Education And Debate

For Debate: The statistical basis of public policy: a paradigm shift is overdue

BMJ 1996; 313 doi: (Published 07 September 1996) Cite this as: BMJ 1996;313:603
  1. R J Lilford, professor of health services researcha,
  2. D Braunholtz, medical statisticianb
  1. a University of Birmingham, Birmingham B16 9PA
  2. b Nuffield Institute for Health, Leeds University, Leeds LS2 9PL
  1. Correspondence to: Professor Lilford.
  • Accepted 17 June 1996

The recent controversy over the increased risk of venous thrombosis with third generation oral contraceptives illustrates the public policy dilemma that can be created by relying on conventional statistical tests and estimates: case-control studies showed a significant increase in risk and forced a decision either to warn or not to warn. Conventional statistical tests are an improper basis for such decisions because they dichotomise results according to whether they are or are not significant and do not allow decision makers to take explicit account of additional evidence—for example, of biological plausibility or of biases in the studies. A Bayesian approach overcomes both these problems. A Bayesian analysis starts with a “prior” probability distribution for the value of interest (for example, a true relative risk)—based on previous knowledge—and adds the new evidence (via a model) to produce a “posterior” probability distribution. Because different experts will have different prior beliefs sensitivity analyses are important to assess the effects on the posterior distributions of these differences. Sensitivity analyses should also examine the effects of different assumptions about biases and about the model which links the data with the value of interest. One advantage of this method is that it allows such assumptions to be handled openly and explicitly. Data presented as a series of posterior probability distributions would be a much better guide to policy, reflecting the reality that degrees of belief are often continuous, not dichotomous, and often vary from one person to another in the face of inconclusive evidence.

Every five to 10 years a “pill scare” hits the headlines. Imagine that you are the chairperson of the Committee on Safety of Medicines. You have been sent the galley proofs of four case-control studies showing that the leading brands of oral contraceptive, which have been widely used for some five years, …

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