Medical Decision Making
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Does One Size Fit All? Investigating Heterogeneity in Men’s Preferences for Benign Prostatic Hyperplasia Treatment Using Mixed Logit Analysis In this study, the authors demonstrate how mixed logit analysis of discrete choice experiment (DCE) data can provide information about unobserved preference heterogeneity. Their application investigates unobserved heterogeneity in men’s preferences for benign prostatic hyperplasia (BPH) treatment. They use a DCE to elicit preferences for seven characteristics of BPH treatment: time to symptom improvement, sexual and nonsexual treatment side effects, risks of acute urinary retention and surgery, cost of treatment, and reduction in prostate size. They investigate the importance of these characteristics and the trade-offs men are willing to make between them. Preferences are elicited from a sample of 100 men attending an outpatient clinic in Ireland. The authors find all treatment characteristics are significant determinants of treatment choice. There is significant preference heterogeneity in the population for four treatment characteristics: time to symptom improvement, treatment reducing prostate size, risk of surgery, and sexual side effects. The importance of preference heterogeneity at the policy level within the context of shared decision making is discussed.
Medical Decision Making - Tập 29 Số 6 - Trang 707-715 - 2009
The Use of Fixed-and Random-Effects Models for Classifying Hospitals as Mortality Outliers: A Monte Carlo Assessment Background. There is an increasing movement towards the release of hospital “report-cards.” However, there is a paucity of research into the abilities of the different methods to correctly classify hospitals as performance outliers.Objective.To examine the ability of risk-adjusted mortality rates computed using conventional logistic regression and random-effects logistic regression models to correctly identify hospitals that have higher than acceptable mortality.Research Design.Monte Carlo simulations.Measures.Sensitivity, specificity, and positive predictive value of a classification as a high-outlier for identifying hospitals with higher than acceptable mortality rates.Results.When the distribution of hospital-specific log-odds of death was normal, random-effects models had greater specificity and positive predictive value than fixed-effects models. However, fixed-effects models had greater sensitivity than random-effects models.Conclusions.Researchers and policy makers need to carefully consider the balance between false positives and false negatives when choosing statistical models for determining which hospitals have higher than acceptablemortality in performance profiling.
Medical Decision Making - Tập 23 Số 6 - Trang 526-539 - 2003
A Comparison of Bayesian Methods for Profiling Hospital Performance There is a growing interest in the use of Bayesian methods for profiling institutional performance. In the literature, several studies have compared different frequentist methods for classifying hospitals as performance outliers. The purpose of this study was to compare 4 different Bayesian methods for classifying hospitals as outcomes outliers, using 30-day hospital-level mortality rates for a cohort of acute myocardial infarction patients as a test case. The 1st Bayesian method involved determining the probability that a hospital’s mortality rate for an average patient exceeded a specified threshold. The 2nd method involved ranking hospitals according to their mortality rate for an average patient. The 3rd method involved determining the probability that a hospital’s standardized mortality ratio exceeded a specified threshold. The 4th method involved ranking hospitals according to their standardized mortality ratio. In most of the scenarios examined, there was only marginal agreement between the different methods. In only 4 of 19 comparisons, was there good agreement between the different methods (0.40 kappa 0.75). Methods based on ranking institutions were relatively insensitive to differences between hospitals. These inconsistencies raise questions about the choice of methods for classifying hospital performance, and they suggest a need for urgent research into which methods are best able to discriminate between institutions and which are most meaningful to decision makers.
Medical Decision Making - Tập 22 Số 2 - Trang 163-172 - 2002
Primary Prevention of Cardiovascular Diseases in General Practice: Mismatch between Cardiovascular Risk and Patients' Risk Perceptions Objective. Guidelines on primary prevention of cardiovascular disease (CVD) emphasize identifying high-risk patients for more intensive management, but patients' misconceptions of risk hamper implementation. Insight is needed into the type of patients that general practitioners (GPs) encounter in their cardiovascular prevention activities. How appropriate are the risk perceptions and worries of patients with whom GPs discuss CVD risks? What determines inappropriate risk perception? Method. Cross-sectional study in 34 general practices. The study included patients aged 40 to 70 years with whom CVD risk was discussed during consultation. After the consultation, the GPs completed a registration form, and patients completed a questionnaire. Correlations between patients' actual CVD risk and risk perceptions were analyzed. Results. In total, 490 patients were included. In 17% of the consultations, patients were actually at high risk. Risk was perceived inappropriately by nearly 4 in 5 high-risk patients (incorrect optimism) and by 1 in 5 low-risk patients (incorrect pessimism). Smoking, hypertension, and obesity were determinants of perceiving CVD risk as high, whereas surprisingly, diabetic patients did not report any anxiety about their CVD risk. Men were more likely to perceive their CVD risk inappropriately than women. Conclusion. In communicating CVD risk, GPs must be aware that they mostly encounter low-risk patients and that the perceived risk and worry do not necessarily correspond with the actual risk. Incorrect perceptions of CVD risk among men and patients with diabetes were striking.
Medical Decision Making - Tập 27 Số 6 - Trang 754-761 - 2007
Are Preferences for Equality a Matter of Perspective? Background . Many subjects attach equal value to different health care programs in surveys eliciting preferences for resource allocation. It has been suggested that subjects may be prepared to attach different priority if they were asked to evaluate someone else’s decision instead of adopting the role of a social decision maker. This study investigated whether the perspective individuals are asked to adopt affects their priority setting decisions and the likelihood of assigning equal value to health care programs. Methods . 1253 members of an Internet panel were presented a set of clinical vignettes describing preventive health care initiatives and were asked to prioritize among these. They choose between “discrimination,” that is, allocating all resources on the better program, and “equality,” that is, dividing the resources equally between programs while reducing efficiency. Respondents were randomized to either of 4 survey versions that differed in terms of perspective (evaluator vs. decision maker) and expert status (expert vs. layperson) of the role to be adopted. Results . Subjects in the evaluator perspectives were more likely to choose equality over discrimination between patients as compared to those in the social decision-maker perspectives, regardless of expert status (odds ratios 2.09 and 2.03, P < 0.0001). Excess rates of equality choices in the evaluator frames resulted from passive acceptance of equality decisions and active revision of prioritization decisions. Conclusion . Preferences for an equal allocation of resources are strongly affected by decision-making perspective but stable across expert status of the adopted role.
Medical Decision Making - Tập 25 Số 4 - Trang 449-459 - 2005
Age Weights for Health Services Derived from the Relative Social Willingness-to-Pay Instrument The effect of a patient’s age on the social valuation of health services remains controversial, with empirical results varying in magnitude and implying a different age-value profile. This article employs a new methodology to re-examine these questions. Data were obtained from 2 independent Web-based surveys that administered the Relative Social Willingness to Pay instrument. In the first survey, the age of the patient receiving a life-saving service was varied. Patients were left with either poor mental or physical health. In the second survey, patient age was varied for a service that fully cured the patient’s poor mental or physical health. In total, therefore, 4 sets of age weights were obtained: weights for life-extending services with poor physical or mental health outcomes and weights for quality-of-life improvement for patients in poor mental or physical health. Results were consistent. Increasing age was associated in each case with a monotonic decrease in the social valuation of the services. The decrease in value was quantitatively small until age 60 years. By age 80 years, the social value of services had declined by about 50%. The decline commenced at an earlier age in the context of physical health, although the magnitude of the decrement by age 80 years was unrelated to the type of service. With 1 exception, there was little difference in the valuation of services by the age of the survey respondent. Respondents aged >60 years placed a lower, not higher, value on quality-of-life improvement for elderly individuals than other respondents. There was no difference in the valuation of life-extending services.
Medical Decision Making - Tập 37 Số 3 - Trang 239-251 - 2017
Probabilistic Sensitivity Analysis Using Monte Carlo Simulation
Medical Decision Making - Tập 5 Số 2 - Trang 157-177 - 1985
Measuring Numeracy without a Math Test: Development of the Subjective Numeracy Scale Background. Basic numeracy skills are necessary before patients can understand the risks of medical treatments. Previous research has used objective measures, similar to mathematics tests, to evaluate numeracy. Objectives. To design a subjective measure (i.e., self-assessment) of quantitative ability that distinguishes low- and high-numerate individuals yet is less aversive, quicker to administer, and more useable for telephone and Internet surveys than existing numeracy measures. Research Design. Paper-and-pencil questionnaires. Subjects. The general public (N = 703) surveyed at 2 hospitals. Measures. Forty-nine subjective numeracy questions were compared to measures of objective numeracy. Results. An 8-item measure, the Subjective Numeracy Scale (SNS), was developed through several rounds of testing. Four items measure people's beliefs about their skill in performing various mathematical operations, and 4 measure people's preferences regarding the presentation of numerical information. The SNS was significantly correlated with Lipkus and others' objective numeracy scale (correlations: 0.63—0.68) yet was completed in less time (24 s/item v. 31 s/item, P < 0.05) and was perceived as less stressful (1.62 v. 2.69, P < 0.01) and less frustrating (1.92 v. 2.88, P < 0.01). Fifty percent of participants who completed the SNS volunteered to participate in another study, whereas only 8% of those who completed the Lipkus and others scale similarly volunteered (odds ratio = 11.00, 95% confidence interval = 2.14—56.65). Conclusions. The SNS correlates well with mathematical test measures of objective numeracy but can be administered in less time and with less burden. In addition, it is much more likely to leave participants willing to participate in additional research and shows much lower rates of missing or incomplete data.
Medical Decision Making - Tập 27 Số 5 - Trang 672-680 - 2007
Validation of a Short, 3-Item Version of the Subjective Numeracy Scale Background and Objective. Efficiency in scale design reduces respondent burden. A brief but reliable measure of numeracy may provide a useful research tool eligible for integration into large epidemiological studies or clinical trials. Our goal was to validate a 3-item version of the Subjective Numeracy Scale (SNS-3). Design and Setting. We examined 7 separate cross-sectional data sets: patients in the emergency department ( n = 208), clinic ( n = 205), and hospital ( n = 460; n = 2053) and patients with chronic kidney disease ( n = 147), with diabetes ( n = 318), and on hemodialysis ( n = 143). Measurements: Internal reliability of the SNS-3 was assessed with Cronbach’s α. Criterion validity was determined by nonparametric correlations of the SNS-3 with SNS-8 and other measures of numeracy; construct validity was determined by correlations with measures of health literacy and education. Results: The SNS-3 had good internal reliability (median Cronbach’s α = 0.78) and correlated highly with the full SNS (median ρ = 0.91). The SNS-3 was significantly correlated with other measures of numeracy (e.g., median ρ = 0.57 with the Wide Range Achievement Test 4), health literacy (e.g., median ρ = 0.35 with the Shortened Test of Functional Health Literacy in Adults), and education (median ρ = 0.41), providing good evidence of criterion and construct validity. Conclusion: The SNS-3 is sufficiently reliable and valid to be used as a measure of subjective numeracy.
Medical Decision Making - Tập 35 Số 8 - Trang 932-936 - 2015
Analytic Choices in Economic Models of Treatments for Rheumatoid Arthritis: What Makes a Difference? Objectives. To compare the analytic judgments, data, and assumptions of different models used in the economic evaluation of infliximab, one of a new class of drugs for rheumatoid arthritis (RA). Methods. A detailed assessment was made of 4 models, 1 submitted (in a reimbursement dossier) by the manufacturer, 1 produced by an independent academic group, and 2 recently published in the literature. Factors considered included the key data inputs, assumptions about the sequencing of treatments for RA, the methods used to calculate health utilities, and the estimation of cost offsets. Results. Two of the 4 models, although embodying different methodological approaches, gave fairly similar results (approximately £25,000–£35,000 cost per additional quality-adjusted life year [QALY] gained). The other 2 models, both by an independent academic group, gave much higher estimates, ranging from £50,000 to £60,000 to more than £100,000 per additional QALY. The differences appeared to depend mainly on differences in model structure, the assumptions about the positioning of infliximab in the treatment sequence, and the relationship between Health Assessment Questionnaire (HAQ) states and QALYs. Conclusions. Economic models of treatments for RA incorporate different key data inputs and analytic judgments. However, convergence was observed in some of the estimates produced by the models, particularly when adjustments were made for some of the differences in input parameters. Nevertheless, differences in the choice of model structure and in key assumptions also had a major impact on results. Therefore, more discussion is needed to reach a consensus on some of these methodological issues.
Medical Decision Making - Tập 25 Số 5 - Trang 520-533 - 2005
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