John N. Lavis, MD, PhD Professor and Canada Research Chair in Knowledge Transfer and Exchange McMaster University Program in Policy Decision-Making McMaster University 27 October 2009 Policy Briefs Workshop: Defining the Problem - Roundtable EVIPNet Policy Briefs Workshop Santiago, Chile

2 Describe the problem in terms of whether it relates to one or more of A risk factor, disease or condition -High and rising prevalence of diabetes (esp. type 2) A program, service or drug currently being used -Many diabetics’ blood sugar and cardiovascular risk factors are not being well monitored and controlled (esp. in comparison) Current health system arrangements within which programs, services and drugs are provided -Few supports to enable effective self-management -About 1/20 diabetics don’t have a primary care physician, and most physicians have few decision supports, no patient roster and no financial incentives for coordinated, proactive care Current degree of implementation of agreed policies -Diabetes Registry has not yet been implemented Q1: What Is the Problem? (CAN)

3 Describe the problem in terms of whether it relates to one or more of A risk factor, disease or condition -High prevalence of type 2 diabetes (esp. among older citizens) A program, service or drug currently being used -Many diabetics’ blood sugar is not being well controlled (HbA1c) Current health system arrangements within which programs, services and drugs are provided -Few supports to enable effective self-management (pt/family) -Poorly functioning interface between first and second levels and few decision supports that influence practice (norms and guidelines, information systems) Current degree of implementation of agreed policies -Networked multidisciplinary teams Q1: What Is the Problem? (COR)

4 Describe the problem in terms of whether it relates to one or more of A risk factor, disease or condition -High prevalence of diabetes, risk factors (overweight/obesity) and complications from diabetes (amputation) A program, service or drug currently being used -Poor adherence to diabetes guidelines among PHC physicians -Many diabetics’ blood sugar is not being well controlled (HbA1c) Current health system arrangements within which programs, services and drugs are provided -Lack of decision supports for PHC physicians, many of whom are new graduates, and more generally a lack of resources (staff) Current degree of implementation of agreed policies Q1: What Is the Problem? (MEX)

5 Describe the problem in terms of whether it relates to one or more of A risk factor, disease or condition -High prevalence of type 2 diabetes, risk factors (overweight) & complications, with urban/rural and ethno-cultural differentials A program, service or drug currently being used -Secondary prevention programs don’t reach many patients, esp. those: 1) in rural areas and from particular ethno-cultural groups, 2) who don’t seek care in formal healthcare sector, and 3) who rely heavily on self-medication Current health system arrangements within which programs, services and drugs are provided -Few ethno-culturally appropriate supports (esp. communication strategies) to enable effective self-management and appropriate engagement with formal sector Current degree of implementation of agreed policies Q1: What Is the Problem? (PAR)

6 Describe the problem in terms of whether it relates to one or more of A risk factor, disease or condition -Higher prevalence of gestational diabetes than in US/Chile and high rates of related hospital admissions and mortality A program, service or drug currently being used -Many indicators proposed but no diagnosis based on their current levels or on changes over time Current health system arrangements within which programs, services and drugs are provided -Many indicators proposed but no diagnosis based on their current levels or on changes over time Current degree of implementation of agreed policies Q1: What Is the Problem? (ARG)

7 Describe the problem in terms of whether it relates to one or more of A risk factor, disease or condition -High prevalence of diabetes, risk factors (overweight/obesity and a poor diet and lack of physical activity) and complications from diabetes (amputation) A program, service or drug currently being used -Health promoters, whose role is to support primary prevention, are offering programs and services that are ineffective or are not offering programs are services that are effective? Current health system arrangements within which programs, services and drugs are provided -Health promoters are not reaching many citizens? Why? Current degree of implementation of agreed policies -Health promoters are not using agreed norms & guidelines? Q1: What Is the Problem? (FEP)

8 Describe the problem in terms of whether it relates to one or more of A risk factor, disease or condition -High prevalence of gestational diabetes and related neonatal mortality, and high prevalence of type 2 diabetes among women of child-bearing age, particularly in the northeast A program, service or drug currently being used -Ministry’s program provides a treatment protocol but adherence to the protocol is low (20%) -Only 16% of diabetics are diagnosed and followed in the formal healthcare sector Current health system arrangements within which programs, services and drugs are provided -? Current degree of implementation of agreed policies Q1: What Is the Problem? (BRA)

9 Most aspects of problem definition require local data Two types of research evidence can be helpful Administrative database studies and community surveys that help to put problems in comparative perspective (e.g., urban/rural and ethnocultural groups in Paraguay, Argentina/Chile & US) Qualitative studies that help to understand how different groups view and experience the problem (e.g., health promoters) Your choice of options hinges on using data and research evidence to clarify a problem in a systematic way, and the options have to match the problem Other Observations