What counts and how to count it: physicians' constructions of evidence in a disinvestment context

Internationally, there is an increasing focus on quality and sustainability measures oriented to reducing inefficiencies in health provision. The use of assisted reproductive technologies (ART) for older women represents a case study in this area. This paper analyses the constructions of evidence brought to bear by ART physicians in the context of deliberative stakeholder engagements (held 2010) around options for restricting public subsidy of ART in Australia. Physicians participated in two deliberative engagements during which they were presented with results of a systematic review of ART effectiveness, as well as ethical and cost analyses. These sessions were part of a broader research program of engagements held with policymakers, community members and consumers. Physicians deliberated around the data presented with a view to formulating an informed contribution to policy. The ensuing discussions were transcribed and subject to discourse analysis. Physicians questioned the evidence presented on the grounds of 'currency', 'proximity', 'selectivity' and 'bias'. We outline physicians' accounts of what should count as evidence informing ART policy, and how this evidence should be counted. These accounts reflect implicit decisions around both the inclusion of evidence (selection) and the status it is accorded (evaluation). Our analysis suggests that participatory policy processes do not represent the simple task of assessing the quality/effectiveness of a given technology against self-evident criteria. Rather, these processes involve the negotiation of different orders of evidence (empirical, contextual and anecdotal), indicating a need for higher-level discussion around 'what counts and how to count it' when making disinvestment decisions.