Swiss Centre for International HealthSwiss Tropical and Public Health Institute

University of Basel

Using evidence to improve health systems: developing evidence-informed guidance on health systems

Xavier Bosch-Capblanch

19th Cochrane Colloquium, Madrid 21st October 2011

2

Project: health systems guidance handbook

– WHO wanted to develop a handbook to produce health systems guidance

– Team: Swiss TPH and NKCHS, assisted by a task force

– Approach: adaptation of methods to produce clinical guidelines

If imitation is the sincerest way of flattery, the clinicians who promoted evidence-based medicine in the 90s should feel flattered

Yamey G, Feachem R. Evidence-based policymaking in global health – the payoffs and pitfalls. BMJ 2011.

3

Picots on a tatted insertion. The picots are the small, oval-shaped loops arranged in threes at the top of the tatted material.

Wikipedia

Francois Edouard Picot - Odalisque (1829) (Stair Sainty Gallery, London)

http://www.mypicot.com/

PICOT in ‘Google’

4

Streptococcus pneumoniae is one of the leading causes of invasive disease, bacterial pneumonia and meningitis among children in low-income countries.

Lucero MG et al. Pneumococcal conjugate vaccines for preventing vaccine-type invasive pneumococcal disease and X-ray defined pneumonia in children less than two years of age. Cochrane Library.

PICOT in the field of public health

Participants: healthy infants

Intervention: pneumococcal vaccine

Comparison: placebo or other vaccines

Outcomes: invasive disease, X-Ray penumonia

Time: follow up 24 months

5

Participants

Intervention

Comparison

Outcomes

Time

Timely

Oriented towards policy

Problem driven

Implementation

Context

Research question Health systems guidance

6

Quality of care:

i) Self-reported outcome measures:

a. of health status and health–related quality of life

b. of patient satisfaction and experience with the process of care.

ii) Clinical behaviours (e.g., prescribing, referrals, treatments)

iii) Intermediate clinical and physiological indicators (e.g. blood pressure)

Scott A et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Library.

Health system problems may be defined in different ways

P

7

Donabedian 1990 Maxwell 1992 HSRG 1992 O'Leary 1992

Patient centeredness Patient perspective

Acceptability Acceptability

Legitimacy

Accessibility Accessibility Accessibility

Equity Equity

Efficacy Efficacy

Effectiveness Effectiveness Effectiveness Effectiveness

Efficiency Efficiency Efficiency Efficiency

Continuity / coordination

Comprehensiveness

RelevanceHSRG: Health Services Research Group

Campbell SM et al. Soc Sci Med 2000

PDifferent definitions on quality of care

8

Types of interventions: Managerial supervision

Types of outcome measures: many (providers, adherence, coverage…)

Bosch-Capblanch X et al. Managerial supervision to improve primary health care in low- and middle-income countries. Cochrane Library.

Types of interventions: we included any type of intervention that…

Types of outcome measures: consumer’s skills for online health literacy

Car J et al. Interventions for enhancing consumers' online health literacy. Cochrane Library

Scope of problems and interventions

Problems:

Interventions:

P

9

PBasic health system problems

10

Lavis JN. How Can We Support the Use of Systematic Reviews in Policymaking? PLOS Medicine 2009.

PFirst step in policymaking process

Don de Savigny, Adam T. Health Systems Thinking. WHO

11

Quino. Mafalda. http://www.clubcultura.com/clubhumor/mafalda/frases/frase_felipe.htm

What if before starting doing what ought to be done

we start doing what we should have

done?

O

12

2. when the recommendation is against an intervention and the 95% confidence interval (or alternative estimate of precision) around the pooled or best estimate of effect

a. the 95% confidence interval (or alternative estimate of precision) around the pooled or best estimate of effect includes no effect and the lower confidence limit includes an effect that, if it were real, would represent a harm that, given the benefits, would still be unacceptable

GRADEProfiler help (3.6)

Complexity of evidence

O

13

It is beneficial to give routine malaria chemoprophylaxis in sickle cell disease in areas where malaria is endemic.Oniyangi O et al. Malaria chemoprophylaxis in sickle cell disease. Cochrane Library.

All trials demonstrate benefit in attenuating or reducing plasma viral load and/or increasing CD4 counts. Walson JL et al. Deworming helminth co-infected individuals for delaying HIV disease progression. Cochrane Library.

…these results indicate that routine surgery cannot be recommended unless within the context of a large, well-conducted randomized controlled trial.Jutte PC et al. Routine surgery in addition to chemotherapy for treating spinal tuberculosis. Cochrane Library.

Choice of therapy for second stage Gambiense HAT will continue to be determined by what is locally available, but eflornithine and NECT are likely to replace melarsoprol, with careful parasite resistance monitoring.Lutke V et al. Chemotherapy for second-stage Human African trypanosomiasis. Cochrane Library.

Immunoglobulins seem to be effective for pre-exposure and post-exposure prophylaxis of hepatitis A. However, caution is warranted for the positive findings due to the limited number of trials, year of conductance, and risk of bias..  Ping Liu J et al. Immunoglobulins for preventing hepatitis A. Cochrane Library.

O

14

It is not possible to draw any conclusions about the effectiveness of strategies to change organisational cultureParmelli E et al. The effectiveness of strategies to change organisational culture to improve healthcare performance. Cochrane Library.

The findings suggest interventions relating to hospital nurse staffing models may improve some patient outcomes… However, these findings should be treated with extreme caution due to the limited evidence available from the research conducted to date. Butler M et al. Hospital nurse staffing models and patient and staff-related outcomes. Cochrane Library.

There is a need to develop rigorous studies to evaluate the effects of social franchising on access to and quality of health services in low- and middle-income countries. Perez Koehlmoos T et al. The effect of social franchising on access to and quality of health services in low- and middle-income countries. Cochrane Library.

The findings of this review do not provide sufficient evidence to support or resist a policy of altering the lengths of primary care physicians' consultations.  Wilson AD et al. Effects of interventions aimed at changing the length of primary care physicians' consultation. Cochrane Library.

There is insufficient evidence for the effectiveness of stress management training interventions to reduce job stress and prevent burnout among healthcare workers beyond the intervention period.  Va Wyk BE et al. Preventive staff-support interventions for health workers. Cochrane Library.

O

15

IMMUNISATION PRACTICES ADVISORY COMMITTEE (TO WHO) - IPAC

• Associate Director of Surveillance and Epidemiology (Canada)• Medical Epidemiologist (Switzerland)• Medical doctor (Switzerland)• Professor of Engineering (USA)• Private Consultant (France)• Adjunct Professor Paediatrics (Jordan)• Maternal Child Health Programme Manager (Nigeria)• Emeritus Professor of Paediatrics (Sri Lanka)• Principal Fellow, Maternal and Child Health (Australia)• Private Consultant (France)• Centre for Data and Epidemiological Surveillance (Indonesia)• Immunization Team Leader (USA)

And observers from Global Health Initiatives, pharmaceutical industry, Non-Governmental Organisations, Research Institutes…

OVery diverse audience

16

The tallest unsupported flagpole measures 165 m (541 ft 4 in), and was erected by Trident Support (USA). It was presented and measured in Dushanbe, Tajikistan, on 24 May 2011. (Guiness World Records)

Annual governmental health budget =(Tajikistan)

O

17

Evidence-related factors limiting the use of research evidence

– “Policy-free” evidence

– Undue focus on RCT

– Poor local applicability

– Lack of focus on social determinants for health

– Lack of complexity

‘External factors’ restricting the use of research evidence:

– Competing influences

– Resources constraints

– Stakeholders and public pressure

– Community views and local competition

Orton L et al. The use of research evidence in public health decision making process: systematic review. PLOS 2011.

Decision to introduce Hepatitis B vaccine at birth related to the death a politician’s friend of liver cancer (IPAC meeting 2011).

OBarriers to the uptake of evidence

18

Adapted contents

Plain language summaires

The evidence was of low to very low quality and the studies showed mixed results. Compared to no supervision, some studies showed that supervision had a small benefit on health worker practices and knowledge, while other studies showed no benefit or were inconclusive. We are therefore uncertain about the effects of supervision on the quality of primary healthcare services. 

Bosch-Capblanch X et al. Managerial supervision to improve primary health care in low- and middle-income countries. Cochrane Library.

O

Thanks to Claire Glenton

19

SUPPORT collaboration

Cochrane Consumers and Communication Review Group

Centre for Health Communication and Participation

O

20

Structured contents

O

21

Cosmetic issues

Thanks to Sarah Rosenbaum

O

22

O

23

– a common taxonomy of HS TOPICs under the policymaking perspective

– a common taxonomy of PICOs questions under the research perspective

– inclusion of non-effectiveness evidence

– a common HS framework to align the approaches of Cochrane reviews on HS

interventions

Can Cochrane reviews be made more appropriate for decision making on health systems?

Implications

PICOTs for TOPICs

24

Contribution / acknowledgments

Project team

Xavier Bosch-Capblanch, Swiss TPH

Simon Lewin, NKCHS (Norway)

Kaspar Wyss, Swiss TPHLise Beck, Swiss TPH

Daniel Dröschel, Swiss TPH

Don de Savigny, Swiss TPH

Taskforce members

Edgardo Abalos, CREP (Argentina);Rifat Atun, GFATMFadi El-Jardali AU Beirut (Lebanon)Timothy Evans, WHOAbdul Ghaffar, AHPSR-WHODavina Ghersi, WHOLucy Gilson, UCT (South Africa)Metin Gulmezoglu, WHOAndy Haines (chair), LSHTM (UK)John Lavis, McMaster U (Canada)Regina Kulier, GRC-WHOSandy Oliver, IOE (UK)Pierre Ongolo-Zogo, CDPBH (Cameroon)Tikki Pang, WHOUlysses Panisset, WHOJohn-Arne Røttingen, NKCHS (Norway)Peter Tugwell, IPH (Canada)Gunn Vist, NKCHS (Norway)

Thanks to Paul Garner for reviewing this presentation

25

Thanks for your attention