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. 2001 May 26;322(7297):1304.

How policy informs the evidence

Comprehensive evidence is needed in decision making

Arminée Kazanjian 1
PMCID: PMC1120390  PMID: 11403058

Editor—Davey Smith et al have identified some problems with evidence based decision making in health care.1 Nevertheless, when these are set against the deficiencies of much current (non-evidence based) decision making, evidence based decision making still compares favourably.

Administrators, facing complex allocation choices within tight budgets, are inclined to focus on economic notions of efficiency and fair play. The rationale is: “If it's not too expensive and seems to help a disadvantaged group we might be prepared to pay for it.” When people are presented with a problem (often the solution is presented first, implying that there must be a problem) they gather whatever information will confirm the merit of the intended intervention as quickly as possible. Inequalities in health are not remedied, nor the health of the population as a whole benefited, by this short term damage control.

Computed tomography is important in examining efficacy (the safety and benefits of treatments used under ideal conditions). But to be of value to policymakers, research should seek to identify evidence supporting effectiveness (whether an intervention is likely to do more good than harm in routine use). The evidence needed for sound policymaking should thus be much more comprehensive than attempts to extrapolate dubious principles from the findings of computed tomography.

Evidence based decision making is, fundamentally, the process of ensuring that the right questions are asked. Is an intervention safe and effective (will it do more good than harm)? Who needs it? Can it be provided under conditions of equal accessibility? Who is the population at risk, and what are the relevant clinical and social determinants? What change may be expected in the burden of disease? What are the social consequences (what are the implications in power and dominance issues, and what public and private interests are being served)? If decisions are based on such comprehensive evidence then the budgetary issues that follow will be much more accurately circumscribed.

Tools exist that can synthesise such data to scientific standards and provide logical and defensible conclusions about impacts on a system, a population, and society.2 Decisions can be then be made that are based on meaningful comparison with interventions competing for the same budget.

Ultimately, the aim of decision making in health care should be to achieve not equal health standards (however low the ceiling) but good health for all population groups–or, to put it another way, the best care for the greatest number of people.

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SUE SHARPLES

References

  • 1.Davey Smith G, Ebrahim S, Frankel S. How policy informs the evidence. BMJ. 2001;322:184–185. doi: 10.1136/bmj.322.7280.184. . (27 January.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Kazanjian A, Green CJ, Bassett K, Brunger F. Bone mineral density testing in social context. Int J Technol Assess Health Care. 1999;15:679–685. [PubMed] [Google Scholar]
BMJ. 2001 May 26;322(7297):1304.

Lessons have also been learnt in disciplines outside medicine

Robert F Boruch 1

Editor—The case study by Macintyre et al and the lessons that they draw from it are excellent.1-1 These lessons are not unlike experiences and lessons in disciplines outside medicine.

In education, crime, and justice, government groups in the United States and elsewhere have also been formed to identify promising practices, exemplary models, and so forth, on the basis of good evidence. As in the health sector, these organisations have had to confront major challenges in identifying and compiling relevant studies, deciding on standards of evidence and when to include or exclude studies, summarising the studies in sensible ways, and deciding that evidence is insufficient for reaching any conclusions and, ultimately, getting the information to the policymaker in a timely fashion.

The Campbell Collaboration (http://campbell.gse.upenn.edu) was inaugurated in February 2000 for these reasons. Modelled partly on the Cochrane Collaboration in health care, the Campbell Collaboration will prepare, maintain, and make accessible systematic reviews of studies of the effectiveness of interventions in education, crime and justice, social work and social welfare, and other social sectors. The first target is randomised trials; the second target is well controlled non-randomised trials. The ultimate aims are to produce information that is useful to the public and social policymakers and to help stimulate the production of better studies of effectiveness.

References

  • 1-1.Macintyre S, Chalmers I, Horton R, Smith R. Using evidence to inform health policy: case study. BMJ. 2001;322:222–225. doi: 10.1136/bmj.322.7280.222. . (27 January.) [DOI] [PMC free article] [PubMed] [Google Scholar]

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