Introduction to Evidence-Based Decision Making in a Public Workers’ Compensation Agency

Peer-reviewed medical literature plays a decisive role in policy development at the Washington State Department of Labor and Industries (L&I). L&I relies on multiple evidence-based mechanisms to make coverage decisions and translate medical science into public policy, including statute, rule writing, executive policy, real-time evidence assessment, pilot testing, and collaboration with researchers. Elements of L&I’s policy process structure and evidence-based culture are also observed in original literature discussing the needs and barriers of incorporating evidence into public policy.

Key points

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Successful policy development and implementation are associated with needs distinct from those of individual clinical encounters.
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The principles of evidence-based medicine remain valuable when applied to population health concerns.
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Characteristics of Washington’s Department of Labor and Industries (L&I) promote the inclusion of original research and evidence-based medicine principles that contribute to quality policy development.
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Washington relies on evidence-based policy to direct resources toward those interventions that work.

Introduction

The Department of Labor and Industries (L&I) is charged with allocating industrial insurance resources to deliver “sure and certain relief for workers, injured in their work, and their families and dependents.” To ensure the responsible stewardship of these resources on behalf of the public, L&I uses as a guide the principle that resources should be directed toward those interventions that work, redirecting resources away from ineffective practices. The paradigm shift and tools that have accompanied the ascendance of the evidence-based medicine movement lend natural support to this objective, consistent with the movement’s goals of deemphasizing “intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision making” as well as to stress “the examination of evidence from clinical research.”

Defined as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients, [t]he practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” To reap the benefits of the research that is the underpinning of evidence-based medicine, L&I has formalized the use of evidence throughout the methods the agency uses to translate medical research into the public policies that protect injured workers and prevent the development and progression of disability.

As a public health agency, regulator, and implementer of policies targeting the health of the entire injured worker population in Washington State, the scope of L&I’s work is necessarily population based, and is thus broader than the integration of clinical acumen and external systematic research on behalf of individual patients described by Sackett and colleagues. Such a population perspective brings with it peculiar needs, the consideration of which continue to be articulated in recent literature recommending the principles and actions that evidence-based medicine should incorporate to best serve patients.

The evidence-based policy literature describes multiple barriers perceived to impair the successful use of academic research in policy development for public health entities, such as L&I. After describing some of those barriers, this article details several of the organizational characteristics and process solutions that have permitted the agency to overcome such hurdles, giving rise to the decisive role that peer-reviewed medical literature now plays in policy development at L&I.

Introduction

The Department of Labor and Industries (L&I) is charged with allocating industrial insurance resources to deliver “sure and certain relief for workers, injured in their work, and their families and dependents.” To ensure the responsible stewardship of these resources on behalf of the public, L&I uses as a guide the principle that resources should be directed toward those interventions that work, redirecting resources away from ineffective practices. The paradigm shift and tools that have accompanied the ascendance of the evidence-based medicine movement lend natural support to this objective, consistent with the movement’s goals of deemphasizing “intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision making” as well as to stress “the examination of evidence from clinical research.”

Defined as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients, [t]he practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” To reap the benefits of the research that is the underpinning of evidence-based medicine, L&I has formalized the use of evidence throughout the methods the agency uses to translate medical research into the public policies that protect injured workers and prevent the development and progression of disability.

As a public health agency, regulator, and implementer of policies targeting the health of the entire injured worker population in Washington State, the scope of L&I’s work is necessarily population based, and is thus broader than the integration of clinical acumen and external systematic research on behalf of individual patients described by Sackett and colleagues. Such a population perspective brings with it peculiar needs, the consideration of which continue to be articulated in recent literature recommending the principles and actions that evidence-based medicine should incorporate to best serve patients.

The evidence-based policy literature describes multiple barriers perceived to impair the successful use of academic research in policy development for public health entities, such as L&I. After describing some of those barriers, this article details several of the organizational characteristics and process solutions that have permitted the agency to overcome such hurdles, giving rise to the decisive role that peer-reviewed medical literature now plays in policy development at L&I.

Public policy and the translation of evidence

Translating the research foundation on which evidence-based medicine rests into public health policy entails difficulties. As Rütten explains, “there are several papers emphasizing that the ‘golden standard’ of evidence-based medicine, with a certain hierarchy of evidence and an emphasis on randomized control trials (RCTs), does not fit well to evidence-based policy.” Distinguishing between the effectiveness of policies containing interventions deemed effective from the effectiveness of those interventions, Rütten also concludes “that interventions proven to be most effective at population level will have no chance to affect the population if the respective policy processes fail to implement them properly.”

Other investigators have also commented on the broader demands made of evidence-based material by the needs of public policy. Boaz and colleagues note that “reviews are now being undertaken for quite diverse purposes. They do not just seek to answer the ‘What works?’ questions that have been considered to be appropriate to medicine. In public policy even that question must be reformulated as ‘What works, for whom, in what circumstances?” In addition, in considering guidelines and coverage policies based on available evidence, public agencies must consider 3 dimensions of evidence: effectiveness, harms, and costs, as is the case with the Health Technology Assessment Program described later.

The character of the policy process also figures prominently in such discourse. Incorporating the research base of evidence-based medicine into health policy that successfully brings the benefits of interventions to populations of people invokes additional considerations not necessarily at work in the decisions made by the individual provider and patient. For example, Bartlett describes how “policy-making is not a rational linear process going from the definition of ends, the gathering of evidence, the formulation of a solution and to its implementation. Rather, policy takes place in a context of bounded rationality, in which political decisions are subject to conflicting pressures from advocacy coalitions and policy transfer from external agencies and institutions.” Or, as Solesbury explains it, evidence-based policy must answer more than just “what works,” but also “what is going on? what’s the problem? is it better or worse than…? what causes it? what might be done about it? at what cost? by whose agency?”

Researchers have articulated barriers to successful policy as well as factors that may contribute to success :

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Visionary leadership
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Personal relationships/contacts with researchers
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Accessible, clearly presented research
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Policy process transparency
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Structured methods to include and analyze relevant and influential data
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Incentivize change; support with training, technical help
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Use demonstrative pilots
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Provide mechanisms to diffuse the knowledge and skill necessary to produce durable change

Frameworks of change: meeting the policy needs of society

L&I is not immune to some of the difficulties that come with incorporating original research evidence into establishing public policy. The agency’s committees (described later) have finite capacities, emphasizing the importance of L&I leadership and its role of prioritizing recommendations for topic selection, thereby furthering its mission and remaining responsive to the needs of the public. Beyond intervention effectiveness, cost and the tradeoffs of resource allocation also figure importantly in implementation planning. Published research is often not designed to answer all the relevant questions that policies need to address, which may dictate choice in policy process: the Health Technology Assessment Program prioritizes topics for which there exists adequate evidence to conduct a complete review. Policy questions may also require a response in less time than a comprehensive review would take.

To address such concerns L&I uses multiple evidence-based processes to deliver coverage policies ( Box 1 ), processes that incorporate many characteristics associated with successful evidence-based policy development:

Box 1

Statutory authority (eg, Prescription Drug Program, Health Technology Assessment Program, Bree Collaborative)
Agency regulatory authority (eg, definitions of proper and necessary care, including requirements for substantial improvement in pain and function outcomes)
Agency executive policy authority (eg, treatment guidelines, opioid regulations)
Real-time evidence assessment (eg, epidemiologic research on causation, research on emerging issues such as Ebola, research in response to legislative inquiries)
Pilot testing (eg, Centers of Occupational Health and Education [COHEs], occupational health best practices)
L&I-funded research, including at the University of Washington: outcomes research, evaluation research (eg, of COHEs), epidemiologic research, research on risk factors for disability

Evidence-based mechanisms for public policy development for health care coverage policy

Although coverage policies and guidelines can address most cases, exceptions to policy may arise when clinical circumstances do not neatly fit existing criteria. For these cases, a robust internal review by occupational health nurses and consulting clinicians (eg, Doctor of Medicine, Doctor of Chiropractic, Doctor of Dental Science) helps determine coverage responsibility. In addition to the evidence-based approaches outlined in Box 1 and these internal review methods, another path may be through the judicial appeals system, wherein a worker or provider may appeal an undesired coverage decision. Although this path ensures reasonable reconsideration for a denied procedure or treatment, the standard is preponderance of evidence based on dueling opinions: the stronger the legal underpinning of evidence-based decisions at the outset, the less likely the need for this judicial process, which is not necessarily as evidence based.

Statutory authority

Bills passed by the Washington State Legislature and signed into law by the Governor create the statutes that frame Washington’s industrial insurance system and provide the legal mandate for L&I’s work. Consistent with the intent of successive governors and legislatures, L&I’s evidence-based approach is substantially authorized in such statutes. Box 2 summarizes the 5 key evidence-based statutes that authorize all public agencies in Washington State that purchase or regulate health care delivery to implement effective evidence-based coverage policies.

Box 2

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