In the early theoretical analysis for my thesis, I came across two key papers: the first is an economic analysis of lifestyle interventions by general practitioners for people with diabetes by Rob Carter and colleagues back in 1997 (Dalton 1997). The second is also an economic analysis, investigating treatment and prevention strategies for obesity commissioned and published by the OECD (Sassi 2009; 2010).
When I say "economic analysis" it means [loosely/broadly] a series of rational hypotheticals to understand what is happening, why, and with what consequences. How it works is you create an evidence-based hypothetical model of a service, or intervention, from the literature, and then you put into the model what you know for sure (from the evidence), then make evidence-informed rationalised assumptions to fill in the gaps to work out stuff like cost-effectiveness. Think of it as a mathematical sequence of events drawn from the literature: if I do this to x, what happens to y?
Or just take this message: economics is a science of decision-making; and health economics is a science of decision-making about health.
This kind of health economic modelling (econometrics) forms one part of the decision-making about health services. You can imagine if you were making decisions about funding one health service over another, the cost effectiveness of a service would be an important part of making that decision. Not the only part of course, and not always the most heavily weighted part of making decisions.
Imagine what happened if we only ever funded the most cost-effective services? What do you think such decision-making would do to equity and justice? This does not mean we blindly fund all health services, or that there should be a blanket fund to anything health. We are all accountable for our use of the scarce resources available, and to do our best to make informed judgements about what we do.
A special note for my dietitian colleagues: my work is about capturing what we do so we can report efficiency and effectiveness. If you feel anxious about this kind of reporting….read related blogs 1 and 2….and know I am here to hold hands as we get on top of this data stuff. Promise. Data will in fact raise and support our professional autonomy and credibility.
Right. Back to the “evidence small changes are good thing”. Carter’s work (Dalton 1997), and more recent, his teaming up with Boyd Swinburn, and Marg Moodie in the ACE series of economic modelling for obesity, consistently supports the early findings:
“…lifestyle changes that can be sustained
over the longer period are better than dramatic changes that cannot be
sustained”
Of course the body of work on the econometrics of prevention and treatment strategies for overweight and obesity are more detailed than this sweeping one-liner I have pulled out of the results. But having read across the literature, I can tell you there is something in the “small changes”. And in fact, Sassi’s work reports:
“The dietitian-GP partnership is
potentially the most cost-effective long term strategy to halt and reverse obesity”I hypothesised the dietitian-GP partnership came out on top is because of the intricacy of making
decisions about food: changing the know what to know how. Dietitians are trained specifically to support behaviour change that is so completely individual driven, public health campaigns for prevention are not sufficient in the day to day challenges of “sticking to the two and five”.
Wait. Before you start tweeting “see small sustainable changes are better” remember how we practice to evidence, and we translate this evidence as suited to the person in front of us? What that means in this scenario is, the evidence suggests, “overall, small changes are good, and are likely cost-effective”. But we know as practitioners some people really do respond better to a dramatic change first, and then need the dietetic support to keep to it – what is best for this person at this time in this clinic with this dietitian? What is the client in front of me really telling me? Of all the options I know of to support this person to achieve their health goals, which ones will I pitch to this person as the MOST SUITABLE option at this time?
Epilogue
Evidence-based practice means the health professional brings all they know about all the evidence, and translates this to present the best option/s for what works for this person at this time. Data from that decision-making provides evidence of what works why/why not to inform clinical decision-making.
Tips du jour:
1. Small changes make a positive contribution to Australia’s health
2. Health economics is one part of the information needed to make decisions about health services
3. Dietitians can make a measurable impact on Australia's health statistics
Other blogs by me
[Series] Trust in professional integrity (March 2014)
March is [unofficially] professional integrity month
The story of dietitians for professional integrity
What is professional integrity?
[Series] Are dietitians effective? (July 2013)
Heads up GPs, we can save $billions together
March is [unofficially] professional integrity month
The story of dietitians for professional integrity
What is professional integrity?
[Series] Are dietitians effective? (July 2013)
Heads up GPs, we can save $billions together
[Other stuff]
References
Organisation for Economic Co-operation and Development (OECD) Publications available at www.oecd.org
Sassi F, Cecchini M, Lauer J, Chisholm D. Improving lifestyles tackling obesity: the health and economic impact of prevention strategies. OECD Health Working Papers No. 48
and
Sassi F. Obesity and the economics of prevention: Fit not fat. OECD 2010
Dalton A, Carter R, Dunt D. The cost-effectiveness of GP-led beahavioural change involving weight reduction: implications for the prevention of diabetes. Centre for Health Program Evaluation, Monash University. Working Paper No. 65 1997
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