In This Issue

June 2009 | Bradford H. Gray

With the inclusion of $1.1 billion for comparative effectiveness research in the 2009 fiscal stimulus bill in the United States, the experience of other countries with such research is of substantial interest in this country. The first article in this issue, “Comparative Effectiveness Research and Evidence-Based Health Policy: Experience from Four Countries,” by Kalipso Chalkidou, Sean Tunis, Ruth Lopert, Lise Rochaix, Peter Sawicki, Mona Nasser, and Bertrand Xerri, describes the work of the relevant agencies in the United Kingdom, France, Australia, and Germany, drawing lessons for the United States. The authors write from firsthand experience in those agencies, as well as from early efforts (under the rubric of technology assessment) in the United States.

Chalkidou and her colleagues describe ten aspects of the work of the cost-effectiveness entities in the four countries, such as prioritization processes, the types of evidence used, relationships to academic and professional groups and to the health care system, and funding sources. Unlike the United States, all four countries explicitly consider costs and cost-effectiveness when making decisions or recommendations. The authors suggest a set of procedural principles and point to the need for a governance structure that broadly represents stakeholders while resisting the paralysis that can result from the involvement of parties at interest. They also discuss the tension between relying on available evidence and carrying out new primary research, as well as the relationship between the development and assessment of evidence and the application of that evidence to policy decisions such as coverage in payment systems.

The next article also is concerned with applying evidence to practice. In “Toward a Transdisciplinary Model of Evidence-Based Practice,” Jason Satterfield, Bonnie Spring, Ross Brownson, Edward Mullen, Robin Newhouse, Barbara Walker, and Evelyn Whitlock compare how thinking about evidence-based practice has developed in medicine, nursing, psychology, social work, and public health. The authors, whose backgrounds are in these fields, describe how each has addressed the topic, particularly how problems common to all are addressed, including what is considered evidence, how patient-specific factors are treated, and the role of expertise. The purpose of this comparative exercise and their article is to propose a model of evidence-based practice that applies to multiple health-related disciplines. They argue that their model has implications for training, practice, and policies, such as those related to licensure and continuing education requirements.

Evaluating the effects of major program reforms can be a challenge for both researchers and policymakers. The next article in this issue applies the “realistic evaluation” approach of Pawson and Tilley (1997) to the assessment of part of the huge effort in the United Kingdom to transform its National Health Service. “How Do You Modernize a Health Service? A Realist Evaluation of Whole-Scale Transformation in London,” by Trisha Greenhalgh, Charlotte Humphrey, Jane Hughes, Fraser Macfarlane, Ceri Butler, and Ray Pawson, is both a methodological and a substantive contribution to the research literature on health services. Realistic evaluation uses multiple methods, including ethnographic observation, semistructured interviews, and reviews of documents, to explore the complex interaction among policies, outcomes, and context.

Greenhalgh and her colleagues focus on services for stroke, kidney disease, and sexual health provided by four large organizations in inner-city London. They describe six key aspects of the modernization effort: integrating services across providers, using evidence, involving service users, supporting self-care, developing the workforce, and extending the range of services. Their findings have applicability beyond the National Health Service, and their article is also one of the first applications of realistic evaluation to large-scale change in health care. Several aspects of their approach are of particular interest, including the researchers’ provision of ongoing feedback to the teams implementing the modernization changes, as well as strategies to minimize researcher bias and heighten rigor.

The next article, “The Converged Experience of Risk and Disease,” by Robert Aronowitz, provides a historical perspective to disease prevention. He suggests that we have not paid enough attention to the increasing tendency to view the risk of disease as a disease in itself. Among the factors contributing to this tendency are the growth of knowledge about the risk factors of chronic diseases; new interventions that can change the natural history of diseases; the enlarged number of people diagnosed with chronic disease as a result of new screening and diagnostic techniques and expanded disease definitions; and more intensive testing and interventions. These changes in our knowledge and thinking have important consequences for medical decision making, the size of the disease/risk population and the market for interventions, the experience and perceptions of disease, and the development of new interventions.

In “Health Consequences of Uninsurance among Adults in the United States: Recent Evidence and Implications,” J. Michael McWilliams summarizes the empirical evidence published since the Institute of Medicine’s 2002 report Care without Coverage: Too Little, Too Late. In this systematic review, McWilliams identifies forty-two new studies, many of which have avoided the methodological limitations of previous research on the topic. He evaluates the methodological strength of the new studies, discusses their significance, draws conclusions, and assesses their policy implications. He finds additional evidence that the lack of insurance, which influences the behavior of both patients and providers, adversely affects health, particularly of people with a variety of acute and chronic conditions. Thus, although universal coverage has many advantages, the health benefits of expanding insurance coverage in the United States may vary within the population.

This issue of the Quarterly concludes with “Housing First for Homeless Persons with Active Addiction: Are We Overreaching?” by Stefan Kertesz, Kimberly Crouch, Jesse Milby, Robert Cusimano, and Joseph Schumacher. The authors review the evidence regarding two approaches to meeting the challenging needs of homeless addicted persons. One is the much publicized “Housing First” approach, which rapidly places such individuals into permanent housing, with supportive services made available but whose use is not required as a condition of receiving housing. In contrast, the “linear” approach makes stepwise moves from rehabilitation settings toward permanent housing.

The authors critically review the research on the two approaches, including information on populations served, costs, and outcomes. They conclude that permanent housing interventions (i.e., Housing First) are most promising for people for whom a nonaddiction psychiatric disorder is the primary problem. The evidence is less clear on how well such programs work for persons with severe substance abuse. The authors note that comparing the research on the two approaches is difficult because they are built on different paradigms regarding conceptions of the problem to be solved, vocabularies and methods, and disciplinary roots (housing policy versus behavioral psychology). They conclude that researchers and advocates should exercise caution when making assertions in this area to policymakers. Research that includes both types of interventions is needed, ideally using randomized controlled designs.

Bradford H. Gray
Editor, The Milbank Quarterly

References
Institute of Medicine. 2002. Care without Coverage: Too Little, Too Late. Washington, D.C.: National Academy Press.

Pawson, R., and N. Tilley. 1997. Realistic Evaluation. London: Sage.

Author(s): Bradford H. Gray

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Volume 87, Issue 2 (pages 335–338)
DOI: 10.1111/j.1468-0009.2009.00559.x
Published in 2009