Evidence and Health Policy: Using and Regulating Systematic Reviews.

Systematic reviews have, increasingly, informed policy for almost 3 decades. In many countries, systematic reviews have informed policy for public and population health, paying for health care, increasing the quality and efficiency of interventions, and improving the effectiveness of health sector professionals and the organizations in which they work. Systematic reviews also inform other policy areas: criminal justice, education, social welfare, and the regulation of toxins in the environment. Although the production and use of systematic reviews has steadily increased, many clinicians, public health officials, representatives of commercial organizations, and, consequently, policymakers who are responsive to them, have been reluctant to use these reviews to inform policy; others have actively opposed using them. Systematic reviews could inform policy more effectively with changes to current practices and the assumptions that sustain these practices-assumptions made by researchers and the organizations that employ them, by public and private funders of systematic reviews, and by organizations that finance, set priorities and standards for, and publish them.

Policy commercializing nonprofits in health: the history of a paradox from the 19th century to the ACA.

UNLABELLED: POLICY POINTS: Health policy in the United States has, for more than a century, simultaneously and paradoxically incentivized the growth as well as the commercialization of nonprofit organizations in the health sector. This policy paradox persists during the implementation of the Affordable Care Act of 2010. CONTEXT: For more than a century, policy in the United States has incentivized both expansion in the number and size of tax-exempt nonprofit organizations in the health sector and their commercialization. The implementation of the Affordable Care Act of 2010 (ACA) began yet another chapter in the history of this policy paradox. METHODS: This article explores the origin and persistence of the paradox using what many scholars call "interpretive social science." This methodology prioritizes history and contingency over formal theory and methods in order to present coherent and plausible narratives of events and explanations for them. These narratives are grounded in documents generated by participants in particular events, as well as conversations with them, observing them in action, and analysis of pertinent secondary sources. The methodology achieves validity and reliability by gathering information from multiple sources and making disciplined judgments about its coherence and correspondence with reality. FINDINGS: A paradox with deep historical roots persists as a result of consensus about its value for both population health and the revenue of individuals and organizations in the health sector. Participants in this consensus include leaders of governance who have disagreed about many other issues. The paradox persists because of assumptions about the burden of disease and how to address it, as well as about the effects of biomedical science that is translated into professional education, practice, and the organization of services for the prevention, diagnosis, treatment, and management of illness. CONCLUSIONS: The policy paradox that has incentivized the growth and commercialization of nonprofits in the health sector since the late 19th century remains influential in health policy, especially for the allocation of resources. However, aspects of the implementation of the ACA may constrain some of the effects of the paradox.

Health inequality and governance in Scotland since 2007.

BACKGROUND: Since Scottish devolution in 1999, successive governments have accorded priority to reducing health inequality and increasing economic growth. The Scottish Nationalist Party Government elected in 2007 and re-elected in 2011 has accorded considerable attention and allocated substantial resources to addressing these priorities. This article describes why, how and with what results to date the participants in the governance of Scotland, broadly defined to include persons outside as well as within central government, have addressed the determinants of health in order to reduce inequality and, as a result, improve the health status of the population. STUDY DESIGN: Interpretive analysis. METHODS: Research for this article applied the methods of interpretive social science to obtain and analyse published and unpublished public documents; secondary sources in relevant disciplines; and interviews with ministers, officials, staff of National Health Service Scotland and its regions, and other persons active in health governance in Scotland. RESULTS: Participants in the governance of health affairs in Scotland are making important contributions to the reduction of health inequality and the improvement of population health by: (1) linking policy to address health inequality with policy to make health care, public health, social and housing services, and education more effective and efficient; (2) linking policy to address the determinants of health with policy to stimulate economic growth and, as a result, increase employment and income; and (3) embracing and applying a unique synthesis of research findings about the causes of deficiencies in population health status that contribute to health inequality. CONCLUSIONS: These findings could contribute to revising the assumptions and recommendations of some of the researchers and policy advisers who study the determinants of population health, and thus of health inequality, in order to recommend policy. Many contributors to the literature on population health argue that the determinants of health are universal, and that effective interventions to address them are also likely to be universal. Research for this article suggests, however, that participants in the governance of one country, and perhaps of each country, take account of its culture, history and current politics when they describe the determinants of health in order to propose policy to reduce health inequality. The Scottish experience described in this article could, therefore, contribute to conversations about health policy that involve leaders in governance from numerous jurisdictions; conversations that have been occurring regularly for two decades.

The governance of disease control in Europe.

The eight articles on the governance of communicable disease control in Europe in this issue contribute information and insight to the literature on health politics, policy, and law. Each is a carefully researched and well-argued analysis of a subject on which its authors are experts. The set will be useful to scholars of comparative health policy as well as to specialists in European affairs. The articles also illustrate two methodological issues in conducting research on the governance of health policy. The first is that how researchers define governance influences what evidence they acquire and how they evaluate it. The second is that governance affects how diseases are conceptualized in order to make and implement policy.

Systematic reviews and health policy: the influence of a project on perinatal care since 1988.

CONTEXT: Interrelated publications between 1988 and 1992 have influenced health policy and clinical practice: The Oxford Database of Perinatal Trials (ODPT), Effective Care in Pregnancy and Childbirth (ECPC), A Guide to Effective Care in Pregnancy and Childbirth (GECPC), and Effective Care of the Newborn Infant (ECNI). These publications applied and advanced methods that had a substantial history in the medical, biological, physical, and social sciences. Their unique contribution was to demonstrate the feasibility of organizing and sustaining programs to conduct systematic reviews across an entire field of health care. The publications also influenced subsequent advances in the methodology of systematic reviews and contributed to their proliferation; in large measure, but not entirely, because their editors and many of the authors participated in organizing and developing the Cochrane Collaboration. This article describes how and why these publications attracted favorable attention and resources from policymakers in numerous countries. METHODS: This article applies historical methods to the analysis of primary sources that help explain the influence of systematic reviews, mainly on health policy. These methods guide an analysis of the rhetoric of the two volumes of ECPC and of primary sources generated as systematic reviews influenced health policy. The analysis of rhetoric employs the methods of intellectual history and social studies of science. The analysis of policymaking uses the methods of political and policy history, political science, and public administration. Because the focus of this article is how science influenced policy it alludes to but does not describe in detail the literature on the methods, production, and publication of systematic reviews. FINDINGS: The influence of the four publications on policy was mainly a result of (1) their powerful blending of the rhetoric of scientific and polemical discourse, especially but not exclusively in ECPC; (2) a growing constituency for systematic reviews as a source of "evidence-based" health care among clinicians, journalists, and consumers in many countries; and (3) recognition by significant policymakers who allocate resources to and within the health sector that systematic reviews could contribute to making health care more effective and to containing the growth of costs. CONCLUSIONS: Analysis of this aspect of the history of producing and applying systematic reviews informs understanding of how knowledge derived from research informs policy.

Realizing and allocating savings from improving health care quality and efficiency.

International efforts to increase the quality and efficiency of health care services may be creating financial savings that can be used to improve population health. This article examines evidence that such savings (ie, a quality/efficiency or value dividend) are accruing and how they have been allocated and assesses the prospects for reallocating future savings to improve population health. Savings have resulted mainly from reducing the number of inappropriate or harmful interventions, managing care of people with chronic disease more effectively, and implementing health information technology. Savings to date have accrued to the revenues of public and private collective purchasers of care and large provider organizations, but none seem to have been reallocated to address other determinants of health. Furthermore, improved quality sometimes increases spending.

The governance of standard-setting to improve health.

This article describes recent events in the governance of standard-setting for 2 areas of US health policy - states' decisions about which prescription drugs to cover under Medicaid and other public programs and making health an aspect of foreign policy - and whether these events offer lessons for policy making. In prescription drug coverage, methodologic advances in research that evaluates health services and the politics of restraining the rate of growth in health expenditures enabled policy makers in most states to establish new public processes for assessing and applying evidence about the effectiveness of competing drugs. Their counterparts in foreign policy, in contrast, made few changes in existing processes for choosing which interventions to support. The history of governance in each area of policy making for health explains the selection of standards to evaluate evidence about interventions and whether and how to use this evidence to guide policy.