Lecture 1 - Policy and Evidence Based Medicine

Question 1

What is policy?

Answer 1

Refers to the statement of intent by a government, organization or institution for a set of action(s) or inaction(s) to achieve long term outcomes
* Policy is a collection of different instruments

Question 2

Examples of policy instruments/tools?

Answer 2

regulations and economic tools, taxation, spending and incentives

Question 3

Define public policy

Answer 3

a collection of policies

Question 4

Define policy making

Answer 4

Making large scale decisions about delivery and management of service at a population level
-Multifaceted and complex
- Interaction with others (i.e. researchers, intermediaries, companies, communities etc.)
-Process is linear AND cyclical

Question 5

Name and define the 2 types of policies

Answer 5

1. Rules that provide guidelines. e.g. rules for employees
2. Laws and regulations to govern issue/problem

Question 6

Name and define the 5 arenas of policy making (LEJHP)

Answer 6

• Legislatures - enact laws
• the executive branch with its administrative agencies, which make and enforce rules to implement the laws
• Judiciary - enforces and also makes policy through its decisions
• Hybrid agencies created by government with some independence e.g., Bank of Canada
• Private organizations that make public policy

Question 7

List the 6 steps of the policy cycle (AFLIEM/T)

Answer 7

1. Agenda setting - Identifying problems that need govt action
2. Policy formulation (research and analysis) - Setting objectives, costs,
   effect of solutions
3. Legitimation/decision making - Legislative support and approval,
   consent of interest groups
4. Implementation - Ensuring organization is responsible and has the resources
5. Evaluation- was it successful?
6. Policy maintenance/termination - succession, modification, or termination

Question 8

List some ideas about “new ways of policy making”

Answer 8

Research, options, advice <decision>, implementation, evaluation --> this is too rigid and must evolve to be an integrated whole</decision>

• More open public policy
• More diversity and inclusion of viewpoints
• People, evidence, and outcomes (3 main things for new way of policy making)
  o Add policy development and policy delivery
• Greater need for collaboration and openness between researchers and policy makers
• Need to have clear objectives, understand outcomes (costs are important to consider, must be grounded in reality and evidence)

Question 9

What does evidence based policy (EBP) ask/ look for?

Answer 9

• Does scientific evidence constitute or determine the policy?
• Which measures should take priority over others to deal with the problem?
• How can we balance other policies against other public goods/social goods? (medical is free, don’t have to fight to get it)
  o side note: ppl with developmental disabilities have long waitlists to get into support programs (must compete for it, all documents and assessments must be correct)

Question 10

What is evidence based medicine (EBM) and what is/was its goal?

Answer 10

Evidence-Based Medicine (EBM) is a decision-making process for patient care
* It integrates clinical expertise, patient values and best research evidence
Origins of EBM
- OG goal was to lead to abandonment of harmful practices or interventions that weren’t working and adopt new ones to reach a better clinical outcome

Question 11

what did epidemiologist: Archie Cochrane do? (in 1972)

Answer 11

Called for international register of RCTs (check Cochrane controlled trials register)
o Found fundamental pillars of NHS: effectiveness, efficacy, equity (Three Es)
o Found Maxwell six (quality of health care)- includes acceptability, access, relevance

Question 12

List the order of the EBM pyramid from bottom to top, cite its relevance

Answer 12

1. background information and expert opinion
2. case reports/case series
3. case control studies
4. cohort studies
5. randomized controlled trials (RCTs)
6. critically appraised topics
7. systematic reviews
8. meta analysis
   Note: 1-5 = unfiltered info, 6-8 = filtered info

-Evidence found in filtered and non-filtered resources
-Allows for clinically relevant research and sound methodology

Question 13

What is evidence based policy? Note where it is derived from

Answer 13

Evidence-based policy derived from evidence-based medicine (EBM)
* Researchers, academics, practitioners and government aim to achieve evidence-based
policy to increase research uptake in policy making
* fosters closer and more effective links between research and policy.
*Both EBM and EBP have gained importance and achieved financial and political support

Examples:
* Rothschild experiment (Kogan and Henkel, 1983) – to enable health research system to respond
to policymaker research priorities
* UK Government Office guides for Science – to enable engagement between academe ad policy
makers

Question 14

What has EBM led to the creation of? Give some examples

Answer 14

organizations dedicated to guidelines and best practices statements.
Examples:
* Govt based e.g., Canadian Task Force on Preventive Health
* Non-Profit organizations e.g., The International Centre for Evidence-Based Medicine Canada (ICEBM)
* The Centre for Evidence-Based Medicine (CEBM) –UK
* The U.S. Preventive Services Task Force
* Cochrane Centre for Systematic Reviews
* EBM Journals

Question 15

What is the problem with getting evidence into policy?

Answer 15

The meaning and practices of evidence-based policy are contested
* Debated - how to restrain the moral, ethical, financial and political influences to use evidence to make best decisions without depriving the non-experts’ rights and privileges
* Academics tend to focus on promoting the use/uptake of academic research
* Little focus on practices of knowledge production and policy making process and its implementation

Question 16

What are researchers unclear about in terms of the process, impact or effectiveness of research in policy?

Answer 16

• The definition of use of terms knowledge translation/ knowledge exchange/evidence use is
  blurred
• What type of knowledge is part of which decision-making process?
• What constitutes and defines ‘evidence’ and ‘policy’?
• Which processes and outcomes are influenced by political efforts and which by academic efforts

Question 17

List 3 barriers to evidence use in policy making

Answer 17

• Importance of personal relationships/contacts between decision-makers and researchers
• Mismatch between definitions of evidence and academic constructions of ‘evidence’
• Need for research to be accessible and clearly presented

Question 18

List additional barriers o use of evidence in policy making

Answer 18

• Policy makers beliefs and attitudes
• Lack of policy makers research skills or awareness
• Little details on the policy process: e.g., who are main actors, where are decisions made, and
  how evidence fits in the process
• Absence of contact, and mutual mistrust, and ‘gulf’ between researchers and policymakers
• Lack of clear or relevant research evidence that is good quality
• Financial constraints –budget struggles
• Other practical constraints – time frame

Question 19

Define the two communities’ hypothesis

Answer 19

Refers to barriers to evidence uptake – differences between researchers and
policy-makers leads to the policy-evidence gap

Question 20

Define the simple pipeline model, and describe new theoretical models being used to replace it

Answer 20

Simple pipeline model - more research leads to higher quality and better effect on policy and practice
* New theoretical models focus on knowledge brokerage/translation as a framework for understanding use
of evidence
* Based on ideas of coproduction and user involvement
* Comparable to “enlightening’ and ‘strategic use’ of evidence by policy makers (Weis, 1977)

Question 21

Weis’s typologies of “utilization of evidence: define the 2 linear models

Answer 21

• Knowledge driven model; basic research-> applied research->development ->application
• Problem solving model: research provides empirical evidence and conclusion to help solve a policy problem

Question 22

Weis’s typologies of “utilization of evidence: define the 4 non-linear models

Answer 22

• Interactive model: policy makers seek knowledge from a variety of sources
• Political model: policy makers take a stand that research is not likely to shake
• Tactical model; sometimes govt agencies use research to deflect criticism
• Enlightenment model: concepts and theoretical perspectives (not findings) of social science research permeates
  the policy-making process

Question 23

What are some approaches to understand utilization of evidence?

Answer 23

empirical ethnography, anthropological or historical approaches

Question 24

List factors affecting use of evidence

Answer 24

• Access to relevant and clear information
• May be due to the methods used in the studies
• Interviews or surveys ask researchers and policy-makers about their perceptions about
  evidence use
• Lack of participant observation to observe how evidence is actually used in practice
• Lack of documentary proof of research use
• EBP research are written by and for academics - little involvement of policy-makers as
  co-authors

Question 25

Assumptions in the literature on evidence-based policy
* Describe Assumption 1: Policy-evidence gap needs bridging

Answer 25

• Policy and academic actors conceptualized as opposing sets of actors
• Recent shift in dichotomous view/debate observed in use of language - Knowledge
  translation/transfer being replaced by learning/contribution/co-production
• Two-way negotiation relationship between research and policy - partnership and equality
• Widely claimed that decisions made in partnership (researchers and policy makers) are more
  likely to result in positive health outcomes – anecdotal cases not self-evident

Question 26

Assumptions in the literature on evidence-based policy
* Describe Assumption 2: Policy is usually not based on evidence/data

Answer 26

• Researchers believe policymakers do not use evidence
• Policymakers are interest-oriented and indifferent to evidence
• Policymakers use wide range of information sources:
• surveillance data, impact assessments, GIS (geographic information system)
• local information or intelligence, patient or practice level data, or that held by local councils
• Using empirical methods to study policymakers in viv

Question 27

Assumptions in the literature on evidence-based policy
* Describe Assumption 3: Policy requires research evidence

Answer 27

• Better policy decisions is a desirable outcome, and evidence should play a role in those decisions
• More evidence would improve policy making (quality) and have a bigger effect (pipeline model)
• Policy requires evidence preferably evaluative intervention research
• Research impact or impact agenda - dominating the field of EBP - does not examine the
  connection of research to policy and practice

Question 28

What are some new directions for EBP research?

Answer 28

• Approach policymakers from an unprejudiced stance, to describe their activities, and to
  identify how they populate policy areas and steer policies through
• Researchers must be able to demonstrate the benefits of greater use of evidence

Question 29

What is the new agenda of EBP research?

Answer 29

• Refocus research on influences on and processes of policy rather than how to increase the
  amount of evidence used
• Determine what information and evidence is normally used as part of policy processes
• Attention to context is vital: research and policy making urgencies differ in different countries
• Apply a broader range of methodologies
• Develop conceptual clarity and use metrics to evaluate ‘impact’ of research on policy and
  populations
• Forming collaborative organizations to conduct research
• Co-creation and co-production of knowledge- more democratic