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Slide 1: Translating Data into Health Policy

Slide 2:

• This conference has been about strategies to develop evidence
• Maximizing the quality of evidence given limited research dollars.
• Cost-effective input into evidence-based policy decisions

Slide 3:

• This conference has been about strategies to develop evidence
• Maximizing the quality of evidence given limited research dollars.
• Cost-effective input into policy decisions
• This session is about the quality of public decision making.

Slide 4: How much benefit is good enough?

• Described CMS coverage policymaking
• Population-level expected outcome decision making
• Efficacy is the decision criterion, not cost.
• Cost enters with price setting
• How would decisions change if CE was a criterion?
• How much benefit is enough?
• At least as much as previously covered item
• Do coverage decisions consistently mirror the evidence?

Slide 5: Opportunity costs and societal trade-offs

• Advice about how to allocate research funding
• Argues for population health perspective in setting funding priorities
• Should use C-E as a measure of value when setting priorities.
• Who decides our national research funding priorities now? How?

Slide 6: Third party payer perspective

• Get revenue from insurers and employers.
• A prudent buyer of "medically necessary services."
• Tries to control volume, not unit price.
• Strives for consistency by using services of proven effectiveness.
• Frustrated by appeals to use unproven, costly therapy.
• Will costly new technology be judged only on efficacy or on cost per QALY?

Slide 7:

• The common theme: decisions about policies to allocate scarce resourcesnvestment in research
• Investment in clinical services
• A common sub-theme: taking a population perspective
• Frustrated by appeals to make exceptions

Slide 8:

• This conference has been about strategies to develop evidence to support decision making about policy
• This session is about the quality of decision making about policy.
• What values drive these decisions?
• Do our policy decisions consistently reflect these values?

Slide 9:

• We can certainly do better in our public policy decision-making.
• Inconsistency in applying principles
• Population perspective
• Evidence-based
• Focus on value (C-E)
• Consistency is good. Can we also allow for reasonable variation in practice?
• Can we develop a consistent approach to allowing some flexibility?

Slide 10: Consistency

• "A foolish consistency is the hobgoblin of little minds."

Ralph Waldo Emerson (as quoted in Next Stop Wonderland)

Slide 11: Advantages to being consistent

• Consistency:
• Rules to evaluate evidence
• Rules for using evidence to make a decision
• Advantages
• To manufacturers (how to plan)
• To funding agencies (what research to fund)
• To researchers (which research to do)
• Doctors and patients (meaning of a recommendation)

Slide 12:

• Consistency of approach:
• We have good decision processes but we're not consistent in applying them.
• USPSTF as a model of consistency and transparency

Slide 13: Wording of Recommendations

1. Strongly recommend good evidence, benefits substantially outweigh harms

• Recommend
• at least fair evidence, benefits outweigh harms
• USPSTF makes no recommendation
• fair to good evidence, benefits and harms closely balanced
• Recommend against routine use
• ineffective or harms outweigh potential benefits

Slide 14: I - Insufficient Evidence to Recommend For or Against

• Lack of evidence on clinical outcomes
• Poor quality of existing studies
• Good quality studies with conflicting results

Confidence interval includes clinically important benefits

Slide 15: U.S. Preventive Services Task Force Over-all Rating of Evidence

• Good
• Fair
• Poor

Slide16: USPSTF Rating System "Good"

• Consistent results
• Well-designed, well conducted
• Representative populations
• Directly assesses effects on health outcomes

Slide 17: USPSTF Rating System "Fair"

• Evidence adequate to determine effects on health outcomes but limited by:
• Number, quality, or consistency of studies
• Generalizability to routine practice
• Indirect character of the effect on health
• outcomes

Slide 18: USPSTF Rating System "Poor"

• Evidence is insufficientto assess effects on health outcomes because
• Limited number studies
• Limited power of studies (wide 95% CI 'inconclusive results)
• Important flaws in design or conduct
• Gaps in the chain of evidence
• Lack of information on health outcomes

Slide 19: How can we do better in policy decisions?

• A problem: the imposition of different value systems on the decision process.
• Politicians, profit, and patients (the 3 Ps)
• Will better quality data lead to better quality decision making?
• Precise, unbiased estimates of health effects based on many studies
• Will better data lead to consistency in policymaking? Will it trump the 3 Ps?

Slide 20:

• We can certainly do better in our public policy decision-making.
• Be more consistent in applying principles of good decision making.
• Learning to allow for reasonable variation in practice.

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