Processes and mechanisms for contextualizing scientific evidence Moving from HTA to HTPA? Véronique Déry MD MSc, Sylvie Beauchamp PhD, Reiner Banken MD MSc, Lise-Ann Davignon MSc From Evidence to Policy To Practice. 2006 CCOHTA Invitational Symposium. Ottawa, April 3, 2006.
Outline The Canadian Health Technology Strategy Concepts, processes and tools for contextualizing scientific evidence at AETMIS An understanding of HTPA Conclusions
The Canadian Health Technology Strategy (HTS) 1.0 HTS 1.0 proposes moving beyond the traditional notion of HTA. Traditional HTA focuses on providing evidence to support policy decisions ( ) A wider spectrum of evidence is required commensurate with the true broad nature of policy development. An HTPA process is specific to a jurisdiction. Each jurisdiction needs structures to ( ) contextualize the products of HTPA to its environment ( )
What is in a context? Context Etymology: Middle English, weaving together of words, from Latin contextus connection of words, coherence 1.the parts of a discourse that surround a word or passage and can throw light on its meaning 2. the interrelated conditions in which something exists or occurs Merriam-Webster Online Dictionary http://www.mw.com/dictionary/context
Contextualization in HTA: A definition Scientific method that brings forward the different perspectives of key informants on components of a context to construct a multidimensional representation of the issues involved. Source : Adapted from Mucchielli A.Dictionnaire des méthodes qualitatives en sciences humaines et sociales.armand Colin. Paris,2005.
Concepts of contextualization practice at AETMIS
Contextualizing assessments Literature Formal and Informal Interactions with Stakeholders and Decision-makers Literature Review and Critical Analysis Contextual data Context Defining / Refining the Assessment Question (s) and Dimensions
The scope of contextualization Interdisciplinary Approach Issues in decision-making Multidimensional Perspective HTA QUESTIONS Scientific Analysis Context Analysis Conclusions Recommendations
Contextualization- The new kid on the block
Scientific evidence and contextualization as the building blocks of the assessments at AETMIS SCIENTIFIC ANALYSIS DIMENSIONS - Technical performance - Efficacy - Effectiveness - Safety - C/E, APPROACHES - Search strategy - Inclusion/exclusion - Level of evidence - Quality of evidence, CONTEXTUALIZATION DIMENSIONS - Feasibility. Acceptability. Capacity. Compliance - Implementation (costs, consequences, ) APPROACHES - Determination of internal DM context - Determination of external DM context. Jurisdictional. Extra-jurisdictional Can it work? Does it work? Should we do it? Source : AETMIS, 2006; Dobrow MJ et al. Social Science and Medicine 2004; 58:207-217. How should we do it?
The building blocks of contextualization INTERNAL DECISION-MAKING (DM) CONTEXT Purpose/Objectives of DM (Why?) Structure of DM process (Who?) Process used for DM and role of actors (How?) Position of actors (status, DM influence, beliefs, ) (How?) EXTERNAL DECISION-MAKING (DM) CONTEXT JURISDICTIONAL Disease pattern specific Stakeholder specific (actors, influence, position, practices, norms, values, ) Economic, legal, ethical, political, organizational, social issues EXTRA- JURISDICTIONAL SCIENTIFIC ANALYSIS CONTEXTUALIZATION Source : AETMIS, 2006; Dobrow MJ et al. Social Science and Medicine 2004; 58:207-217.
Principles of contextualization Each key informant has his own definition of the issues. The context can be assessed according to elements judged to be relevant. Methods of qualitative research allow to understand without explaining. Previous context knowledge determines the exhaustivity of data collection. Data triangulation allows a synthesis of divergent and convergent definitions. Deliberation to attain consensus is not essential, could even be detrimental The multidimensional representation allows to formulate recommendations that take into account the overall situation. Sources : Mucchielli A. Dictionnaire des méthodes qualitatives en sciences humaines et sociales Paris, Armand Colin; 2005. Leys M. International Journal of Technology Assessment in Health Care 2003; 19(2):317-329.
Continuum of informal data, contextualization and qualitative Informal data research Contextualization Qualitative Research Qualitative Methods: rigour, coherence, data collection, validation Diversification of perspectives Consensus and saturation
Objective Differences between qualitative research and contextualization Selection of key informants Analysis Approach Characteristic Expected results Qualitative Research Production of new knowledge According to the research question Qualitative linked to the research question and the theoretical framework Saturation point of information Contextualization Informing a multidimensional decision According to the assessment question, the context of HT use, and the imperatives of decision-making Qualitative linked to the assessment question and the constitutive elements of the context Diversity of perspectives
Similarities between contextualization and qualitative research Characteristic Rigour Coherence Data Validation Similarity According to same quality standards* (i.e., credibility, transferability, dependability, confirmability **) In all steps of the process Most analysis done with words (i.e., beliefs, opinions, representations, expressed needs, ) Interjudge and triangulation * Different quality assurance (QA) frameworks exist and are used according to specific needs. **As an example, some QA standards are presented. Source : Leys M. International Journal of Technology Assessment in Health Care 2003; 19(2):317-329.
Documenting interactions: A first step for rigorous contextualisation
Tool for contextualization : the record of interaction Objectives: To document the process of contextualization To log the decisions made by the HTA practitioners (milieu, key informants, methods) To plan the next steps of contextualization
Tool for contextualization: the record of interaction Date of event/date of entry Description of key informant Objectives of interaction Methods of data collection Informal meeting Semi directed interview Field observation Other Summary Next steps Name of assesser(s) Source : Adapted from Miles MB. Huberman AM, Analyse des données qualitatives. Éditions du renouveau pédagogique. Bruxelles, 2003.
Moving from HTA to HTPA?
Decision-making Systematic Review Contextualization Field Evaluation Outcome Research Health Technology Policy Analysis
Conclusions Scientific credibility of an HTA (HTPA) depends on the rigour of its scientific processes. Social credibility of an HTA (HTPA) relies on proper contextualization. While not feasible for all HTAs (HTPAs) notably because of time constraints due to decision-making timelines, contextualization contributes to the perceived relevance and utility of HTA (HTPA) (in Quebec). Contextualization shares common grounds with qualitative research in terms of its methods and approaches for assuring rigour, coherence, validation, Contextual validity should be an important methodological issue in HTA (HTPA) as is analytical or clinical validity. Contextualization, combined with systematic reviews, field evaluations and outcome research, could form the basis of the newer concept of HTPA in Canada.
Agence d évaluation des technologies et des modes d intervention en santé 2021 Union Ave., Suite 1040 Montréal (Québec) H3A 2S9 www.aetmis.gouv.qc.ca