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The role of evidence in policy development : the example of in vitro fertilization Baird, Patricia A. 1999

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Centre for Health Servicesand Policy ResearchThe Role of Evidence in PolicyDevelopment:The Example of in vitro FertilizationPatricia A. BairdHPRU99:13D December, 1999Health Policy Research UnitDiscussion Paper SeriesTHE UNIVERSITY OF BRITISH COLUMBIAThe Role of Evidence in Policy Development:The Example of in vitro FertilizationPatricia A. BairdUniversity Distinguished ProfessorFaculty of MedicineUniversity of British ColumbiaAndVice-President, The Canadian Institute for Advanced ResearchDecember, 1999Centre for Health Services and Policy ResearchUniversity of British Columbia429 - 2194 Health Sciences MallUniversity of British ColumbiaVancouver, BCV6T 1Z3The Centre for Health Services and Policy Research was established by the Board ofGovernors of the University of British Columbia in December 1990. It was officiallyopened in July 1991. The Centre's primary objective is to co-ordinate, facilitate, andundertake multidisciplinary research in the areas of health policy, health services research,population health, and health human resources. It brings together researchers in a varietyof disciplines who are committed to a multidisciplinary approach to research, and topromoting wide dissemination and discussion of research results, in these areas. TheCentre aims to contribute to the improvement of population health by being responsive tothe research needs of those responsible for health policy. To this end, it provides aresearch resource for graduate students; develops and facilitates access to health andhealth care databases; sponsors seminars, workshops, conferences and policyconsultations; and distributes Discussion Papers, Research Reports and publicationreprints resulting from the research programs of Centre faculty.The Centre's Health Policy Research Unit Discussion Paper series provides a vehicle forthe circulation of (pre-publication) work of Centre faculty, staff and associates. It isintended to promote discussion and to elicit comments and suggestions that might beincorporated within revised versions of these papers. The analyses and interpretations, andany errors in the papers, are those of the listed authors. The Centre does not review oredit the papers before they are released.A complete list of available Health Policy Research Unit Discussion Papers and Reprints,along with an address to which requests for copies should be sent, appears at the back ofeach paper.The role of evidence in policy development: The example of in vitro fertilizationIntroductionThis paper discusses how in vitro fertilization provides a good example of the fact that researchevidence is only part of a complexly interacting mix in policy development.In vitro fertilization literally means "fertilization in glass". It involves obtaining eggs from awoman; in doing this she is usually injected with hormones to stimulate the production of eggs.Her hormone levels are monitored with blood tests and ultrasound, and just before ovulationoccurs she is given a light anaesthetic, or a sedative and local anesthesia. An ultrasound-guidedhollow needle is passed through the vaginal wall into her pelvic cavity to the ovary. Usually it ispossible to aspirate and retrieve several eggs. They are put into a petri dish where either freshsperm, or thawed sperm that has been frozen and stored, is added to them. The petri dish is keptin an incubator and on the third day, those eggs that have fertilized and produced dividing zygotesare available for transfer to a uterus. So as to increase the chances of pregnancy several zygotesare usually transferredFrom this description it is clear that the technology doesn't need the individuals themselves tohave ever interacted or even to have met. Fertilization outside the body opens up the reproductiveprocess to being manipulated in different ways, with the consequence that a child can be producedusing IVF in many different scenarios. Four examples illustrate this. The most common scenario iswhere IVF is done using the sperm and eggs of a couple intending to carry the pregnancy andraise the child. Another not unusual category of use is for couples where the woman is older oreven post menopausal. Because live births using older eggs in IVF are much less likely, the couplepay for IVF using the sperm of the man and the egg of a younger third party ; his partner howevercarries the pregnancy and they raise the child . A third scenario occurs when IVF is done using thesperm and eggs of a couple who hire another woman to carry the pregnancy, but they intend toraise it - so called IVF surrogacy. IVF can also be done using the sperm and eggs of a couplewho hand over the zygote to another couple who carry the child and raise it - embryo donation.This brief list does not exhaust the possibilities of permutation and combination of how IVF maybe used.If we consider only situations where cohabiting couples wish to have IVF using their owngametes and intend to carry and raise the child, they are usually divided into several clinicalcategories. The most often used ones are:• Fallopian tube blockage• Endometriosis• Ovulatory problems• Sperm defects• Unexplained infertility-Is IVF equally useful or indicated for each of these? Before going over what the evidence on thisis, it is worth noting the difficulties of assessment in this area and why it is not easy or straightforward to answer the question.Factors to be considered in assessing IVFEven if nothing is done, couples who come for treatment have some chance of having a child. It isonly possible to assess how many births are due to treatment if you know how many births wouldhave occurred in that group of couples if they had just kept on trying without treatment. And howmany would have occurred anyway depends not only on which of the above categories they fallinto, but on how long they have been trying, and the age of the woman, because the longer theyhave been trying without success, and the older the woman is, the less likelihood of having a baby.The Royal Commission on New Reproductive Technologies found that many clinics take coupleswith a relatively short duration of trying to conceive, and pregnancies without any treatmentwould not be uncommon in these people.(I)This is illustrated by some surveys of the general population done for the Royal Commission. Ifinfertility is defined as the percentage of couples where the woman is between 18 to 44, who are2cohabiting for one year without contracepting, but who don't become pregnant, then 8.5% areinfertile. If you change the definition, to require a time period of two years, then 7% are definedas infertile. This means that in the general population about 18% of those defined as infertile afterone year of trying, become pregnant during the next year, simply by waiting longer.Data on the background live birth rate in couples who come for treatment and are followed beforetreatment are rare, but a recent Canadian multi-centre study found the cumulative rate ofconceptions leading to live birth in untreated infertile couples who came to them was 14.3% at 12months.(2) We know that treatment-independent pregnancies occur in women who are put onwaiting lists, therefore the number of births following treatment is not a direct measure ofeffectiveness of treatment. It is also necessary to know the baseline rate for the group untreatedbefore you can assess how much, or if, the live birth rate has increased from baseline.As background, it is worth knowing that the average monthly chance of conception for couples inthe general population who are not using a contraceptive method is about 20-25% (There is arange in couples' ability to conceive, so the peak conception rate is 33% in the first month oftrying, then it falls quickly) .What is the research evidence on results of IVF?A meta analysis was done 8 years ago for the Royal Commission, looking at the effectiveness ofIVF for each of the previously listed categories currently used to justify IVF in couples. A priori,the Commission decided that IVF would be considered effective for a given category ifappropriately designed randomized clinical trials existed that allowed meta analysis of combinedstudies to give a total of at least 200 couples in the control and 200 couples in the treatmentgroups, and a greater chance of a liveborn infant was found in the treatment group.Researchers for the Commission identified a total of 501 randomized trials in the literature.Relatively few were of sufficient quality for meta analysis - for example the method ofrandomization was unstated or pseudo randomized in 200 of the 501 trials. Many studies reported3only pregnancy rates, not live births, and since many IVF pregnancies are lost, it is not useful touse the pregnancy rate as a successful outcome.The research showed that IVF gave a better chance than no treatment of having a liveborn childfor bilaterally blocked tubes. This is the indication less than half the time it is used. IVF was foundunproven for the other categories of indication. That is not to say it is ineffective - the evidence tojudge simply was not available. There was not enough reliable evidence for the remainingcategories to say whether the treatment was more likely to result in a livebirth than no treatment.One comment about the fourth category - sperm defects. The Commission examined classical IVFfor sperm defects, but a technique in its infancy at that time, called intracytoplasmic sperminjection used in conjunction with IVF, has become widespread for male infertility.Thatconstitutes another whole topic of its own, which is not addressed in this paper.-Perhaps the Commission's work is now out of date and there is better proof that IVF works?After all, IVF is very widely practiced - surely the data are better now? Because of the debateregarding funding of IVF services in Alberta, the Alberta Heritage Foundation commissioned areport in 1997 on the current status of IVF.This was a very thorough review of all studies published in the 5-year period 1992-97.(3) It foundthat IVF has diffused widely without comprehensive assessment of its efficacy and safety. It foundinadequate and insufficient data, with small uncontrolled studies with different designs, differingpatient populations and differing definitions of outcome measures. It found that "reliableconclusions cannot be drawn on the effectiveness of IVF for most indications other than damaged,occluded and absent fallopian tubes. For other indications, the present evidence does not establishwhether IVF is more effective than conventional treatment or no treatment".So in a nutshell - IVF gives a better chance of a liveborn baby if there is bilateral tubal occlusion,for other indications we do not know yet if it is better than no treatment. Overall, the live birthrate per IVF treatment cycle is 15.5% currently in data from Britain based on about 27,000 cycles4in the year 1997, and about 14.0% if you base the rate on the more than 128,000 cycles done overthe six years 1991-1997.(4)Risks. costs and complicationsThere are risks and costs to both the women and children involved, as well as costs to the healthcare system and other social systems which have to deal with the complications and consequencesofIVF. What are immediate risks to the woman from the treatment? The ovulation inducinghormones used may cause ovarian hyperstimulation syndrome - which can be mild, moderate orsevere. (Severe occurs in 0.4 - 4.0% of cycles) Ovarian enlargement, nausea, vomiting, visualdisturbances and fluid retention may occur. Severe cases occur in a small percentage of cycles andmay have complications which on occasion are life threatening or fatal. Bleeding and infection inthe pelvis do not occur often but as with any invasive procedure, they do occur.With regard to the long term, a large review in 1993 raised the possibility that women who hadreceived these hormones had a 2-3 times increased risk of ovarian cancer years later. Infertilityitself may be a risk factor for ovarian cancer, and longer term follow-up of large cohorts ofwomen who have been in IVF programs will be needed to clarify this.There are other risks as well. A pregnancy after IVF is more likely to be multiple - to be twins,triplets or quadruplets. Counting the percentage of pregnancies that are multiple, which is usuallydone, understates the problem, because one pregnancy may give rise to several infants - and it isthese as individuals who may have complications and ongoing problems. In the British IVFregistry data, 47%, and in the Canadian data, 40%, of individual babies born after IVF come froma multiple pregnancy.(4)For the mother, multiple pregnancy poses risks of toxemia, difficult delivery, caesarian section,post delivery haemorrhage etc. If she's carrying three or more, she usually spends several to manyweeks in hospital. Miscarriage occurs in about 25% of women who test as pregnant after IVF.5Being multiple also poses risks for the fetuses. They are much more likely to be premature andlow birth weight. The percentage of IVF babies that are low birth weight «2500 gm.) is shownbelow:-General Population <6%IVF singletons 12%IVF twins 55%IVF triplets 94%Neonatal intensive care, which is very expensive, is more likely to be needed, and low birthweight infants after fertility treatment are becoming a significant cost for neonatal units. In fact ahigh proportion (262/328) of the triplet and quad pregnancies in Britain take place after IVFtreatment. The cost consequences of prematurity and low birth weight do not stop at neonatalcare. At every stage, multiple births entail higher costs to parents, and to health and socialservices and educational systems.(5) Developmental delays and cerebral palsy are more common,and low birth weight children have more hospitalizations and limitations of activity. And asubstantial proportion of the .Ym low birth weight children will require continuing care andspecial educational, vocational and support services for a good part of their lives. IVF babies have3-4 times the population rate for still birth and for deaths in early life.In Canada, and in fact in most countries, the long-term outcomes are presently not welldocumented. IVF clinics usually do not have data subsequent to the birth, and the Commissionfound that some do not even have birth outcome, but use pregnancy rates as their measures ofsuccess.Another complication which requires resources is ectopic pregnancy, which is at least 25 times ascommon after IVF, and risks the life of the mother, so that the pregnancy has to be terminated.These occur in a few percent of women after IVF, possibly partly because women with tubalproblems are selected for IVF.6Because of all the hazards of multiple pregnancy, selective reduction, where some fetuses areaborted to give the others a chance to survive, is frequently offered.Another cost, which is not measured in dollars but which is real, is that women and their partnershave to cope with the psychosocial and emotional effects of treatment failure, since in any cycle oftreatment by far the most likely outcome is failure to have a baby .And then lastly, there are the financial costs. The out-of-pocket cost to couples in the U.S. isbetween $8-12,000 per cycle. A 1994 study in a Boston hospital showed the marginal costsincurred per successful delivery after IVF were about $67,000 US for the first cycle of treatmentto $114,000 for the 6th cycle. For older couples in some diagnostic categories, the cost was$800,000 per cycle because there were so few live births to this group.(6)The current situation of IVF use in CanadaA 1996 survey of provincial and territorial medical insurance plans showed only Ontario pays forIVF, and it pays for 3 cycles of IVF treatment for patients with bilateral tubal occlusion.(7) PEl,pays a part of physician charges for patients having IVF at a private clinic in Halifax. Currently,there are less than two dozen IVF facilities in Canada located in six provinces (11 of them inOntario). Most are located within public facilities but are private clinics. IVF is a field wheremedical practice has developed outside the publicly supported system to a much greater extentthan most other fields.Although the IVF procedure itself is not funded publicly in most of Canada, most associated costsare billed to provincial medical plans. For example the diagnostic tests and consultations fordiagnosis are usually covered, and in addition laparoscopies, ultrasound exams and blood tests formonitoring are probably billed to the medical plans. And of course, any complications that occurare a cost to the public medical care system - the miscarriages, ectopic pregnancies, prematurebirths, neonatal intensive care and care for ongoing medical or educational problems.7The private IVF clinics are usually owned and operated physicians. Physician ownership ofmedical facilities providing services has been shown to increase the use of those services when thephysician is in a position to recommend they are needed.(8) The publicly funded medical systemunavoidably ends up bearing financial costs generated by the private clinics, with no means ofrecovering those costs from private clinics. The nature and number of privately provided IVFservices are determined solely by the private providers, but they have unavoidable consequencesfor the public system - which has no way of controlling them in light of its own priorities. Theexistence of private clinics undercuts the system's ability to set priorities in allocating resources.In essence, a large part of the cost of IVF is already being funded by provincial health plans, andthe costs consequent to IVF that the public system has to pick up means that private services arevery heavily subsidized by the taxpayer. If the amount charged to patients at private infertilityclinics reflected all costs actually involved as it is now practiced in this country, fees would haveto be set much higher and fewer prospective clients would be able to afford it.Do we have reliable data on the way IVF is practiced and the outcomes in Canada?The short answer is no. In a 1991 cross country survey of IVF facilities, the Commission foundincomplete and unsatisfactory record keeping; for example a third of clinics didn't record multiplebirths, and a sixth of them didn't have information on outcome at all. It found that theinformational material provided to patients was often unclear, and that consent forms variedenormously. In most material there was little mention of risks of multiple birth and itsconsequences. I think it is inexcusable that good information about multiple pregnancy is not astandard part of disclosure for consent to IVF. The Commission found that "success" rates werevariously defined, so that whether consent to treatment was informed was questionable for someprograms. Half of the programs had no limit on the number of treatment cycles. Half said they didnot provide information to the Voluntary Registry which some practitioners had made valiantefforts to develop.8Some Canadian practitioners have made strenuous efforts to develop a voluntary registry, butthere is still a dearth of data on outcome after IVF in Canada. For 1992 it recorded 524 live birthsafter 4,154 treatment cycles started, or a live birth rate of 12%. This probably represents about3,000 women, 70% of them in Ontario. There are no follow-up data on long term effects. Thedata collected are not specific to treatment cycles, they are incomplete, and data on the outcomeof pregnancy are lacking or not well monitored. However, for the years 1987-92; it has thefollowing data.(9)Pregnancy outcome unknown 13.4%For the remaining 86.6% of pregnancies:22.5% spontaneous abortion5.1% ectopic pregnancy31.5% low birth weightWhat would the research evidence suggest as policy?This would be from the point of view of a policy maker trying to maximize the general good,using finite funds. I can tell you what policies the Royal Commission recommended. Itrecommended that IVF be offered as treatment only for indications where it has been shown to beeffective - to date, this is bilaterally blocked fallopian tubes. It was judged to be misleading topatients and costly to the health care system to offer IVF as a treatment for indications where ithas not been proven to be effective; it should be offered in those situations in the context ofresearch trials in which women are fully informed participants. We recommended that multi-centreclinical trials and evaluation for other categories of indications for use of IVF be carried out, andon the basis of the resulting evidence be considered for coverage.Because of the consequences I outlined earlier, the Commission believed that IVF should not beoffered except in a regulated manner through the public system. To offer it only to those who canpay for the procedure is unjust, commercializes family formation, and puts serious burdens on themedical care system because of inappropriate use. We recommended that all facilities should be9required to have a licence from a regulatory body, and that to obtain a licence, certain standardsshould be complied with. These included such things as provision of clear information on successrates defined in a standard way; risks being disclosed to prospective participants in understandableand standard formats; and specified data being collected and reported to a central registry.Some decisions are not medical decisions, for example, whether post menopausal women shouldhave access to young eggs, or whether other kinds of third party reproduction should bepermitted. These are decisions society has a legitimate interest in, and not private decisionswithout any consequences for others. The Commission recommended a regulatory agency be putin place with legislation that made it mandatory for all IVF facilities to be licensed and itrecommended that licensed facilities should not provide IVF in all situations requested. If researchevidence or social attitudes change, it would be possible for the regulatory agency to adjust itspolicies, without going back to legislation.What are the forces and interests at play in influencing policy development?Why is IVF very widely disseminated and practiced in spite of being invasive, costly, withsignificant harmful side effects, and a lack of evidence that it works other than for blocked tubes?Obviously, there are some forces and interests at play here. There are numerous players in thisarena; misinformation abounds and is actively, but not always knowingly, disseminated to thepublic and to prospective users, in the service of particular interests.Some of the players and factors are:• Service providers working in clinics, laboratories and supporting facilities have a vested interestin believing IVF works, and they actively promote the use of IVF. Many of them, even somemedically trained IVF practitioners, do not have the relevant expertise to evaluate whether it iseffective or not. Many assume all the births after IVF are because ofIVF, and many stronglybelieve they are bringing a benefit to those they treat - and perhaps not completely unrelated, thisbelief aligns with their interests.• Most infertile couples do not have the background to evaluate evidence on effectiveness, andthey are told by IVF clinics and physicians, and indeed strongly believe, that IVF is their best10chance of having a baby. Having a family is central in most of our lives, and people are willing togo to great lengths if they think a certain course will enable them to have a child. Strong emotionsare involved, motivating them to lobby for what they perceive as their chance to have a baby oftheir own. Those who can well afford IVF talk in the rhetoric of individual choice, and freedom tochoose, and they emphatically do not want to see limits on their options.These two groups have strong perceived interests in not wanting regulation or limits to theiroptions. They are self identified and are strong and effective lobbyists not to have regulation.• Women's groups are another advocacy source, but their positions have differed from one toanother, with some advocating banning IVF, many others advocating accountability in how it isused and a few advocating free choice. There is no one single position by women's groups.• The public in general is very aware of the importance to people's emotional lives of having afamily. As a result , because most people think IVF works, they think couples who want to have itshould beable to do so. "Miracle baby" stories with identifiable happy parents make much betternews than the risks and failures, which are not newsworthy, and do not usually involve identifiablepeople. For example, the birth of quintuplets and pictures of their parents are a "news" story, buttheir on-going handicaps and developmental delays at age 2 or 3 years are not, so that most of themedia coverage to date has not been balanced. The public is much more aware of the successesthan aware of the failures and tragedies.• Governments (both federal and provincial) have been reluctant to set limits in such anemotionally loaded area - in this context it is very easy for government to be portrayed in themedia as harshly and tyrannically denying couples the chance at a family. As a result, privateclinics have basically been without oversight or limits. The provincial medical plans have beenreluctant to cover IVF, probably feeling that not covering it will save money. But leaving itoutside accountability in the private clinics does not save their budgets money - in fact, it justmeans they subsidize IVF yet can't control policies in how it will be used. If IVF were coveredand regulated, it likely would cost less because of more appropriate use.11• There are some macro "structural" factors at playas well. Canada is a federated nation and thismakes it more complex to get coordinated policy across the country. We are also in an era whenfederal/provincial relationships are being redefined, with the provinces wanting more say. Thismakes national leadership on any front more complex and difficult.The Commission proposed a National Regulatory Body at a time when the federal governmentwas focused on the Referendum regarding separation of Quebec from Canada. The climate ofintergovernmental authority clearly was not conducive to them taking a lead on policyimplementation. The federal government was not able to act authoritatively - its leadership rolewas under threat. At that time any proposed national initiative could be used as a lightning rod toshow that the Federal government was telling Quebecers what to do. That meant an "equivalent"way had to be developed for Quebec to look after its own provincial policy, in a way congruentwith the other provinces. This takes time and is more complex.The Commission proposed a new regulatory body at a time when all the federal thrust was onbudgetary restraint to get the national debt under control. The government said that reducing thedebt was its number one priority, and toward that end put a big emphasis on down-sizing ingovernment. It proposed an initiative that no department had budgeted for, and there were noidentified funds to set it up. So in order to become funded and implemented, it had to competewith other priorities and to displace something already funded. Doing anything new in a time ofbudgetary restraint and down-sizing is extremely difficult.A last effect of the budgetary restraint was a government policy of decreasing staffing andrestructuring the bureaucracy. As a result, individuals were moved around frequently, and so theydid not get to know a portfolio in depth, or come to understand the implications of policy optionsin this area. The knowledge base and champions for appropriate policy initiation within thegovernment bureaucracy for reproductive technologies was lacking.12A last aspect, one that is generalizable and affects many areas of policy making, is that the public ingeneral have diffuse rather than concentrated interests, and this may be an impediment to getting policy inthe public interest implemented. Groups such as medical professional groups, researchers, or infertilitygroups are well organized, have a large personal stake in policy decisions - their interest is concentrated ­and they have a disproportionate influence on policy. They may be able to skew policy and it is in theirinterest to do so.For example, our recommendations are seen as a threat to self regulation and autonomy by some medicalprofessional groups, and they make strong representation against them to decision-makers. This is in spiteof the fact that the preferences and priorities of individuals with concentrated interests may be quitedifferent than those expressed by members of the general public. Those who would benefit fromregulation are diffuse, not self identified, and without an organized voice or resources. It is all of us whohave a stake in the effective use of medical resources and in the kind of community we live in. Theopponents - medical professional groups; individuals who want the procedure and can pay for it - are wellorganized, and have a large personal stake in policy decisions.So special interest groups are more likely to influence policy decisions than those holding diffuse publicinterests, even though the latter are far more numerous.Significant policy change in this area will require that the federal government be seen to be and actas a legitimate policy broker with provinces in particular, and that it enact federal legislation. It isalways easier for governments to do nothing than to act, so it may take a high profile harm in thefield of reproductive technology use for the public to become concerned enough that politiciansfeel they have to regulate.Although the window for policy implementation has not been open, it may now be opening. Theissue of reproductive technology use, including IVF, seems to have come nearer the top of thepolitical agenda. It has been announced there is to be legislation in the New Year. Publiclyprovided care for important medical services is part of Canadian public values . Currently in mostfacilities, the people able to have IVF are limited to those with either money or private insurance,or those willing to barter their eggs for the service. The Commission found the public consensus13in Canada is not to go the way of the market for forming families. Policy intervention to changethe balance between state, health care professionals, and private financial interests in this arearequires consolidation of political authority and the will. If that evolves, I think the Canadianpublic in general will be supportive of regulation and more evidence-based use.(1O)References1. Proceed with Care: Final Report ofthe Royal Commission on New ReproductiveTechnologies . Canada Communications Group, Ottawa. 1993.2. Collins, lA. et al. The prognosis for live birth among untreated infertile couples.Fertility and Sterility. 64(1):22-28, 1995.3. Corabian P. In vitro fertilization and embryo transfer as a treatment for infertility.Alberta Heritage Foundation/or Medical Research. HTA 3,1997.4. Human Fertilisation and Embryology Authority. Seventh Annual Report. TheStationery Office, U'K, 1998.5. Bergh et al. Deliveries and children born after in-vitro fertilisation in Sweden 1982-95:A retrospective cohort study. The Lancet. 354:159-1585, 1999.6. Neumann, PJ. et al. The cost of a successful delivery with in vitro fertilization.New England Journal ofMedicine. 331(4):239-243, 1994.7. A report on IVF services in Canada.1n/ertility Awareness Association ofCanada.Ottawa. 1996.8. Hillman, RI. et al. Frequency and costs of diagnostic imaging in office practice:A comparison of self-referring and radiologist-referring physicians. New England Journal0/Medicine. 323(23):1604-1608, 1990.9. Leader, A. The Canadian IVF Registry experience - How are we doing? Journal SOGe.17:272-278, 1995.10. Tuohy, C.H. What drives change in health care policy: A comparative perspective.The Timlin Lecture. University of Saskatchewan, Saskatoon, Saskatchewan. 1995.14HEALTH POLICY RESEARCH UNITCentre for Health Services and Policy Research429 - 2194 Health Sciences MallUniversity of British ColumbiaVancouver, B.C. CANADAV6T 1Z3Telephone:Fax:Website:(604) 822-4969(604) 822-5690www.chspr.ubc.caDISCUSSION PAPERS & REPRINTSHPRU99:13D The Role ofEvidence inPolicy Development: The Example ofinvitro Fertilization. December, 1999 (P. Baird)$8.00HPRU99:12D Explaining the Unk between Socioeconomic Status and Health. February, 1999 (A. Ostry). $8.00HPRU99:11R (C.B. Forrest, G.B. Glade, B. Starfield, A.E. Baker, M. Kang, R.J. Reid) (July, 1999) Gatekeeping and Referral ofChildren andAdolescents to Specialty Care, Pediatrics, Vol. 104, No.1. No Charge.HPRU99:10D Patterns ofSpecialist ofReferral for Patients with Newly-diagnosed Diabetes inAlberta. August, 1999 (R. J.Reid, B.Starfield, C.B. Forrest, P.W. Ladenson, M. Diener-West). $8.00HPRU99:9D Measuring Morbidity inPopulations: Performance ofthe Johns Hopkins Adjusted Clinical Group (ACG) Case-mixAdjustment System inManitoba. June, 1999 (R. Reid, L. MacWilliam, N.P. Roos, B. Bogdanovich, C. Black). $10.00(This discussion paper isbeing simultaneously released as aworking paper ofthe Manitoba Centre for Health Policyand Evaluation, University ofManitoba).HPRU99:8D Housing and Health Inequalities: Review and Prospects for Research. July, 1999 (J.R. Dunn). $8.00HPRU99:7D Summary report ofthe incidence andprevalence ofworker injury and subject outcome inBritish Columbia: Arecordlinkage stUdy. March, 1999 (C. Hertzman, K. McGrail, R. Hirtle). $8.00HPRU99:6D Social Capital 4: An Empirical Exploration ofRelationships among Individual-level Social and Human CapitalAttributes andSelf·rated Health Status inSaskatchewan, Canada. February, 1999 (Gerry Veenstra). $5.00HPRU99:5D Determinants ofHealth: Impact on Health and Social Policy. Summary ofthe 11 1ll Annual Health Policy Conference,Centre forHealth Services and Policy Research. $8.00D=Discussion Paper R=ReprintHEALTH POLICY RESEARCH UNITDISCUSSION PAPERS & REPRINTSHPRU99:4D Reducing Birth Defects inPopulations. January, 1999 (PabiciaA BaiId). $8.00HPRU99:3D Social Capital 3:An Empirical Exploration ofRelationships among IndMdlJlJl-Jevei Social-Psychological andActionComponents ofSocial Capital. January, 1999 (Gerry Veenstra). $8.00HPRU99:2D Social Capital2: Results from Empirical Exploration into the Relationship between Social Capital and thePerformance ofDistrict Health Boards in Saskatchewan, Canada. January, 1999 (Gerry Veenstra). $8.00HPRU99:1 D Social Capita/1:An Hypothesized Relationship between Social Capital inCommunffies and Effective PolmcalGovernance byRegional Health Authorities. January, 1999 (Gerry Veenstra, Jonathan Lomas). $8.00HPRU98:15R (Robert G. Evans, Morris L Barer) (1998) Anancing and Delivering Health Care inCanada: Lots ofSound and Fury,but Uttle "Reform", Korean Review ofPublic Administration, Vol. 3,No.1, 1998, 25-49. No charge.HPRU98:14D The Utilization ofAcute Care Medical Beds inPrince Edward Island. November, 1998 (Charles J. WrightKaren Cardiff). $8.00HPRU98:13D Utilization ofPalliative Care Services in Vancouver: 199()'1993. November, 1998 (Karen Cardiff, David Hsu andDavid Kuhl). $8.00HPRU98:12D Health for AllorWealth for Some? Conflicting Goals inHealth Care Reform. October, 1998 (Robert G. Evans).$8.00HPRU98:11 D Health Reform: What "Business" isitofBusiness? October, 1998 (Robert G. Evans). $8.00HPRU98:10D Income-Related Health Inequality in Canada. October, 1998 (Karin H. Humphries, Eddy van Doorslaer). $8.00HPRU98:9D(a) Waiting Usts and Waiting Times for Health Care inCanada: More Management// More Money?? Summary Report.July, 1998 (PaUl McDonald, Sam Shortt, Claudia Sanmartin, Morris Barer, Steven Lewis and Sam Sheps).No charge.HPRU98:9D(b) Waiting Usts and Waiting Times for Health Care inCanada: More Managementl/ More Money?? Full Report.July, 1998 (Paul McDonald, Sam Shortt, Claudia Sanmartin, Morris Barer, Steven Lewis and Sam Sheps).No charge.HPRU98:8R Evans, R.G. (1998) "New bottles, same old wine: Right and wrong on physician supplY', Canadian MedicalAssociation Journal, March 24, 1998; 158:757-9. No charge.HPRU98:7R Evans, R.G. (1996) "Toward aHealthier Economics (Reflections on Ken Bassett's Problem)~ Health, HealthCare and Health Economics: Perspectives on Distribution (August 1998), pg. 465-500. No charge.2HEALTH POLICY RESEARCH UNITDISCUSSION PAPERS & REPRINTSHPRU98:6D Paper Tiger orToothless Tabby? Regulation ofPrescription Drug Promotion in Canada. July, 1998(Barbara Mlntzes). $8.00HPRU98:5D Ues, Damned Ues, and Health Care Zombies: Discredited Ideas that Will Not Die. March, 1998 (Morris L. Barer,Robert G. Evans, Clyde Hertzman, Mira John) No Charge. (Released as HPI Discussion Paper #10, Health PolicyInstiMe, The University ofTexas-Houston, Health Science Center)HPRU98:4R Evans, A.G. (1996) "Healthy, Wealthy and Cunning? Profit andLoss from Health Care Reform~ The VancouverInstiMe: An Experiment inPublic Education. JBA Press, UBC (1998), p. 446-486.HPRU98:3D The Quick and the Dead: The Utilisation ofHospital Services in British Columbia, 1969 to1995196. February, 1998(Kimberlyn MMcGrail, Robert GEvans, Morris LBarer, Samuel BSheps, Clyde Hertzman and Arminee Kazanjian).$5.00HPRU98:2D Quebec's Drug Insurance Plan: A Prescription For Canada? February, 1998 (Steve Morgan). $5.00HPRU98:1D Genetic Technologies andAchieving Health for PopUlations. January, 1998. (Patricia A. Baird). $5.00HPRU97:14R (C.B. Forrest, A. J.Reid) (November/December, 1997) "Passing The Baton: HMOs' Influence On Referrals ToSpecialty Care.," Health Affairs, Vol. 16, no. 6,p. 157-162. No Charge.HPRU 97:13R (Robert G. Evans) (March, 1997) "Health care reform: who's selling the market, and why: Journal ofPublic HealthMedicine, Vol. 19, no. 1,pp.45-49.HPRU 97:12R (Morris L. Barer, Laura Wood) (Fall 1997) "Common Problems, Different "Solutions": Learning from InternationalApproaches to Improving Medical Services Access for Underserved Populations~ Dalhousie Law Journal, Vol. 20,no. 2, p321-358. No Charge.HPRU 97:11 R (Peter N. Nemetz, Cynthia Leibson, James M. Naessens, Mary Beard, Eric Tangalos, Leonard T.KUrland) (1996) •Determinants ofthe Autopsy Decision:AStatistical Analysis"American Journal ofClinicalPathology, Augus~ 1997 Vol. 108 No.2.HPRU 97:10D Cloning ofAnimals and Humans: What should the Policy Response be? September, 1997 (Patricia A. Baird). $5.00HPRU97:9D Adapting to Adversity, Protecting the Principles, Resisting Reactionary "Reforms": Canada's Health Care SystemIn the 1990s (August 1997) (Robert G. Evans). $5.00HPRU 97:8R (Cameron A. Mustard, Anita L. Kozyrskyj, Morris L. Barer, Sam Sheps) (May, 1997) "Emergency Department UseAsAComponent ofTotal Ambulatory Care: APopulation Perspective" Canadian Medical Association Journal,January 13, 1998; 158(1). No Charge.3HEALTH POLICY RESEARCH UN1TDISCUSSION PAPERS &REPRINTSHPRU 97:70 Acute Medical Beds: How Are They Used In British Columbia? April, 2997 (Chides Wright, Karen Cardiff, MilesKIlshaw). $8.00HPRU 97:6R (David R. Meddings, Clyde Hertzman, Morris L. Balef', Aobert G. EvaRS, Anninee Kazanjian, KImberlyn M. McGrail,Samuel B. Sheps) (1997) "Socioeconomic Status,Mortality, and the Development of Cataract ata YoungAge", Social Science and Medicine (June 1998) VoI46(11): 1451-1457. No charge.HPRU 97:50 Issues for Canadian Pharmaceutical Policy. FebruaJY, 1997 (Steven G. Morgan). $8.00HPRU 97:40 Mortality and MorbidityAssociated with the Distribution ofMonthly WelUire Payments. March, 1997 (Glen Verheul,Sharon Manson Singer, James M. Christenson). No charge.HPRU 97:30 Global Consumption from the Perspective ofPopulation Health. January, 1997 (Clyde Hertzman, Shona Kelly). $5.00HPRU 97:20 Utili~tlon ofPhysician Services In the United States byResidents ofOntario. January, 1997 (Steven J. Katz,Diana Verrilli, Morris L. Barer). $8.00HPRU 97:10 Evaluating Amendments to the Canadian Patent Act. January, 1997 (Steve Morgan, Morris L. Barer). $5.00HPRU 96:14R (R. Chamberlayne, B. Green, M. L. Barer, C. Hertzman, W. Lawrence, S.Sheps) (1998) "Creating a Population­Based Unked Health Database: ANew Resource for Health Services Research", Canadian Journal ofPublic Health89(4):270-73 July/Aug, 1998.HPRU 96:13R a-d a) Maticka-Tyndale, E., Godin, G., LeMay, G, Adrien, A., Manson-Singer, S., Willms, D., Cappon, P., Brade~ R.(1996) "Canadian Ethnocultural Communities Facing AIDS: OverviewandSummary ofSurvey Results fromPhase 1/1." Canadian Journal ofPublic Health, 87-supplement 1,May-June 1996, pp 838-42. No charge.b) Godin, G.,Maticka-Tyndale, E., Adrlen, A., Manson-Singer, S.,Willms, D.,Cappon, P., Bradet, R., Daus, T.,(1996) ·Understanding Use ofCondoms Among Canadian Ethnocultural Communities: Methods and MainFindings ofthe Survey. "Canadian Journal ofPublic Health, 87-supplement 1,May-June 1996, pp. 833-37. Nocharge.c) Manson-Singer, S., Willms, D., Adrien, A., Baxter, J., Brabazon, C., Leune, V., Godin, G., Maticka-Tyndale, E.,Cappon, P. (1996) •Many Voices -Sociocultural Results ofthe Ethnocultural Communities Facing AIDS Study inCanada. "Canadian Journal ofPublic Health, 87-supplement 1,May-June 1996, pp. S26-32. No charge.d) Adrlen, A., Godin,G.,Cappon, P., Manson-Singer, S., Maticka-Tyndale, E., Willms, D. (1996) "Overview oftheCanadian Study on the Determinants ofEthnoculturally Specific Behaviours Related to HIV/AIDS."CanadianJournal ofPublic Health, 87-supplement 1,May-June 1996, pp. 84-10. No charge.HPRU 96:12R Meddings, D.R.,SA Marion, M.L. Barer, R.G. Evans, B. Green, C. Hertzman, A. Kazanjian, K.M. McGrail, S.B.Sheps, "Mortality Rates After Cataract Extraction~ Epidemiology 10(3):288-293, May, 1999.HPRU 96:110 To Be orNot To BeinHospital: ANew Approach to an Old Problem. October 1996. (Karen Cardiff, Samuel B.Sheps, David M. Thompson) $8.004HEALTH POLICY RESEARCH UNITDISCUSSION PAPERS & REPRINTSHPRU 96:1 aD Price Regulation ofPharmaceuticals In Canada. October 1996. (Aslam H. Anls, Quan Wen) $8.00HPRU 96: 9D Therapeutic Management ofHIV Disease Among Physicians inaHIVlAJDS Drug Treatment Program: The Role ofExperience and Physician Characteristics In Adherence to Clinical Guidelines. September 1996 (Katherine V. Heath,Robert S. Hogg, Joel Manson-Singer, Martin T. SChechter, Michael V. O'Shaughnessy, Julio S.G. Montanger) $8.00HPRU 96:8D Some Data Issues inGenetics Research: Registries, Record Unkage, and Privacy Protection. June 1996 (PatriciaBaird) $5.00HPRU 96:7D The Eyes Have It: Cataract Surgery and Changing Pattems ofDay Surgery. June 1996 (David R. Meddings,Kimbe~yn M.McGrail, Morris L. Barer, Clyde Hertzman, samuel B. Sheps, Robert G. Evans, Arrnlnee Kazanjian)$8.00HPRU 96:6R Barer, M.L., Lomas, J., Sanmartin, C. (1996) uRe-minding Our Ps and Qs: Medical Cost Controls inCanada" HealthAffairs, 15:2, Summer 1996, pp 216-234. No charge.HPRU 96:5D What's Been Saidand What's Been Hid: Population Health, Global Consumption, and the Role ofNational HealthData Systems. February 1996 (Clyde Hertzman) $8.00HPRU 96:4R Robert G. Evans (1996) "Going for Gold: the Redistributive Agenda Behind Market-Based Health Care Reform~Journal ofHealth Politics, Policy and Law, Vol. 22, No.2, April 1997. No charge.HPRU 96:3D Sharing the Burden, Containing the Cost: Fundamental Conflicts inHealth Care Finance.January 1996 (Robert G.Evans) $8.00HPRU 96:2D Regulating Reproductive Technologies: Individual and Societal Interests. January 1996 (Patricia Baird) $5.00HPRU 96:1 D Isthere Ufe After Death (of Federal Transfers). December 1995 (Michael Mendelson) $5.00HPRU 95:9D Environment and Health in the Philippines. December 1995 (Clyde Hertzman, Elma B. Torres, Ronald D. Subidaand Maria Barroetavena). No ChargeHPRU 95:8R Evans, R.G., Barer, M.L., Stoddart, G.L. (1995) 'User Fees for Health Care: why aBad Idea Keeps Coming Back (Or,What~ Health Got toDo with It?)' Canadian Joumal on Aging, Vol. 14 no. 21995, 360-390. No charge.HPRU 95:7D Physician Expenditure Control in Canada: Re-minding our Ps and Qs. September, 1995 (Morris L.Barer,Claudia C. Sanmartin and Jonathan Lomas). Cost $7.00.5HEALTH POLICY RESEARCH UNITDISCUSSION PAPERS & REPRINTSHPRU 95:6R Barer, Morris L., Mannor, Theodore R., Morrison, Ellen M. (1995) "Health Care Reform inthe United States:On the Road to Nowhere (Again)?" Soc. ScI. Mad. Vol 41, No.4, pp 453·460. No charge.HPRU 95:5R Robert G. Evans, Anthony J.Culyer (1995) "Mark Pauly on Welfare Economics: Normative Rabbits from PositiveHats·, Journal ofHealth Economics 15 (1996) 243·251. No chargeHPRU 95:40 The Effects ofBritish Columbia's Physician Payment Initiatives: Making Sense ofthe Dollars. March, 1995(Robert G. Evans, Marina V. Pascali and Morris L. Barer). Cost $8.00.HPRU 95:30 Research inHuman Genetics: Promise, Pitfalls and Policy Challenges. February, 1995 (Patricia Baird, M.O.).Cost $5.00.HPRU 95:20 Marketing the Market, RegUlating Regulators: Who Gains? Who Loses? What Hopes? What Scope? January,1995. (Robert G.Evans). Cost $8.00.HPRU 95:1R Barer. M.L.. "So Near, And Yet So Far: "A Canadian Perspective on U.S. Health Reform"", Journal ofHealth Politics,Policy and Law, Vol. 20, No.2, Summer, 1995.HPRU 94:10R Hogg, R.G., Strathdee, SA, Craib, K.J.P., O'Shaughnessy, M.V. and Montaner, J.S.G., Schechter, M.T. 'Lowersocioeconomic status and shorter survival following HIV infection", The Lancet, Vol 334, p 1120-1124. No charge.HPRU 94:9R Evans, R.G. (Fall 1994) 'Health and Wealth', Daedalus, Journal ofAmerican Academy ofArts and Sciences123 (4): 21-42. No charge.HPRU 94:80 An Empirical Evaluation ofComputerized Databases for Emergency Care. October, 1994 (George E. Pugh,Joseph K. Tan). Cost $8.00.HPRU 94:7R Evans, R.G., Health, Hierarchy and Hominicls: Biological COffelates ofthe Socia-Economic Gradient inHealth.Refonning Health Care Systems, ad. A.J. Culyer and Adam Wagstaff. Cheltenham: Edwrd Elgar, 1996: 35-64.No charge.HPRU 94:6R Ellencweig, A.Y. and Pagliccia N. (1994), 'Utilization Patterns ofCohorts ofElderly Clients: AStructural EquationModel', Health Services Research 29(2): 225·245. No charge.HPRU 94:50 ItAin't Necessarily So: The Cost Implications ofHealth Care Reform inthe United States. April, 1994(M.L. Barer, R.G. Evans, Matthew Holt, J.I. Morrison). Cost $8.00.HPRU 94:40 Diagnostic and Screening Programs for Fetal Anomalies and Genetic Disease: How should we evaluatethem? April, 1994 (P. Baird). Cost $8.00.6

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