semi-structuré auprès de huit informateurs clés, de neuf organisations médicales. L’induction analytique fut utilisée. L’article empirique présente l’ensemble des résultats empiriques de la thèse. Les résultats montrent une intégration croissante de concepts en économie dans le discours officiel des organisations de médecine familiale. Cependant, au niveau de la pratique, l'économisation de ce discours ne semble pas être une représentation fidèle de la réalité puisque la très grande majorité des participants n'incarnent pas ce discours. Les contributions incluent une compréhension approfondie des processus sociaux qui influencent les schèmes de perception, de pensée, d’appréciation et d’action des médecins de famille quant au rôle de l’évaluation économique dans la pratique clinique et la volonté des médecins de famille à contribuer à une allocation efficiente, équitable et légitime des ressources.Health economic evaluations are analytic techniques to assess the relative costs and consequences of health services. Their role is to inform the decision-making process. A vast amount of resource allocation decisions are undertaken at the clinical-encounter level; especially in primary care. Since every decision has an opportunity cost, ignoring economic information in family physicians’ practices may have a broad impact on health care efficiency. There is little evidence on the influence of economic evaluation on clinical practice. The objective of the thesis is to understand the role of economic evaluation in family physicians’ practices. Its contributions are presented in four original articles (philosophical, theoretical, methodological, and empirical). The philosophical article suggests that complexity and reflexivity are two important issues for economic evaluation. Complexity thinking is the philosophical perspective (overarching epistemological approach) underpinning the thesis. This way of thinking focuses attention on explanation and understanding and gives particular emphasis to relations and interactions (interactive causality). This increased emphasis on the context and process of data production highlights the importance of reflexivity in the research process. The theoretical article develops a new and different conceptualization of the research problem. The originality of the thesis also lay in the research problem being approached from the perspective of Pierre Bourdieu's sociological theory. Bourdieu’s approach embraces complexity. Moving away from individualist, rational models of action, it can contribute to a more complete and complex understanding of social phenomena by revealing the structuring effects of social fields on the individual’s dispositions and practices. The methodological article presents the protocol of a qualitative embedded multiple-case study research. There were two embedded units of analysis: the family physicians (micro-individual level) and the field of family medicine (macro-structural level). Eight case studies were performed with the family physician as the unit of analysis. The sources of data collection for the micro-level were eight life history interviews with family physicians, documents and observational evidence. The sources of data collection for the macro-level were documents, and eight open-ended focused interviews with key informants, from nine medical organizations. The analytic induction approach to data analysis was used. The empirical article presents all the empirical findings of the thesis. The findings show an increasing integration of economics concepts into the official discourse of family medicine organizations. However, at the level of practice, the economization of this discourse does not seem to be true depictions of reality as the very great majority of the study participants do not embody this discourse. The contributions include a deep understanding of the social processes that influence family physicians’ schemes of perception, thought, appreciation and action with respect to the role of economic evaluation in their practices, and the family physicians’ willingness to contribute to efficient, fair and legitimate resource allocation

The role of economic evaluation in the decision-making process of family physicians: design and methods of a qualitative embedded multiple-case study

<p>Abstract</p> <p>Background</p> <p>A considerable amount of resource allocation decisions take place daily at the point of the clinical encounter; especially in primary care, where 80 percent of health problems are managed. Ignoring economic evaluation evidence in individual clinical decision-making may have a broad impact on the efficiency of health services. To date, almost all studies on the use of economic evaluation in decision-making used a quantitative approach, and few investigated decision-making at the clinical level. An important question is whether economic evaluations affect clinical practice. The project is an intervention research study designed to understand the role of economic evaluation in the decision-making process of family physicians (FPs). The contributions of the project will be from the perspective of Pierre Bourdieu's sociological theory.</p> <p>Methods/design</p> <p>A qualitative research strategy is proposed. We will conduct an embedded multiple-case study design. Ten case studies will be performed. The FPs will be the unit of analysis. The sampling strategies will be directed towards theoretical generalization. The 10 selected cases will be intended to reflect a diversity of FPs. There will be two embedded units of analysis: FPs (micro-level of analysis) and field of family medicine (macro-level of analysis). The division of the determinants of practice/behaviour into two groups, corresponding to the macro-structural level and the micro-individual level, is the basis for Bourdieu's mode of analysis. The sources of data collection for the micro-level analysis will be 10 life history interviews with FPs, documents and observational evidence. The sources of data collection for the macro-level analysis will be documents and 9 open-ended, focused interviews with key informants from medical associations and academic institutions. The analytic induction approach to data analysis will be used. A list of codes will be generated based on both the original framework and new themes introduced by the participants. We will conduct within-case and cross-case analyses of the data.</p> <p>Discussion</p> <p>The question of the role of economic evaluation in FPs' decision-making is of great interest to scientists, health care practitioners, managers and policy-makers, as well as to consultants, industry, and society. It is believed that the proposed research approach will make an original contribution to the development of knowledge, both empirical and theoretical.</p

Complexity and reflexivity: Two important issues for economic evaluation in health care

Economic evaluations are analytic techniques to assess the relative costs and consequences of health care programmes and technologies. Their role is to provide rigorous data to inform the health care decision-making process. Economic evaluation may oversimplify complex health care decisions. These analyses often ignore important health consequences, contextual elements, relationships or other relevant modifying factors, which might not be appropriate in a multi-objective, multi-stakeholder issue. One solution would be to develop a new paradigm based on the issues of perspective and context. Complexity theory may provide a useful conceptual framework for economic evaluation in health care. Complexity thinking develops an awareness of issues including uncertainty, contextual issues, multiple perspectives, broader societal involvement, and transdisciplinarity. This points the economic evaluation field towards an accountability and epistemology based on pluralism and uncertainty, requiring new forms of lay-expert engagement and roles of lay knowledge into decision-making processes. This highlights the issue of reflexivity in economic evaluation in health care. A reflexive approach would allow economic evaluators to analyze how objective structures and subjective elements influence their practices. In return, this would point increase the integrity and reliability of economic evaluations. Reflexivity provides opportunities for critically thinking about the organization and activities of the intellectual field, and perhaps the potential of moving in new, creative directions. This paper argues for economic evaluators to have a less positivist attitude towards what is useful knowledge, and to use more imagination about the data and methodologies they use.Health economics Complexity theory Reflexivity Economic evaluation in health care

Complex Problems or Simple Solutions? Enhancing Evidence-based Economics to Reflect Reality

• The production of health, illness and recovery in populations is a complex process that embodies a wide range of influences and interactions between influences • Economic evaluation approaches oversimplify the decision-makers' problem by adopting inappropriate research paradigm that ignores the contexts in which health problems are experienced and health care is delivered • Complexity theory provides a basis for studying problems in their contexts and addressing questions about the circumstances under which interventions work best and what works in specific circumstances • Broad-based economic models already exist with the capacity to incorporate complexity

Economic evaluation to inform health care decision-making: Promise, pitfalls and a proposal for an alternative path

Health economic evaluation aims at providing information on the efficiency of interventions. Since the 1980s, there have been major developments in the field, especially in terms of methodologies. As the field has expanded and developed, methodologies have become increasingly sophisticated. In parallel, over the past decade, the conduct of economic evaluations has become more and more institutionalized with, among other things, the creation of the National Institute for Health and Clinical Excellence (NICE) in England and Wales and a growing number of health technology assessment (HTA) agencies around the world. Yet the literature has identified important barriers to the use of economic evaluation in decision-making, among them the difficulty of deciphering economic evaluation research. The way the field expanded has thus created a paradox: whereas economic evaluation is seen as an insightful tool for achieving efficiency in health care, its methodological developments have decreased decision-makers' capacity to use it. In this paper, based on a literature survey, we explore this shift by first analyzing how the field of economic evaluation has developed in recent years. Second, we discuss how economic evaluation information is perceived and used in decision-making. Third, we consider a possible direction for reconciling economic evaluation and decision-making. The originality of this article is that it not only highlights the increasing gap between the aim of economic evaluation and its effective use in decision-making but also proposes, based on existing methodologies, a competing approach to the currently dominant paradigm.Health economics Economic evaluation Decision-making Review

The role (or not) of economic evaluation at the micro level: Can Bourdieu's theory provide a way forward for clinical decision-making?

Despite increasing interest in health economic evaluation, investigations have shown limited use by micro (clinical) level decision-makers. A considerable amount of health decisions take place daily at the point of the clinical encounter; especially in primary care. Since every decision has an opportunity cost, ignoring economic information in family physicians' (FPs) decision-making may have a broad impact on health care efficiency. Knowledge translation of economic evaluation is often based on taken-for-granted assumptions about actors' interests and interactions, neglecting much of the complexity of social reality. Health economics literature frequently assumes a rational and linear decision-making process. Clinical decision-making is in fact a complex social, dynamic, multifaceted process, involving relationships and contextual embeddedness. FPs are embedded in complex social networks that have a significant impact on skills, attitudes, knowledge, practices, and on the information being used. Because of their socially constructed nature, understanding preferences, professional culture, practices, and knowledge translation requires serious attention to social reality. There has been little exploration by health economists of whether the problem may be more fundamental and reside in a misunderstanding of the process of decision-making. There is a need to enhance our understanding of the role of economic evaluation in decision-making from a disciplinary perspective different than health economics. This paper argues for a different conceptualization of the role of economic evaluation in FPs' decision-making, and proposes Bourdieu's sociological theory as a research framework. Bourdieu's theory of practice illustrates how the context-sensitive nature of practice must be understood as a socially constituted practical knowledge. The proposed approach could substantially contribute to a more complex understanding of the role of economic evaluation in FPs' decision-making.Health economics Economic evaluation Decision-making Primary care Knowledge translation Family physicians Bourdieu's theory of practice General practitioners

The administration of diets contaminated with low to intermediate doses of deoxynivalenol and supplemented with antioxidants and binding agents slightly affects the growth, antioxidant status and vaccine response in weanling pigs

This study aimed to evaluate the impact of grading levels of deoxynivalenol (DON) in the diet of weaned pigs, as well as the effects of a supplementation with antioxidants (AOX), hydrated sodium calcium aluminosilicates (HSCAS) and their combination on the growth, antioxidant status, immune and vaccine response against the porcine reproductive and respiratory syndrome virus (PRRSV) and porcine circovirus 2 (PCV2). At weaning, 336 piglets were allocated to six dietary treatments according to a randomized complete block design. Treatments were as follows: basal diet (CTRL); basal diet containing DON at 1.2 mg/kg (DON1.2); basal diet containing DON at 2.4 mg/kg (DON2.4); DON2.4 diet + a mix of AOX which included vitamins A and E at 20,000 IU and 200 IU/kg feed respectively, selenized yeast at 0.3 mg/kg and a grape seed extracts at 100 mg/kg feed (DON2.4+AOX); DON2.4 diet + modified HSCAS at 1 g/kg (DON2.4+HSCAS); DON2.4+AOX+HSCAS. Pigs were vaccinated against PRRSV and PCV2 at 7 d; at 0, 14 and 35 d growth performance were recorded, and blood samples were collected in order to evaluate the oxidative status, inflammatory blood markers, lymphocyte blastogenic response and vaccine antibody response. Increasing intake of DON resulted in a quadratic effect at 35 d in the lymphocyte proliferative response to Concanavalin A and PCV2 as well as in the anti-PRRSV antibody response, whereas the catalase activity decreased in DON2.4 pigs compared to the CTRL and DON1.2 groups (P ≤ 0.05). Compared to the DON2.4 diet, the AOX supplementation slightly reduced G:F ratio (P = 0.026) and increased the ferric reducing ability of plasma as well as α-tocopherol concentration (P < 0.05), whereas the association AOX+HSCAS increased the anti-PRRSV IgG (P < 0.05). Furthermore, the HSCAS supplement reduced haptoglobin levels in serum at 14 d compared to the DON2.4 group; however, its concentration decreased in all the experimental treatments from 14 d to 35 d and particularly in the DON2.4+AOX pigs, whereas a different trend was evidenced in the DON2.4+HSCAS group, where over the same period haptoglobin concentration increased (P < 0.05). Overall, our results show that the addition of AOX and HSCAS in the diet may alleviate the negative effects due to DON contamination on the antioxidant status and immune response of vaccinated weanling pigs