Incorporating evidence and politics in health policy: Can institutionalising evidence review make a difference?

Much of the evidence translation literature focuses narrowly on the use of evidence in the initial policy formulation stages, and downplays the crucial role of institutions and the inherently political nature of policy making. More recent approaches acknowledge the importance of institutional and political factors, but make no attempt to incorporate their influence into new models of evidence translation. To address this issue, this article uses data from a comparative case study of bowel cancer screening policy in Australia, the United Kingdom and New Zealand, to propose alternative models of evidence incorporation which apply to all stages of the policy process.Stacy Carter is supported by a NHMRC Career Development Fellowship (2012-2015) APP103296

'When good evidence is not enough: the role of context in bowel cancer screening policy in New Zealand'.

Bowel cancer is a serious health problem in developed countries. Australia, the United Kingdom (UK) and New Zealand (NZ) reviewed the same randomised controlled trial evidence on the benefits and harms of population-based bowel cancer screening. Yet only NZ, with the highest age standardised rate of bowel cancer mortality, decided against introducing a bowel cancer screening programme. This case study of policy making explores the unique resource, ethical, institutional and political environments in which the evidence was considered. It highlights the centrality of context in assessing the relative worth of evidence in policy making and raises questions about the suitability of knowledge utilisation strategies.NHMRC Program Grant (402764

Getting evidence into policy: The need for deliberative strategies?

Getting evidence into policy is notoriously difficult. In this empirical case study we used document analysis and key informant interviews to explore the Australian federal government’s policy to implement a national bowel cancer screening programme, and the role of evidence in this policy. Our analysis revealed a range of institutional limitations at three levels of national government: within the health department, between government departments, and across the whole of government. These limitations were amplified by the pressures of the 2004 Australian federal election campaign. Traditional knowledge utilisation approaches, which rely principally on voluntarist strategies and focus on the individual, rather than the institutional level, are often insufficient to ensure evidence-based implementation. We propose three alternative models, based on deliberative strategies which have been shown to work in other settings: review of the evidence by a select group of experts whose independence is enshrined in legislation and whose imprimatur is required before policy can proceed; use of an advisory group of experts who consult widely with stakeholders and publish their review findings; or public discussion of the evidence by the media and community groups who act as more direct conduits to the decision-makers than researchers. Such deliberative models could help overcome the limitations on the use of evidence by embedding public review of evidence as the first step in the institutional decision-making processes. Highlights Achieving evidence-based policy implementation is much harder than the rhetoric suggests. Our case study showed traditional voluntarist approaches are not enough to overcome institutional filtering of the evidence. Deliberative strategies open up the decision-making processes to greater expert and public scrutiny. Our framework illustrates the potential for deliberative strategies to increase the relative weight of evidence in policy. This article challenges researchers and policy-makers to acknowledge and address the institutional context of decision-making. Keywords: Australia; Health policy; Decision-making; Evidence; Knowledge utilisation; Bowel cancer; Screening; DeliberativeNHMR

Colorectal cancer screening: Why immunochemical fecal occult blood tests may be the best option

Abstract Background:There are many test options available for colorectal cancer screening. The choice of test relates to the objectives of those offering or considering screening. Discussion:While all screening programs aim to detect disease early in order to improve the length and/or quality of life for the individual, some organizations and individuals prefer screening tests that offer the opportunity for cancer prevention. Others favor maximizing participation or the opportunity for shared decision-making, including discussion of information on test quality and availability. We propose three additional objectives for screening: minimizing harms, optimizing economic efficiency and maximizing equity of access to screening. Summary:Applying these objectives to colorectal cancer screening, we advocate the use of immunochemical FOBTs as the preferred screening strategy, as it satisfies all three of these important objectives. Keywords:Screening objectives, Colorectal cancer, Fecal occult blood testing, Harm minimization, Equity, Economic efficiency, Prevention, Participatio

The Role of Personalized Choice in Decision Support: A Randomized Controlled Trial of an Online Decision Aid for Prostate Cancer Screening

Importance Decision support tools can assist people to apply population-based evidence on benefits and harms to individual health decisions. A key question is whether “personalising” choice within decisions aids leads to better decision quality. Objective To assess the effect of personalising the content of a decision aid for prostate cancer screening using the Prostate Specific Antigen (PSA) test. Design Randomized controlled trial. Setting Australia. Participants 1,970 men aged 40–69 years were approached to participate in the trial. Intervention 1,447 men were randomly allocated to either a standard decision aid with a fixed set of five attributes or a personalised decision aid with choice over the inclusion of up to 10 attributes. Outcome Measures To determine whether there was a difference between the two groups in terms of: 1) the emergent opinion (generated by the decision aid) to have a PSA test or not; 2) self-rated decision quality after completing the online decision aid; 3) their intention to undergo screening in the next 12 months. We also wanted to determine whether men in the personalised choice group made use of the extra decision attributes. Results 5% of men in the fixed attribute group scored ‘Have a PSA test’ as the opinion generated by the aid, as compared to 62% of men in the personalised choice group (χ2 = 569.38, 2df, p< 0001). Those men who used the personalised decision aid had slightly higher decision quality (t = 2.157, df = 1444, p = 0.031). The men in the personalised choice group made extensive use of the additional decision attributes. There was no difference between the two groups in terms of their stated intention to undergo screening in the next 12 months. Conclusions Together, these findings suggest that personalised decision support systems could be an important development in shared decision-making and patient-centered care.funded by the National Health and Medical Research Council of Australia under Program Grant number 6633003

Is informed consent related to success in exercise and diet intervention as evaluated at 12 months? DR's EXTRA study

<p>Abstract</p> <p>Background</p> <p>There is a permanent need to evaluate and develop the ethical quality of scientific research and to widen knowledge about the effects of ethical issues. Therefore we evaluated whether informed consent is related to implementation and success in a lifestyle intervention study with older research participants. There is little empirical research into this topic.</p> <p>Methods</p> <p>The subjects (n = 597) are a subgroup of a random population sample of 1410 men and women aged 57-78 years who are participating in a 4-year randomized controlled intervention trial on the effects of physical exercise and diet on atherosclerosis, endothelial function and cognition. Data were collected in two steps: A questionnaire about informed consent was given to all willing participants (n = 1324) three months after the randomization. Data on implementation and success in the exercise and diet interventions were evaluated at 12 months by intervention-group personnel. The main purpose of the analysis procedure performed in this study was to identify and examine potential correlates for the chosen dependent variables and to generate future hypotheses for testing and confirming the independent determinants for implementation and success. The nature of the analysis protocol is exploratory at this stage.</p> <p>Results</p> <p>About half of the participants (54%) had achieved good results in the intervention. Nearly half of the participants (47%) had added to or improved their own activity in some sector of exercise or diet. Significant associations were found between performance in the interventions and participants' knowledge of the purpose of the study (p < 0.001), and between success in interventions and working status (p = 0.02), and the participants' knowledge of the purpose of the study (p = 0.04).</p> <p>Conclusion</p> <p>The main finding of this study was that those participants who were most aware or had understood the purpose of the study at an early stage had also attained better results at their 12-month intervention evaluation. Therefore, implementation and success in intervention is related to whether subjects receive a sufficient amount and are able to comprehend the information provided i.e. the core principles of informed consent.</p> <p>Trial Registration</p> <p>(ISRCTN 45977199)</p