计量经济分析 = Econometric analysis

Shared decision-making in the medical encounter: What does it mean? (or it takes at least two to tango)

Evidence-based policy is a dominant theme in contemporary public services but the practical realities and challenges involved in using evidence in policy-making are formidable. Part of the problem is one of complexity. In health services and other public services, we are dealing with complex social interventions which act on complex social systems--things like league tables, performance measures, regulation and inspection, or funding reforms. These are not 'magic bullets' which will always hit their target, but programmes whose effects are crucially dependent on context and implementation. Traditional methods of review focus on measuring and reporting on programme effectiveness, often find that the evidence is mixed or conflicting, and provide little or no clue as to why the intervention worked or did not work when applied in different contexts or circumstances, deployed by different stakeholders, or used for different purposes. This paper offers a model of research synthesis which is designed to work with complex social interventions or programmes, and which is based on the emerging 'realist' approach to evaluation. It provides an explanatory analysis aimed at discerning what works for whom, in what circumstances, in what respects and how. The first step is to make explicit the programme theory (or theories)--the underlying assumptions about how an intervention is meant to work and what impacts it is expected to have. We then look for empirical evidence to populate this theoretical framework, supporting, contradicting or modifying the programme theories as it goes. The results of the review combine theoretical understanding and empirical evidence, and focus on explaining the relationship between the context in which the intervention is applied, the mechanisms by which it works and the outcomes which are produced. The aim is to enable decision-makers to reach a deeper understanding of the intervention and how it can be made to work most effectively. Realist review does not provide simple answers to complex questions. It will not tell policy-makers or managers whether something works or not, but will provide the policy and practice community with the kind of rich, detailed and highly practical understanding of complex social interventions which is likely to be of much more use to them when planning and implementing programmes at a national, regional or local level.

Realist review - a new method of systematic review designed for complex policy interventions

One of the most consistent findings from clinical and health services research is the failure to translate research into practice and policy. As a result of these evidence-practice and policy gaps, patients fail to benefit optimally from advances in healthcare and are exposed to unnecessary risks of iatrogenic harms, and healthcare systems are exposed to unnecessary expenditure resulting in significant opportunity costs. Over the last decade, there has been increasing international policy and research attention on how to reduce the evidence-practice and policy gap. In this paper, we summarise the current concepts and evidence to guide knowledge translation activities, defined as T2 research (the translation of new clinical knowledge into improved health). We structure the article around five key questions: what should be transferred; to whom should research knowledge be transferred; by whom should research knowledge be transferred; how should research knowledge be transferred; and, with what effect should research knowledge be transferred? We suggest that the basic unit of knowledge translation should usually be up-to-date systematic reviews or other syntheses of research findings. Knowledge translators need to identify the key messages for different target audiences and to fashion these in language and knowledge translation products that are easily assimilated by different audiences. The relative importance of knowledge translation to different target audiences will vary by the type of research and appropriate endpoints of knowledge translation may vary across different stakeholder groups. There are a large number of planned knowledge translation models, derived from different disciplinary, contextual (i.e., setting), and target audience viewpoints. Most of these suggest that planned knowledge translation for healthcare professionals and consumers is more likely to be successful if the choice of knowledge translation strategy is informed by an assessment of the likely barriers and facilitators. Although our evidence on the likely effectiveness of different strategies to overcome specific barriers remains incomplete, there is a range of informative systematic reviews of interventions aimed at healthcare professionals and consumers (i.e., patients, family members, and informal carers) and of factors important to research use by policy makers. There is a substantial (if incomplete) evidence base to guide choice of knowledge translation activities targeting healthcare professionals and consumers. The evidence base on the effects of different knowledge translation approaches targeting healthcare policy makers and senior managers is much weaker but there are a profusion of innovative approaches that warrant further evaluation.

https://link.springer.com/content/pdf/10.1186%2F1748-5908-7-50.pdf

Knowledge translation of research findings

政治自由主义 = Political liberalism

Conceptual, methodological, and practical issues await those who seek to understand how to make better use of health services research in developing public policy. Some policies and some policymaking processes may lend themselves particularly well to being informed by research. Different conclusions about the extent to which policymaking is informed by research may arise from different views about what constitutes health services research (is it citable research or any professional social inquiry that can aid in problem solving?) or different views about what constitutes research use (is it explicit uses of research only, or does it also include tacit knowledge or the positions of stakeholders when they are informed by research and are influential in the policymaking process?). Some conditions may favor the use of research in policymaking, like sustained interactions between researchers and policymakers. Results from an exploratory study on the use of health services research by Canadian provincial policymakers illustrate these issues.

/pdf/examining-the-role-of-health-services-research-in-public-52wp9p4a72.pdf

Examining the Role of Health Services Research in Public Policymaking

This chapter provides an overview of normative analysis in the health sector in recent decades. It surveys two distinct, but related, literatures. The first is normative analysis of the operation of health care and health care insurance markets, market failure, and the scope for non-market institutional arrangements to improve the efficiency and equity of the financing, funding, organization and delivery of health care. The second is the debate about the most appropriate normative framework within which to carry out normative analysis in the health sector, focusing on the welfarist and extra-welfarist frameworks. This is a debate about assumptions and methods. Although the rival frameworks share the broad conclusion that market failure pervades the health sector, the diagnoses regarding nature of that failure sometimes differ and, more importantly, the prescriptions to improve efficiency and equity often differ. Because it is not always clear what writers mean by “welfare economics” and “extra-welfarism,” I briefly summarize key concepts of efficiency and key assumptions and elements of each framework. The three subsequent sections then analyze the nature of health care as an economic commodity and the implications of these characteristics both for the operation of health care and health care insurance markets and for the methods of normative economic analysis. Section 4 surveys prominent approaches to analyzing equity in health care. Section 5 examines the methods of normative analysis as applied to evaluate individual health care services. Finally, I end with some observations on recent discussions of the role of normative economic analysis in policy making and of health economists as policy advisors.

An Overview of the Normative Economics of the Health Sector

Background Prescription of new drugs contributes to substantial increases in annual drug expenditures. A small proportion of physicians appear to be early users of new prescription drugs and little is known about their characteristics. Objective To estimate the initial utilization rate of new prescription drugs among physicians, and the physician and practice characteristics associated with early use. Design Cumulative prospective assessment over a 5 year period (1989-1994) of new drug utilization rates in a randomly selected cohort of Quebec physicians. Participants 1661 physicians and 669,867 elderly patients. Outcome Prescribing rate of 20 new drugs, in 6 therapeutic categories, to elderly patients in the first 6 months after inclusion in the Quebec formulary. Results The 20 new drugs were prescribed by 1.3-22.3% of physicians, and there was an 8 to 17-fold difference in new drug utilization rates among prescribers. Characteristics associated with higher rates of utilization differed for general practitioners and specialists. Male general practitioners, and physicians graduating from the most recently established medical school in the province, had higher rates of new drug utilization, whereas recent graduation was only associated with higher utilization rates among specialists. Practice volume was associated with higher rates of utilization among GPs. For both GPs and specialists, having a high proportion of elderly in one's practice and a rural or remote practice location was associated with lower utilization rates. Conclusions Physician sex, specialty, medical school, years since graduation, practice location, volume, and relative proportion of elderly in the physician's practice influence the utilization of new drugs.

Physician and practice characteristics associated with the early utilization of new prescription drugs.

Pricing life: Why it's time for health care rationing Peter A. Ubel Cambridge (MA): MIT Press; 2001 208 pp US$14.95 (paper) ISBN 0-262-71009-9

Peter Ubel, a general internist who has published extensively on ethics, equity and medical decision-making, has written a book on health care rationing

Cost and effect

Explicit financial incentives, especially pay-for-performance (P4P) incentives, have been extensively employed in recent years by health plans and governments in an attempt to improve the quality of health care services. This study exploits a natural experiment in the province of Ontario, Canada to identify empirically the impact of pay-for-performance (P4P) incentives on the provision of targeted primary care services, and whether physicians' responses differ by age, practice size and baseline compliance level. We use an administrative data source which covers the full population of the province of Ontario and nearly all the services provided by practicing primary care physicians in Ontario. With an individual-level data set of physicians, we employ a difference-in-differences approach that controls for both "selection on observables" and "selection on unobservables" that may cause estimation bias in the identification. We also implemented a set of robustness checks to control for confounding from the other contemporary interventions of the primary care reform in Ontario. The results indicate that, while all responses are of modest size, physicians responded to some of the financial incentives but not the others. The differential responses appear related to the cost of responding and the strength of the evidence linking a service with quality. Overall, the results provide a cautionary message regarding the effectiveness of pay-for-performance schemes for increasing quality of care.

Jeremiah Hurley

Papers

Examining the Role of Health Services Research in Public Policymaking

An Overview of the Normative Economics of the Health Sector

Physician and practice characteristics associated with the early utilization of new prescription drugs.

Cost and effect

Physician Response to Pay-for-Performance: Evidence from a Natural Experiment