Translating research into policy and practice in developing countries: a case study of magnesium sulphate for pre-eclampsia.

BACKGROUND: The evidence base for improving reproductive health continues to grow. However, concerns remain that the translation of this evidence into appropriate policies is partial and slow. Little is known about the factors affecting the use of evidence by policy makers and clinicians, particularly in developing countries. The objective of this study was to examine the factors that might affect the translation of randomised controlled trial (RCT) findings into policies and practice in developing countries. METHODS: The recent publication of an important RCT on the use of magnesium sulphate to treat pre-eclampsia provided an opportunity to explore how research findings might be translated into policy. A range of research methods, including a survey, group interview and observations with RCT collaborators and a survey of WHO drug information officers, regulatory officials and obstetricians in 12 countries, were undertaken to identify barriers and facilitators to knowledge translation. RESULTS: It proved difficult to obtain reliable data regarding the availability and use of commonly used drugs in many countries. The perceived barriers to implementing RCT findings regarding the use of magnesium sulphate for pre-eclampsia include drug licensing and availability; inadequate and poorly implemented clinical guidelines; and lack of political support for policy change. However, there were significant regional and national differences in the importance of specific barriers. CONCLUSION: The policy changes needed to ensure widespread availability and use of magnesium sulphate are variable and complex. Difficulties in obtaining information on availability and use are combined with the wide range of barriers across settings, including a lack of support from policy makers. This makes it difficult to envisage any single intervention strategy that might be used to promote the uptake of research findings on magnesium sulphate into policy across the study settings. The publication of important trials may therefore not have the impacts on health care that researchers hope for.

Are QALYs based on time trade-off comparable?--A systematic review of TTO methodologies.

A wide range of methods is used to elicit quality-of-life weights of different health states to generate 'Quality-adjusted life years' (QALYs). The comparability between different types of health outcomes at a numerical level is the main advantage of using a 'common currency for health' such as the QALY. It has been warned that results of different methods and perspectives should not be directly compared in QALY league tables. But do we know that QALYs are comparable if they are based on the same method and perspective?The Time trade-off (TTO) consists in a hypothetical trade-off between living shorter and living healthier. We performed a literature review of the TTO methodology used to elicit quality-of-life weights for own, current health. Fifty-six journal articles, with quality-of-life weights assigned to 102 diagnostic groups were included. We found extensive differences in how the TTO question was asked. The time frame varied from 1 month to 30 years, and was not reported for one-fourth of the weights. The samples in which the quality-of-life weights were elicited were generally small with a median size of 53 respondents. Comprehensive inclusion criteria were given for half the diagnostic groups. Co-morbidity was described in less than one-tenth of the groups of respondents. For two-thirds of the quality-of-life weights, there was no discussion of the influence of other factors, such as age, sex, employment and children. The different methodological approaches did not influence the TTO weights in a predictable or clear pattern. Whether or not it is possible to standardise the TTO method and the sampling procedure, and whether or not the TTO will then give valid quality-of-life weights, remains an open question.This review of the TTO elicited on own behalf, shows that limiting cost-utility analysis to include only quality life weights from one method and one perspective is not enough to ensure that QALYs are comparable.

Roughly right or precisely wrong? Systematic review of quality-of-life weights elicited with the time trade-off method.

OBJECTIVE: Cost-utility analysis is gaining importance as a tool for setting priorities in health care. The approach requires quality-of-life weights on a scale from 0.00 (corresponding to death) to 1.00 (corresponding to perfect health). Different methods and perspectives of the evaluators tend to give different results. Time trade-off (TTO) is the most commonly used method to elicit quality-of-life weights for quality-adjusted life-years (QALYs). How reliable are the results of this method, when limited to one specific perspective, as input for cost-utility analysis? METHOD: Systematic literature review of empirical studies in which the TTO is elicited by the respondent on their own behalf. RESULTS: In 56 papers, quality-of-life weights for 102 diagnostic groups were given. Ranking of the diagnostic groups according to their quality-of-life weights had no apparent relation to severity. One specific diagnostic group was assigned quality-of-life weights ranging from 0.39 to 0.84. Altogether, 57% of respondents did not trade any life-time at all in exchange for health improvements. The distributions studied were skewed towards 1.00 and were bimodal without a central tendency. The correlation between the TTO and related methods was generally weak. Possible explanations for the poor empirical properties of the TTO are inappropriate use of the method, lack of representative samples, or that the TTO does not measure what it claims to measure. CONCLUSION: In the light of these findings, the TTO elicited from the patient perspective, as currently practised, should not be used as an input for QALYs or for comparisons of diagnostic groups.

Health policy-makers' perceptions of their use of evidence: a systematic review.

OBJECTIVES: The empirical basis for theories and common wisdom regarding how to improve appropriate use of research evidence in policy decisions is unclear. One source of empirical evidence is interview studies with policy-makers. The aim of this systematic review was to summarise the evidence from interview studies of facilitators of, and barriers to, the use of research evidence by health policy-makers. METHODS: We searched multiple databases, including Medline, Embase, Sociofile, PsychLit, PAIS, IBSS, IPSA and HealthStar in June 2000, hand-searched key journals and personally contacted investigators. We included interview studies with health policy-makers that covered their perceptions of the use of research evidence in health policy decisions at a national, regional or organisational level. Two reviewers independently assessed the relevance of retrieved articles, described the methods of included studies and extracted data that were summarised in tables and analysed qualitatively. RESULTS: We identified 24 studies that met our inclusion criteria. These studies included a total of 2041 interviews with health policy-makers. Assessments of the use of evidence were largely descriptive and qualitative, focusing on hypothetical scenarios or retrospective perceptions of the use of evidence in relation to specific cases. Perceived facilitators of, and barriers to, the use of evidence varied. The most commonly reported facilitators were personal contact (13/24), timely relevance (13/24), and the inclusion of summaries with policy recommendations (11/24). The most commonly reported barriers were absence of personal contact (11/24), lack of timeliness or relevance of research (9/24), mutual mistrust (8/24) and power and budget struggles (7/24). CONCLUSIONS: Interview studies with health policy-makers provide only limited support for commonly held beliefs about facilitators of, and barriers to, their use of evidence, and raise questions about commonsense proposals for improving the use of research for policy decisions. Two-way personal communication, the most common suggestion, may improve the appropriate use of research evidence, but it might also promote selective (inappropriate) use of research evidence.

[Evaluation of reimbursement applications for new drugs]. / Vurderinger av refusjonssøknader for nye legemidler.

BACKGROUND: It has been suggested that decisions about which drugs should be reimbursed by the Norwegian National Insurance Administration (NIA) are ad hoc and made without explicit criteria for evaluating applications. MATERIAL AND METHODS: We assessed all documents that we were able to retrieve from the NIA for a sample of 31 applications to add new drugs to the drug benefit program, mainly in the 1990s. The assessment was done with respect to two questions. First, to what extent were different factors explicitly evaluated, such as treatment effects, side effects, cost-effectiveness and reimbursement costs? Second, to what extent did these factors affect the decisions that were made? RESULTS: We found documents for 19 of the 31 drugs. For the 19 drugs and nine factors that we considered as potentially important in making a decision (a total of 19 x 9 = 171 possible assessments), we found a total of only eight explicit written evaluations. In 10 out of 19 cases costs to the NIA and control of these costs, or use of the drug, appeared to have an important impact on the decision that was reached. INTERPRETATION: Based on the documents to which we have had access, the NIA's evaluations have not been systematic or transparent for the vast majority of drugs.