true 2009-07-14T15:06:18Z 2009-07-14 <p><strong>Objective.</strong> To compare depression health state preference scores across four groups: (1) general population, (2) previous history of depression but not currently depressed, (3) less severe current depression, and (4) more severe current depression. </p><p><strong>Data Sources.</strong> Primary data were collected from 95 general population, 163 primary care, and 83 specialty mental health subjects. </p><p><strong>Study Design.</strong> Stratified sampling frames were used to recruit general population and patient subjects. Subjects completed cross-sectional surveys. Key variables included rating scale and standard gamble scores assigned to depression health state descriptions developed from the Patient Health Questionnaire-9 (PHQ-9) and SF-12. </p><p><strong>Data Collection/Extraction Methods</strong>. Each subject completed an in-person interview. Forty-nine subjects completed test/retest reliability interviews. </p><p><strong>Principal Findings.</strong> Depressed patient preference scores for three of six SF-12 depression health states were significantly lower than the general population using the rating scale and two of six were significantly lower using standard gamble. Depressed patient scores for five of six PHQ-9 depression health states were significantly lower than the general population using the rating scale and two of six were significantly lower using standard gamble. </p><p><strong>Conclusions.</strong> Depressed patients report lower preference scores for depression health states than the general population. <br />In effect, they perceived depression to be worse than the general public perceived it to be. Additional research is needed to examine the implications for cost-effectiveness ratios using general population preference scores versus depressed patient preference scores.&#160; </p> 1004 29 Depression, Rating Scale, Standard Gamble, Cost-utility, Health-related Quality of Life 1406-1423 44 5 2009-07-14T15:12:34Z true 2009-08-31T20:51:36Z 2009-04-01 <div style="display: inline;" class="articleText"><h4 class="h4">Study objective: To be able to adhere to discharge instructions after a visit to the emergency department (ED), patients should understand both the care that they received and their discharge instructions. The objective of this study is to assess, at discharge, patients' comprehension of their ED care and instructions and their awareness of deficiencies in their comprehension.</h4><h4 class="h4">Methods:&#160; We conducted structured interviews of 140 adult English-speaking patients or their primary caregivers after ED discharge in 2 health systems. Participants rated their subjective understanding of 4 domains: (1) diagnosis and cause; (2) ED care; (3) post-ED care, and (4) return instructions. We assessed patient comprehension as the degree of agreement (concordance) between patients' recall of each of these domains and information obtained from chart review. Two authors scored each case independently and discussed discrepancies before providing a final concordance rating (no concordance, minimal concordance, partial concordance, near concordance, complete concordance).</h4><h4 class="h4">Results:&nbsp; Seventy-eight percent of patients demonstrated deficient comprehension (less than complete concordance) in at least 1 domain; 51% of patients, in 2 or more domains. Greater than a third of these deficiencies (34%) involved patients' understanding of post-ED care, whereas only 15% were for diagnosis and cause. The majority of patients with comprehension deficits failed to perceive them. Patients perceived difficulty with comprehension only 20% of the time when they demonstrated deficient comprehension.</h4><h4 class="h4">Conclusion:&nbsp; Many patients do not understand their ED care or their discharge instructions. Moreover, most patients appear to be unaware of their lack of understanding and report inappropriate confidence in their comprehension and recall.</h4> </div> 1006 251 454-461.e15 53(4) 5 2009-09-02T19:38:09Z true 2009-07-13T18:22:02Z 2009-02-02 1003 250 24 18 5 2009-07-13T18:24:00Z true 2009-01-29T14:30:02Z 2009-01-29 <p>For human-subjects research, maximum regulation does not mean maximum protection.<br />Stop regulating minimal risk research, say Scott Kim, Peter Ubel and Raymond De Vries.</p><p><a title="http://www.nature.com/nature/journal/v457/n7229/pdf/457534a.pdf" href="http://www.nature.com/nature/journal/v457/n7229/pdf/457534a.pdf">Nature, 457, </a><a title="http://www.nature.com/nature/journal/v457/n7229/pdf/457534a.pdf" href="http://www.nature.com/nature/journal/v457/n7229/pdf/457534a.pdf">2009</a><a title="http://www.nature.com/nature/journal/v457/n7229/pdf/457534a.pdf" href="http://www.nature.com/nature/journal/v457/n7229/pdf/457534a.pdf">:534-535.</a></p> 966 239 Institutional Review Boards, Minimal-Risk Research http://www.nature.com/nature/journal/v457/n7229/full/457534a.html 534-535 457 5 2009-06-09T21:27:31Z true 2009-01-21T19:50:20Z 2009-01-20 896 205 5 2009-01-21T19:50:20Z true 2009-01-04T20:24:03Z 2009-01-02 <p>OBJECTIVE: To determine whether a moral reasoning exercise can improve response quality to surveys of healthcare priorities METHODS: A randomised internet survey focussing on patient age in healthcare allocation was repeated twice. From 2574 internet panel members from the USA and Canada, 2020 (79%) completed the baseline survey and 1247 (62%) completed the follow-up. We elicited respondent preferences for age via five allocation scenarios. In each scenario, a hypothetical health planner made a decision to fund one of two programmes identical except for average patient age (35 vs 65 years). Half of the respondents (intervention group) were randomly assigned to receive an additional moral reasoning exercise. Responses were elicited again 7 weeks later. Numerical scores ranging from -5 (strongest preference for younger patients) to +5 (strongest preference for older patients); 0 indicates no age preference. Response quality was assessed by propensity to choose extreme or neutral values, internal consistency, temporal stability and appeal to prejudicial factors. RESULTS: With the exception of a scenario offering palliative care, respondents preferred offering scarce resources to younger patients in all clinical contexts. This preference for younger patients was weaker in the intervention group. Indicators of response quality favoured the intervention group. CONCLUSIONS: Although people generally prefer allocating scarce resources to young patients over older ones, these preferences are significantly reduced when participants are encouraged to reflect carefully on a wide range of moral principles. A moral reasoning exercise is a promising strategy to improve response quality to surveys of healthcare priorities.</span></p> 884 50 57-64 35(1) 5 2009-01-04T20:24:03Z true 2008-12-04T12:33:53Z 2008-12-15 <p>BACKGROUND:&#160;To help oncologists and breast cancer patients make informed decisions about adjuvant therapies, online tools such as Adjuvant! provide tailored estimates of mortality and recurrence risks. However, the graphical format used to display these results (a set of 4 horizontal stacked bars) may be suboptimal. The authors tested whether using simpler formats would improve comprehension of the relevant risk statistics.</p><p>METHODS:&nbsp;A total of 1619 women, aged 40-74 years, completed an Internet-administered survey vignette about adjuvant therapy decisions for a patient with an estrogen receptor-positive tumor. Participants were randomized to view 1 of 4 risk graphics, a base version that mirrored the Adjuvant! format, an alternate graph that showed only 2 options (those that included hormonal therapy), a graph that used a pictograph format, or a graph that included both changes. Outcome measures included comprehension of key statistics, time required to complete the task, and graph-perception ratings.</p><p>RESULTS:&nbsp;The simplifying format changes significantly improved comprehension, especially when both changes were implemented together. Compared with participants who viewed the base 4-option bar graph, respondents who, instead, viewed a 2-option pictograph version were more accurate when they reported the incremental risk reduction achievable from adding chemotherapy to hormonal therapy (77% vs 51%; P&lt; .001), answered that question more quickly (median time, 28 seconds vs 42 seconds; P&lt; .001), and liked the graph more (mean, 7.67 vs 6.88; P&lt; .001).</p><p>CONCLUSIONS:&nbsp;Although most patients will only view risk calculators such as Adjuvant! in consultation with their clinicians, simplifying design graphics could significantly improve patients' comprehension of statistics essential for informed decision making about adjuvant therapies.&nbsp;</p><p>Cancer 2008. Published 2008 by the American Cancer Society.</p> 882 17 decision aids, risk, patient education, audiovisual aids 3382-3390 113(12) 5 2008-12-04T19:17:00Z true 2008-12-19T21:05:17Z 2008-12-02 <p>Objective: The authors addressed a lingering concern in research on hedonic adaptation to adverse circumstances. This research typically relies on self-report measures of well-being, which are subjective and depend on the standards that people use in making judgments. The authors employed a novel method to test for, and rule out, such scale recalibration in self-reports of well-being. Design: The authors asked patients with chronic illness (either lung disease or diabetes) and nonpatients to evaluate quality of life (QoL) for the patients' disease. In addition, the authors also asked them to rank and rate the aversiveness of a diverse set of adverse circumstances, allowing examination of both the numerical ratings and ordering among items. Main Outcome Measures: The authors compared patients' and nonpatients' ratings and rankings for the patients' disease and other conditions. Results and Conclusion: The authors found that patients not only assigned higher numerical QoL ratings to their own disease than did nonpatients but also ranked it higher among the broad set of conditions. These results suggest that scale recalibration cannot account for discrepant QoL ratings between patients and nonpatients. More generally, this study presents a new approach for measuring well-being that is not subject to the problem of scale recalibration. </p> 883 28 669-675 27(6) 5 2008-12-19T21:05:17Z true 2008-11-18T14:30:37Z 2008-11-18 <p>Objective: To evaluate the ability of six graph formats to impart knowledge about treatment risks/benefits to low and high numeracy individuals.</p><p>Methods: Participants were randomized to receive numerical information about the risks and benefits of a hypothetical medical treatment in one of six graph formats. Each described the benefits of taking one of two drugs, as well as the risks of experiencing side effects. Main outcome variables were verbatim (specific numerical) and gist (general impression) knowledge. Participants were also asked to rate their perceptions of the graphical format and to choose a treatment.</p><p>Results: 2412 participants completed the survey. Viewing a pictograph was associated with adequate levels of both types of knowledge, especially for lower numeracy individuals. Viewing tables was associated with a higher likelihood of having adequate verbatim knowledge vs. other formats (p &lt; 0.001) but lower likelihood of having adequate gist knowledge (p &lt; 0.05). All formats were positively received, but pictograph was trusted by both high and low numeracy respondents. Verbatim and gist knowledge were significantly (p &lt; 0.01) associated with making a medically superior treatment choice.</p><p>Conclusion: Pictographs are the best format for communicating probabilistic information to patients in shared decision making environments, particularly among lower numeracy individuals.</p><p>Practice Implications: Providers can consider using pictographs to communicate risk and benefit information to patients of different numeracy levels.</p> 880 71 Graphical format Informed decision making Numeracy 448-455 73(3) 5 2008-11-20T02:59:17Z true 2008-11-19T03:03:25Z 2008-11-15 <p> BACKGROUND &amp; AIMS: Although priority for liver transplantation is determined by the model for end-stage liver disease (MELD) score, the quality of organs used is subject to physician discretion. We aimed to determine whether implementation of MELD affected the quality of organs transplanted, the type of patients who receive the higher-risk organs, and the impact of these changes on their posttransplant survival. METHODS: Data were analyzed from the United Network for Organ Sharing of adults who underwent deceased-donor liver transplantation between January 1, 2007, and August 1, 2007 (n = 47,985). Dependent variables included the donor risk index (a continuous variable that measures the risk of graft failure associated with a particular organ) and patient survival after transplantation. RESULTS: The overall organ quality of transplanted livers has worsened since MELD implementation, with an increase in the donor risk index equivalent to a 4% increased risk of graft failure after adjusting for temporal trends (P &lt; .001). This was accompanied by a shift from using the higher-risk organs in the more urgent patients (in the pre-MELD era) to using the higher-risk organs in the less urgent patients (in the post-MELD era). Posttransplant survival has worsened over time (hazard ratio, 1.017/y; P = .005) among the less urgent patients (MELD scores, &lt;20); mediation analysis suggests this change in survival was caused primarily by changes in organ quality. CONCLUSIONS: As an unintended consequence of the MELD allocation policy, patients that are least in need of a liver transplant now receive the highest-risk organs. This has reduced posttransplant survival in recent years among patients with low MELD scores.</span></p> 881 147 1568-74 135(5) 5 2008-11-19T03:03:25Z true 2008-11-04T02:45:24Z 2008-11-01 <p>OBJECTIVE: To experimentally test whether using pictographs (image matrices), incremental risk formats, and varied risk denominators would influence perceptions and comprehension of side effect risks in an online decision aid about prophylactic use of tamoxifen to prevent primary breast cancers. METHODS: We recruited 631 women with elevated breast cancer risk from two healthcare organizations. Participants saw tailored estimates of the risks of 5 side effects: endometrial cancer, blood clotting, cataracts, hormonal symptoms, and sexual problems. Presentation format was randomly varied in a three factor design: (A) risk information was displayed either in pictographs or numeric text; (B) presentations either reported total risks with and without tamoxifen or highlighted the incremental risk most relevant for decision making; and (C) risk estimates used 100 or 1000 person denominators. Primary outcome measures included risk perceptions and gist knowledge. RESULTS: Incremental risk formats consistently lowered perceived risk of side effects but resulted in low knowledge when displayed by numeric text only. Adding pictographs, however, produced significantly higher comprehension levels. CONCLUSIONS: Pictographs make risk statistics easier to interpret, reducing biases associated with incremental risk presentations. PRACTICE IMPLICATIONS: Including graphs in risk communications is essential to support an informed treatment decision-making process.</p> 877 71 Risk communication; Decision aids; Cognitive biases; Patient education 209-214 73(2) 5 2008-11-07T20:01:14Z true 2008-11-07T20:14:48Z 2008-08-25 <p> BACKGROUND: The utilitarian foundation of decision analysis limits its usefulness for many social policy decisions. In this study, the authors examine a method to incorporate competing ethical principles in a decision analysis of liver transplantation for a patient with acute liver failure (ALF). METHODS: A Markov model was constructed to compare the benefit of transplantation for a patient with ALF versus the harm caused to other patients on the waiting list and to determine the lowest acceptable 5-y posttransplant survival for the ALF patient. The weighting of the ALF patient and other patients was then adjusted using a multiattribute variable incorporating utilitarianism, urgency, and other principles such as fair chances. RESULTS: In the base-case analysis, the strategy of transplanting the ALF patient resulted in a 0.8% increase in the risk of death and a utility loss of 7.8 quality-adjusted days of life for each of the other patients on the waiting list. These harms cumulatively outweighed the benefit of transplantation for an ALF patient having a posttransplant survival of less than 48% at 5 y. However, the threshold for an acceptable posttransplant survival for the ALF patient ranged from 25% to 56% at 5 y, depending on the ethical principles involved. DISCUSSION: The results of the decision analysis vary depending on the ethical perspective. This study demonstrates how competing ethical principles can be numerically incorporated in a decision analysis.</span></p> 878 64 763-772 28(5) 5 2008-11-19T02:59:38Z true 2009-01-19T23:28:22Z 2008-08-01 893 202 285-289 112(2) 5 2009-01-19T23:28:22Z true 2008-09-22T14:01:11Z 2008-08-01 <p>Health behavior intervention studies have focused primarily on comparing new programs and existing programs via randomized controlled trials. However, numbers of possible components (factors) are increasing dramatically as a result of developments in science and technology (e.g., Web-based surveys). These changes dictate the need for alternative methods that can screen and quickly identify a large set of potentially important treatment components. We have developed and implemented a multiphase experimentation strategy for accomplishing this goal. We describe the screening phase of this strategy and the use of fractional factorial designs (FFDs) in studying several components economically. We then use 2 ongoing behavioral intervention projects to illustrate the usefulness of FFDs. FFDs should be supplemented with follow-up experiments in the refining phase so any critical assumptions about interactions can be verified.</p> 876 120 1354-1359 98(8) 5 2008-11-10T20:03:21Z true 2008-09-22T14:01:11Z 2008-08-01 <p>OBJECTIVE: The National Institutes of Health and American College of Obstetricians and Gynecologists consensus guidelines state that cesarean delivery on maternal request is not recommended for women desiring several children. We sought to estimate the accuracy with which women were able to predict their final parity. METHODS: Women (N=1,719) completed an Internet survey regarding childbearing. Parous women finished with childbearing recalled the maximum number of children they planned to give birth to while pregnant with their first child. This estimate was compared with their final parity. RESULTS: Of the women who completed the survey, 458 women planned a maximum of two or fewer children and had completed childbearing. Correlation between planned maximum number of children and actual parity was poor (r=0.04, 95% confidence interval 0.00-0.13). In fact, 39% (95% confidence interval 34-43%) underestimated their final parity. CONCLUSION: At the time of first pregnancy, many women underestimate their final parity. This raises questions about making an estimate of parity a consideration for offering cesarean delivery on maternal request. LEVEL OF EVIDENCE: III.</p> 865 202 285-289 112 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2008-07-10 <p>&#160;PURPOSE: Although breast-conserving surgery (BCS) is often assumed to result in minimal deformity, many patients report postoperative breast asymmetry. Understanding the effect of asymmetry on psychosocial functioning is essential for patients to make an informed choice for surgery. PATIENTS AND METHODS: All women who underwent BCS at the University of Michigan Medical Center (Ann Arbor, MI) during a 4-year period were surveyed using a mailed questionnaire (N = 714; response rate = 79.5%). Women were queried regarding five aspects of psychosocial functioning: quality of life (QOL), depression, fear of recurrence, stigmatization, and perceived change in health status. Postoperative breast asymmetry was assessed using items from the Breast Cancer Treatment and Outcomes Survey. Multiple regression was used to examine the relationship between breast asymmetry and each outcome, controlling for age, time from surgery in years, race, education level, disease stage, surgical treatment, and the occurrence of postoperative complications. RESULTS: Women with pronounced breast asymmetry were significantly more likely to feel stigmatized as a result of their breast cancer treatment (odds ratio [OR] = 4.58; 95% CI, 2.77 to 7.55) and less likely to report unchanged or improved health after treatment (OR = 0.43; 95% CI, 0.27 to 0.66). Minimal breast asymmetry was associated with higher QOL scores (86.3 v 82.4, P &lt; .001). Finally, women with pronounced breast asymmetry were more likely to exhibit depressive symptoms (minimal asymmetry, 16.2%; moderate asymmetry, 18.0%; pronounced asymmetry, 33.7%, Wald test = 16.6; P = .002). CONCLUSION: Pronounced breast asymmetry after BCS is significantly correlated with poor psychosocial functioning. Identifying patients at risk for postoperative asymmetry at the time of consultation may allow for improved referral for supportive counseling, prosthetics, and reconstruction.</p> 417 42 3331-7 26(20) 5 2008-11-14T18:36:03Z true 2008-09-22T14:01:11Z 2008-06-15 <p> </p> 572 85 http://ovidsp.tx.ovid.com/spb/ovidweb.cgi?QS2=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 1542-1544 85(11) 5 2008-11-19T03:05:11Z true 2009-01-19T22:41:08Z 2008-06-01 888 129 S195-216 37(2) 5 2009-01-19T22:41:08Z true 2008-09-22T14:01:11Z 2008-05-31 <p>Objective: Patients with chronic health conditions usually place higher utility on their condition than the public does. One explanation for this discrepancy is that healthy people focus on the negative aspects of the condition without considering their own ability to emotionally adapt to the condition over time. The aim of this randomized experimental study was to test whether people would give higher utility ratings for chronic health conditions when they were encouraged to consider their own ability to adapt to difficult situations before giving their ratings. Main Outcome Measure: Utility ratings for four chronic health conditions. Results: The authors presented scenarios describing 4 chronic health conditions to 1,117 respondents drawn from a demographically balanced U.S. Internet panel. The adaptation exercise did not influence respondents’ valuations. However, utility values increasingly improved with decreasing ratings of how upsetting it would be to live with the condition over time. Conclusion: The authors speculate that asking people to think about adaptation changes their evaluations of what it would feel like to live with chronic illness, but doing so does not change how much they are willing to trade off to avoid that chronic illness. </p> 560 28 394-9 27(3) 5 2008-11-14T17:01:30Z true 2008-09-22T14:01:11Z 2008-03-01 <p>Communications of treatment risk, such as medication package inserts, commonly report total rates of adverse reactions (e.g., 4% get heartburn with placebo, 9% with medication). This approach, however, requires mental arithmetic to distinguish the incremental risk caused by medication (here, 5%) from the total post-treatment risk. In two Internet-administered survey experiments (N = 2,012 and 1,393), we tested whether explicitly reporting the incremental risk and framing it as the "additional risk" of complications influenced people's impressions of adverse event risks. Study 1 compared side-by-side displays of total risks against sequential presentations that highlighted the incremental risk, using both text and graphical formats. Results showed that incremental risk formats significantly lowered participants' worry about complications and reduced biases caused by varying the risk denominator. Study 2 unpacked this factor and showed that its effect on both perceived likelihood and worry derives primarily from the incremental risk framing rather than from sequential presentation. Explicitly reporting incremental risk statistics appears to facilitate recognition of how much risk already exists at baseline. Presenting adverse reaction risks in this manner may improve patient comprehension of the effects of treatment decisions and support effective risk communication.</p> 559 47 http://dx.doi.org/10.1080/10810730701854011 107-124 13(2) 5 2008-11-07T20:35:42Z true 2008-09-22T14:01:11Z 2008-01-01 665 146 85-92 3(1) 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2008-01-01 418 125 1795-1810 92(8-9) 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2007-12-01 <p>OBJECTIVE: To test whether providing comparative risk information changes risk perceptions. METHODS: Two hundred and forty-nine female visitors to a hospital cafeteria were randomized to one of two conditions which differed in whether their hypothetical breast cancer risks was lower or higher than the average women's. Participants read a scenario describing a breast cancer prevention pill and indicated their: (1) likelihood of taking the pill and (2) perception of whether the pill provides breast cancer risk reduction. RESULTS: Women told that their hypothetical risk of breast cancer was above average were more likely to endorse taking the pill (2.79 vs. 2.23, F=4.95, p=0.002) and more likely to believe that the pill provided a significant risk reduction in breast cancer (3.15 vs. 2.73, F=4.32, p=0.005), even though the risks were equivalent. CONCLUSIONS: Providing people with comparative risk information changes their risk perceptions. People who have above average risk may feel compelled to take a treatment because they are at above average risk and therefore may not thoroughly consider the trade-offs in the risks and benefits of treatment. PRACTICE IMPLICATIONS: Physicians and decision aid developers must reconsider the practice of communicating "average risk" information to patients.</p> 435 71 140-144 69 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2007-11-01 <p>We tested whether adding interpretive labels (eg, "negative test") to prenatal genetic screening test results changes perceived risk and preferences for amniocentesis. STUDY DESIGN: Women (N = 1688) completed a hypothetical pregnancy scenario on the Internet. We randomly assigned participants into 2 groups: high risk of fetal chromosomal problems (12.5/1000) or low risk (2/1000). After prenatal screening, estimated risk was identical (5/1000) for all participants, but results were provided either alone or with interpretive labels. RESULTS: When receiving test results without labels, all participants react similarly. With labels, the participants who received "positive" or "abnormal" results reported a higher perceived risk (P &lt; .001), greater worry (P &lt; .001), and greater interest in amniocentesis (57% vs 37%; P &lt; .001) than did the participants who received "negative" or "normal" results. CONCLUSION: Interpretive labels for test results can induce larger changes to a woman's risk perception and behavioral intention than can numeric results alone, which create decision momentum. This finding has broad clinical implications for patient-provider communication.</p> 383 9 528.e1-528.e6 197(5) 5 2008-11-07T20:41:46Z true 2008-09-22T14:01:11Z 2007-10-18 <p>Purpose. To review research from the behavioral sciences that demonstrates how predictions of future events - and memories of past events - are often systematically biased. Method. Description of how these biases present challenges for subjective outcome measurement in rehabilitation settings, and for measuring health utility. Results. Two new techniques for outcome measurement that have been specifically designed to resist these biases - Ecological Momentary Assessment and the Day Reconstruction Method are successful. Conclusion. We propose that these techniques could be adopted for measuring rehabilitation outcomes.</p> 414 114 http://www.galenicom.com/en/medline/article/17943514/Mispredictions+and+misrecollections:+Challenges+for+subjective+outcome+measurement. 1-7 1 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2007-10-01 573 124 http://www.liebertonline.com/doi/abs/10.1089/jpm.2007.0096 1007-1009 10(5) 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2007-10-01 <p><strong>Background.</strong> In a companion article, the authors describe the Subjective Numeracy Scale (SNS), a self-assessment of numerical aptitude and preferences for numbers that correlates strongly with objective numeracy. Objective. The objective of this article is to validate the Subjective Numeracy Scale using measures of subjects' capacity to recall and comprehend complex risk statistics and to complete utility elicitations. Research Design. The study is composed of 3 general public surveys: 2 administered via the Web and 1 by paper and pencil. Subjects. Studies 1 and 3 surveyed 862 and 1234 people, respectively, recruited via a nationwide commercial Internet survey panel. Study 2 involved 245 people who completed paper-and-pencil surveys in a Veterans Administration hospital. Measures. The authors tested whether one's score on the SNS predicted the likelihood of correct recall and interpretation of risk information (studies 1 and 2A) or the likelihood of effectively completing a time tradeoff or person-tradeoff utility elicitation (studies 2B and 3). In Studies 1 and 2, the authors also tested whether an objective test of quantitative ability would predict performance. Results. In all studies, survey participants with higher SNS scores performed significantly better than other respondents. The predictive ability of the SNS approached that observed for objective numeracy. Conclusions. The SNS effectively predicts both risk comprehension and completion of utility elicitations without requiring survey participants to complete time-consuming and stress-inducing mathematics tests. The authors encourage the use of the SNS in a variety of health services research contexts.</p><p>For a copy of the SNS, see our Tools for Researchers section.</p> 413 64 http://mdm.sagepub.com/cgi/content/abstract/27/5/663 663-671 27(5) 5 2008-11-14T17:38:47Z true 2008-09-22T14:01:11Z 2007-10-01 <p>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 <a href="/research_tools/sns">Subjective Numeracy Scale (SNS)</a>, 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 &lt; 0.05) and was perceived as less stressful (1.62 v. 2.69, P &lt; 0.01) and less frustrating (1.92 v. 2.88, P &lt; 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.</p><p>For a copy of the SNS, see our <a href="/research_tools">Tools for Researchers</a> section.</p> 186 64 numeracy, risk communication, decision making, literacy, measurement 672-680 27(5) 5 2008-11-14T17:37:38Z true 2008-09-22T14:01:11Z 2007-09-27 <p>When making many types of decisions, people are confronted with default options — the events or conditions that will be set in place if no alternatives are actively chosen. Because default options are implemented even if decision makers do not actively choose them, they hold a privileged status among all possible choices. Default options strongly influence behaviors in settings that are not related to health care. For instance, employees more frequently contribute to retirement funds in an automatic-enrollment system than they do in systems that require active participation.1 Drivers' preferences for a high tort-insurance option increase when it is offered . . . </p> 334 67 http://content.nejm.org/cgi/content/extract/357/13/1340 1340-1344 357 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2007-09-15 <p>Objective: To summarize existing research on individual numeracy and methods for presenting risk information to patients. Methods: We selectively retrieved articles from MEDLINE and the Social Sciences Citation Index. Results: Many Americans have low numeracy skills, a deficit that impedes effective health care. Approaches to risk communication vary in current practice, but how risks are presented can significantly affect both patients’ risk perceptions and their knowledge. Conclusions: Adhering to some basic principles for presenting risk information to patients can improve understanding. However, different risk-communication methods may be needed for individuals with high versus low levels of numeracy. </p> 331 92 numeracy, decision aids, graphs, visual displays, informed consent, shared decision making, patient education http://www.ajhb.org/2007/s1/Suppl0707Fagerlin.pdf S47-S56 31(Suppl. 1) 5 2008-11-06T23:30:54Z true 2008-09-22T14:01:11Z 2007-09-01 <p>Health decision aids are a potentially valuable adjunct to patient-physician communication and decision making. Although the overarching goal of decision aids--to help patients make informed, preference-sensitive choices--is widely accepted, experts do not agree on the means to achieve this end. In this article, the authors critically examine the theoretical basis and appropriateness of 2 widely accepted criteria used to evaluate decision aids: values clarification and reduction of decisional conflict. First, they argue that although clarifying values is central to decision making under uncertainty, it is not clear that decision aids--as they have been conceived and operationalized so far--can and should be used to achieve this goal. The pursuit of clarifying values, particularly values clarification exercises, raises a number of ethical, methodological, and conceptual issues, and the authors suggest research questions that should be addressed before values clarification is routinely endorsed. Second, the authors argue that the goal of reducing decisional conflict is conceptually untenable and propose that it be eliminated as an objective of decision aids.</p> 503 64 http://mdm.sagepub.com/cgi/reprint/27/5/609 609-618 27 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2007-08-01 <p>We examined whether trait disgust sensitivity predicts well-being in colostomy patients, and whether disgust predicts stigmatizing attitudes about colostomy in non-patients. 195 patients with a colostomy returned a mailed survey including measures of disgust sensitivity, life satisfaction, mood, and feelings of being stigmatized. We also conducted an internet-survey of a non-patient sample (n = 523). In the patient sample, we observed negative correlations between a bowel-specific measure of disgust sensitivity and life satisfaction (r = −.34, p<.01), and colostomy adjustment ( r = −.42, p<.01), and a positive correlation with feeling stigmatized because of the colostomy (r = .54, p<.01). Correlations between a general trait disgust measure and these outcomes were more modest. A structural equation model indicated that colostomy patients who had high disgust sensitivity felt more stigmatized, and this was in turn strongly related to lower life satisfaction. Concordantly, in the non-patient sample we observed that disgust sensitivity was a significant, positive predictor of wanting less contact with colostomy patients (r = .22, p < .01).</p> 567 123 787–803 41(4) 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2007-07-01 415 23 51-55 37 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2007-05-01 <p>Person tradeoff (PTO) elicitations assess people's values for health states by asking them to compare the value of treatment programs. For example, people might be asked how many patients need to be cured of health condition X to equal the benefit of curing 100 people of condition Y. However, when faced with PTO elicitations, people frequently refuse to make quantifiable tradeoffs, exhibiting 2 kinds of refusals: 1) They say that 2 treatment programs have equal value, that curing 100 of X is just as good as curing 100 of Y, even if X is a less serious condition than Y, or 2) they say that the 2 programs are incomparable, that millions of people need to be cured of X to be as good as curing 100 of Y. The authors explore whether people would be more willing to make tradeoffs if the focus was changed from trading off groups of patients to choosing the best decision or evaluating treatment benefits. DESIGN: . Two randomized trials used diverse samples (N=2400) via the Internet to test for the effect of perspective on refusal rates. The authors predicted that perspectives that removed people from decision-making roles would increase their willingness make tradeoffs. RESULTS: Contrary to expectations, refusal rates increased when people were removed from decision-making roles. In fact, the more pressure put on people to make a decision, the less likely they were to refuse to make tradeoffs. CONCLUSION: To reduce PTO refusals, it is best to adopt a decision-maker perspective.</p> 323 64 266-288 27 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2007-04-01 <p>Objective: Previous research has demonstrated that people perceive treatments as less effective when survival graphs show fewer years of data versus more data. We tested whether using mortality graphs would reduce this temporal inconsistency bias. Methods: A demographically diverse sample of 1461 Internet users read about a hypothetical disease and then were randomized to view either survival or mortality graphs that showed either 5 years of data or 15 years of treatment outcomes data. Participants identified the most effective treatment, provided ratings comparing the effectiveness of two treatments, and answered comprehension questions. Results: Treatment effectiveness ratings varied significantly between respondents seeing the 5 year and 15 year survival graphs even though the relative risk reduction was the same in both cases. This variation was significantly reduced in the mortality graph conditions. Responses on comprehension measures were mixed: viewers of mortality graphs were less able to identify which treatment was more effective but better able to correctly report individual data points. Conclusions: Perceptions of treatment effectiveness appear more temporally consistent with mortality graphs than with survival graphs. Practice implications: All line-based risk graphics (whether framed in survival or mortality terms) should highlight duration information to facilitate improved comprehension of treatment effectiveness.</p> 188 71 Risk communication, Visual displays, Cognitive biases 100-107 66(1) 5 2008-12-09T02:32:32Z true 2008-09-22T14:01:11Z 2007-01-01 <p>Open-ended methods that elicit willingness-to-pay (WTP) in terms of absolute dollars often result in high rates of questionable and highly skewed responses, insensitivity to changes in health state, and raise an ethical issue related to its association with personal income. We conducted a 2x2 randomized trial over the Internet to test 4 WTP formats: 1) WTP in dollars; 2) WTP as a percentage of financial resources; 3) WTP in terms of monthly payments; and 4) WTP as a single lump-sum amount. WTP as a percentage of financial resources generated fewer questionable values, had better distribution properties, greater sensitivity to severity of health states, and was not associated with income. WTP elicited on a monthly basis also showed promise.</p> 530 57 http://journal.sjdm.org/jdm06163.pdf 96-106 2(2) 5 2008-11-14T19:11:46Z true 2008-09-22T14:01:11Z 2006-11-17 <p>When survey respondents rate the quality of life (QoL) associated with a health condition, they must not only evaluate the health condition itself, but must also interpret the meaning of the rating scale in order to assign a specific value. The way that respondents approach this task depends on subjective interpretations, resulting in inconsistent results across populations and tasks. In particular, patients and non-patients often give very different ratings to health conditions, a discrepancy that raises questions about the objectivity of either groups? evaluations. In this study, we found that the perspective of the raters (i.e., their own current health relative to the health conditions they rated) influences the way they distinguish between different health states that vary in severity. Consistent with prospect theory, a mild and a severe lungdisease scenario were rated quite differently by lung disease patients whose own health falls between the two scenarios, whereas healthy non-patients, whose own health was better than both scenarios, rated the two scenarios as much moresimilar. In addition, we found that the context of the rating task influences the way participants distinguish between mild and severe scenarios. Both patients and non-patients gave less distinct ratings to the two scenarios when each were presented in isolation than when they were presented alongside other scenarios that provided contextual information about the possible range of severity for lung disease. These results raise continuing concerns about the reliability and validity of subjective QoL ratings, as these ratings are highly sensitive to differences between respondent groups and the particulars of the rating task.Keywords: quality of life, health state measurement, prospect theory, medical decision making.</p> 187 57 http://journal.sjdm.org/jdm06018.pdf 146-152 1(2) 5 2008-11-14T19:05:40Z true 2008-09-22T14:01:11Z 2006-09-30 <p>The tendency to overestimate the influence of circumstances on well-being has been demonstrated for a range of life events, but the perceived impact of aging on well-being has been largely overlooked. People seem to dread growing old, despite evidence that well-being improves with age. We compared the self-reported happiness of younger adults (mean age = 31) and older adults (mean age = 68) with their estimates of happiness at different ages. Self-reports confirmed increasing happiness with age, yet both younger and older participants believed that happiness declines. Both groups estimated declining happiness for the average person, but only older adults estimated this decline for themselves.</p> 183 46 167-182 7(2) 5 2008-11-14T18:57:12Z true 2008-09-22T14:01:11Z 2006-07-01 <p>Imagine that you have just received a colon cancer diagnosis and need to choose between two different surgical treatments. One surgery, the “complicated surgery,�? has a lower mortality rate (16% vs. 20%) but compared to the other surgery, the “uncomplicated surgery,�? also carries an additional 1% risk of each of four serious complications: colostomy, chronic diarrhea, wound infection, or an intermittent bowel obstruction. The complicated surgery dominates the uncomplicated surgery as long as life with complications is preferred over death. In our first survey, 51% of a sample (recruited from the cafeteria of a university medical center) selected the dominated alternative, the uncomplicated surgery, justifying this choice by saying that the death risks for the two surgeries were essentially the same and that the uncomplicated surgery avoided the risk of complications. In follow-up surveys, preference for the uncomplicated surgery remained relatively consistent (39%–51%) despite (a) presenting the risks in frequencies rather than percents, (b) grouping the 4 complications into a single category, or (c) giving the uncomplicated surgery a small chance of complications as well. Even when a pre-decision “focusing exercise�? required people to state directly their preferences between life with each complication versus death, 49% still chose the uncomplicated surgery. People’s fear of complications leads them to ignore important differences between treatments. This tendency appears remarkably resistant to debiasing approaches and likely leads patients to make healthcare decisions that are inconsistent with their own preferences.</p> 152 57 risk communication, medical decisions, cognitive biases 64-75 1(1) 5 2008-11-14T17:47:47Z true 2008-09-22T14:01:11Z 2006-06-01 <p> Community members often evaluate health conditions more negatively than do the patients who have them. The authors investigated whether experience with a health condition reduces this discrepancy by surveying colostomy patients by mail (n = 195), some of whom (n = 100) had their colostomies reversed and normal bowel function restored. The authors also surveyed a community sample recruited via the Internet (n = 567). They then compared all 3 groups' utility value for life with a colostomy by using the time trade-off utility measure and by examining ratings of current quality of life. Despite having direct experience with the health condition, former colostomy patients provided much lower utility valuations than did current patients. In fact, their valuations were similar to those given by a community sample. Rather than accurately remembering their actual experiences with colostomies, the former patients may have applied a theory of how colostomies had influenced their lives; this is consistent with other research on theory driven recall bias.</span></p> 321 28 adult, aged, colostomy psychology, female, humans, male, mental recall, Michigan, middle aged, quality of life, questionnaires 688-695 25 5 2008-11-12T23:24:55Z true 2008-09-22T14:01:11Z 2006-06-01 <p>&#160;Few effective treatment options are available for patients with advanced hepatocellular carcinoma (HCC). Some transplant centers have begun offering living donor liver transplantation (LDLT) for selected patients whose HCC exceeds Milan criteria by a small margin. However, this remains a controversial subject. In this article, we weigh the arguments for and against LDLT for advanced HCC. Because donor autonomy forms the crux of this dilemma, the real question becomes: to whom does the decision belong, the individual donors or the medical community? We argue that donor autonomy should not be paramount in settings where the recipient benefit is uncertain.</p> 319 85 hepatocellular carcinoma pathology, hepatocellular carcinoma surgery, humans, Italy, liver neoplasms pathology, liver neoplasms surgery, liver transplantation ethics, living donors ethics, neoplasm staging, risk assessment 1136-1139 82(9) 5 2008-11-14T18:21:40Z true 2008-09-22T14:01:11Z 2006-05-01 <p>BACKGROUND: Many people display omission bias in medical decision making, accepting the risk of passive nonintervention rather than actively choosing interventions (such as vaccinations) that result in lower levels of risk. OBJECTIVE: Testing whether people's preferences for active interventions would increase when deciding for others versus for themselves. RESEARCH DESIGN: Survey participants imagined themselves in 1 of 4 roles: patient, physician treating a single patient, medical director creating treatment guidelines, or parent deciding for a child. All read 2 short scenarios about vaccinations for a deadly flu and treatments for a slow-growing cancer. PARTICIPANTS: Two thousand three hundred and ninety-nine people drawn from a demographically stratified internet sample. MEASURES: Chosen or recommended treatments. We also measured participants' emotional response to our task. RESULTS: Preferences for risk-reducing active treatments were significantly stronger for participants imagining themselves as medical professionals than for those imagining themselves as patients (vaccination: 73% [physician] & 63% [medical director] vs 48% [patient], Ps<.001; chemotherapy: 68% & 68% vs 60%, Ps<.012). Similar results were observed for the parental role (vaccination: 57% vs 48%, P=.003; chemotherapy: 72% vs 60%, P<.001). Reported emotional reactions were stronger in the responsible medical professional and parental roles yet were also independently associated with treatment choice, with higher scores associated with reduced omission tendencies (OR=1.15 for both regressions, Ps<.01). CONCLUSIONS: Treatment preferences may be substantially influenced by a decision-making role. As certain roles appear to reinforce "big picture" thinking about difficult risk tradeoffs, physicians and patients should consider re-framing treatment decisions to gain new, and hopefully beneficial, perspectives.</p> 177 44 choice behavior, decision making, humans, influenza vaccines, patient participation, patient satisfaction, physician-patient relations 618-622 21 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2006-05-01 <p> PURPOSE: Research on survey methodology has demonstrated that seemingly innocuous aspects of a survey's design, such as the order of questions, can produce biased results. The current investigation extends this work by testing whether standard survey introductions alter the observed associations between variables. METHODS: In two experimental studies, we invited Parkinson's disease (PD) patients to participate in a telephone survey of (a) Parkinson's patients, conducted by a regional medical center, or (b) the general population, conducted by a regional university. The survey in Study 1 (n = 156) first assessed life-satisfaction, and subsequently health satisfaction. In Study 2 (n = 99), we reversed the order of the two questions, asking the health questions first. RESULTS: When the introduction focused on Parkinson's disease, we observed an increased correlation between life-satisfaction and a later question about health satisfaction (r = 0.34 vs. 0.63 after general population versus Parkinson's introduction, respectively; Study 1). In Study 2, asking the health questions first resulted in high correlations regardless of the introduction; in addition, judgments of life-satisfaction were lower after the Parkinson's-focused introduction. CONCLUSIONS: When participants were informed prior to the survey that its purpose was to examine well-being in PD, health satisfaction was a much more important component of life-satisfaction, accounting for three times as much variation. We hypothesize that the survey introduction primed participants' health status, resulting in an artificially large correlation with life-satisfaction.</span></p> 176 78 attitude to health, communication, holistic health, humans, interviews methods, Parkinson disease psychology, patient satisfaction, Pennsylvania, personal satisfaction, psychometrics instrumentation, quality of life, research design, sickness impact profi 621-630 15 5 2008-11-12T23:17:34Z true 2008-09-22T14:01:11Z 2006-03-01 320 57 134-145 1(2) 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2006-01-01 <p>&#160;Historically, patients with rare diseases have been underserved by commercial drug development. In several jurisdictions, specific legislation has been enacted to encourage the development of drugs for rare diseases (orphan drugs), which would otherwise not be commercially viable. However, because of the small market, these drugs are often very expensive. Under the standard methods of health technology assessment (HTA) incorporating economic evaluation, orphan drugs do not usually prove to be cost-effective and this, coupled with their high cost, means that funding and patient access may be limited. However, these restrictions may not be in line with societal preferences. Therefore, this study discusses whether the standard methods of HTA are adequate for assisting decisions on patient access to and funding of orphan drugs and outlines a research agenda to help understand the societal value of orphan drugs and issues surrounding their development, funding, and use.</p> 322 32 36-42 23(1) 5 2008-11-14T19:09:32Z true 2008-09-22T14:01:11Z 2005-12-20 <p>PURPOSE Women with BRCA1/2 mutations are faced with complex decisions about breast and ovarian cancer risk management. This study was conducted to determine the effect of a tailored decision support system (DSS) that provides individualized survival and cancer incidence curves specific to expected outcomes of alternative management strategies. PATIENTS AND METHODS This was a double-blind, randomized controlled trial of 32 women with BRCA1/2 mutations. Primary outcome measures were decision satisfaction, cancer anxiety, perceptions of cancer risk given alternative management strategies, and management decisions. Results Twenty-seven women completed a 6-week follow-up. Women in the intervention arm (n = 13) reported significantly higher decision satisfaction at follow-up than women in the control arm (n = 14; adjusted mean difference, 9.7; P &lt; .0005). The effect of the DSS was greater among women with low cancer anxiety at baseline than women with high cancer anxiety at baseline (P = .01 for interaction). However, the DSS did not significantly alter cancer anxiety at follow-up, perceptions of cancer risk given alternative management strategies, or management decisions. CONCLUSION The presentation of individualized survival and incidence curves for alternative management options improves satisfaction about cancer risk management decisions among women with BRCA1/2 mutations without increasing anxiety or changing management decisions. The benefit of the DSS is greatest among women with relatively low cancer-related anxiety at baseline.</p> 173 42 adult, anxiety, breast neoplasms epidemiology, breast neoplasms genetics, breast neoplasms therapy, decision making, clinical decision support systems, double-blind method, female, BRCA1 genes, BRCA2 genes, humans, incidence, middle aged, patient satisfac 9319-9328 23(36) 5 2008-11-14T18:53:23Z true 2008-09-22T14:01:11Z 2005-12-01 <p>Whether the number of organs available for transplant would be positively or negatively affected by providing benefits to families of organ donors has been debated by policymakers, ethicists and the transplant community at large. We designed a telephone survey to measure public opinion regarding the use of benefits in general and of five types in particular: funeral benefits, charitable contributions, travel/lodging expenses, direct payments and medical expenses. Of the 971 adults who completed the survey (response rate = 69%), all were from Pennsylvania households, 45.6% were registered organ donors, and 51.7% were nonwhite. Although 59% of respondents favored the general idea of incentives, support for specific incentives ranged from 53% (direct payment) to 84% (medical expenses). Among those registered as donors, more nonwhites than whites supported funeral benefits (88% vs. 81%; p = 0.038), direct payment (63% vs. 41%; p &lt; 0.001) and medical expenses (92% vs. 84%; p = 0.013). Among those not registered as donors, more nonwhites supported direct payment (64% vs. 46%; p = 0.001). Most respondents believed that benefits would not influence their own behavior concerning donation but would influence the behavior of others. While benefits appear to be favored, their true impact can only be assessed through pilot programs.</p> 172 11 adolescent, adult, aged, aged 80 and over, data collection, ethnic groups, female, humans, insurance benefits economics, interviews, male, middle aged, motivation, tissue donors psychology, tissue donors supply & distribution, tissue and organ procurement http://www.blackwell-synergy.com/doi/full/10.1111/j.1600-6143.2005.01106.x 2999-3008 5 5 2008-11-14T18:54:27Z true 2008-09-22T14:01:11Z 2005-11-15 <p>PURPOSE: When making medical decisions, people often care not only about what happens but also about whether the outcome was a result of actions voluntarily taken or a result of inaction. This study assessed the proportion of people choosing nonoptimal treatments (treatments which reduced survival chances) when presented with hypothetical cancer scenarios which varied by outcome cause. METHODS: A randomized survey experiment tested preferences for curing an existent cancer with 2 possible treatments (medication or surgery) and 2 effects of treatment (beneficial or harmful). Participants were 112 prospective jurors in the Philadelphia County Courthouse and 218 visitors to the Detroit-Wayne County Metropolitan Airport. RESULTS: When treatment was beneficial, 27% of participants rejected medication, whereas only 10% rejected surgery with identical outcomes ( 2 = 5.87, P &lt; 0.02). When treatment was harmful, participants offered surgery were significantly more inclined to take action (65% v. 38%, chi(2) = 11.40, P = 0.001), even though doing so reduced overall survival chances. CONCLUSIONS: Faced with hypothetical cancer diagnoses, many people say they would pursue treatment even if doing so would increase their chance of death. This tendency toward active treatment is notably stronger when the treatment offered is surgery instead of medication. Our study suggests that few people can imagine standing by and doing nothing after being diagnosed with cancer, and it should serve to remind clinicians that, for many patients, the best treatment alternative may not only depend on the medical outcomes they can expect to experience but also on whether those outcomes are achieved actively or passively.</p> 157 64 omission bias,decision-making,survey,cancer 614-619 25(6) 5 2008-11-14T18:55:44Z true 2008-09-22T14:01:11Z 2005-11-10 <p>BACKGROUND: Person trade-off (PTO) elicitations yield different values than standard utility measures, such as time trade-off (TTO) elicitations. Some people believe this difference arises because the PTO captures the importance of distributive principles other than maximizing treatment benefits. We conducted a qualitative study to determine whether people mention considerations related to distributive principles other than QALY-maximization more often in PTO elicitations than in TTO elicitations and whether this could account for the empirical differences. METHODS: 64 members of the general public were randomized to one of three different face-to-face interviews, thinking aloud as they responded to TTO and PTO elicitations. Participants responded to a TTO followed by a PTO elicitation within contexts that compared either: 1) two life-saving treatments; 2) two cure treatments; or 3) a life-saving treatment versus a cure treatment. RESULTS: When people were asked to choose between life-saving treatments, non-maximizing principles were more common with the PTO than the TTO task. Only 5% of participants considered non-maximizing principles as they responded to the TTO elicitation compared to 68% of participants who did so when responding to the PTO elicitation. Non-maximizing principles that emerged included importance of equality of life and a desire to avoid discrimination. However, these principles were less common in the other two contexts. Regardless of context, though, participants were significantly more likely to respond from a societal perspective with the PTO compared to the TTO elicitation. CONCLUSION: When lives are at stake, within the context of a PTO elicitation, people are more likely to consider non-maximizing principles, including the importance of equal access to a life-saving treatment, avoiding prejudice or discrimination, and in rare cases giving treatment priority based purely on the position of being worse-off.</p> 170 73 http://www.pophealthmetrics.com/content/3/1/10 10 3(1) 5 2008-11-14T18:51:58Z true 2008-09-22T14:01:11Z 2005-10-01 <p>BACKGROUND: If an 85-year-old man rates his health as 90 on a scale in which 100 represents perfect health, would his rating mean the same thing as a 90 rating from a 25-year-old? We conducted a randomized trial of 3 different ways of eliciting subjective health ratings from participants in the Health and Retirement Study to test whether the meaning of perfect health changes as people age, causing people to recalibrate their self-reported health ratings to account for their age. METHODS: The Health and Retirement Study (HRS) is a nationally representative, prospective study of 22,000 persons born in 1947 or earlier. The data analyzed in this study come from the self-assessed health utilities module administered in 2002 to 1031 randomly selected HRS respondents. Respondents were randomized to receive one of 3 versions of a subjective health rating task. In the perfect health version, they were asked how they would rate their current health on a scale from 0 to 100, in which 0 represents death and 100 represents perfect health. In the your-age version, the phrase for someone your age was added to the end of the question to encourage people to recalibrate their responses based on age, and in the 20-year-old version, the phrase for a 20-year-old was added to minimize recalibration. RESULTS: A total of 1015 subjects responded to the rating task (98% response rate). Health ratings varied significantly across versions, with subjects responding to the 20-year-old version reporting lower health (mean rating 66 of 100) than those responding to the your-age version (mean rating of 73, P&lt;0.001) or the perfect health version (mean rating of 73, P&lt;0.001). This result suggests that subjects interpret perfect health to mean perfect health for someone your age. However, additional analysis showed that the interpretation of the phrase perfect health lies somewhere between the other 2 versions. For example, responses to the perfect health and 20-year-old versions varied significantly by respondent age (both P's&lt;0.075), whereas responses to the your-age scale did not (P=0.8). CONCLUSION: The phrase perfect health is ambiguous, causing some people to recalibrate their responses based on their age. Such ambiguity threatens the validity of common subjective health ratings, thereby reducing the comparability of responses across people of different ages or different circumstances.</p> 167 62 activities of daily living, age factors, aged, aged 80 and over, analysis of variance, attitude to health, calibration, female, geriatric assessment methods, health status, humans, interviews, male, prospective studies, psychometrics instrumentation, self http://gateway.ut.ovid.com/gw1/ovidweb.cgi?QS2=434f4e1a73d37e8c01e9bb09ab15b39201d3938fc4fac764480bdf67a29cc2698e755d1cf41cd8a179e4af6dda638b370d2948880c0e39fedb562c5f2b3bb09e4f0628090eb2a63f9fc8f46b886a084ea18ee3464a94734f4b65fa2d15391f802e8a5f3412b8e9c10a9d7a98fa5b131e878601758bfa17eba3da9e30c0c18a046f9db727f2857bbc24cefbb042df620025b8324b72639d95cfe17f0a8ec30e02c833871dce5dfec66fad8468ef0ff41eb8dd41f9223c1649e26128871337e00889bb6beef2b76490af8ef59df8a5b466004f54d2c5cc72d30e6069cfd61bfd9af309301a2f232ad3a876c8d34c30f3d0b554e34f99939c0f 1054-1057 43(10) 5 2008-11-14T18:49:44Z true 2008-09-22T14:01:11Z 2005-09-30 165 1 attitude of health personnel, dissent and disputes, emergency medicine trends, hospital emergency service trends, health knowledge attitudes practice, 20th century history, humans, organizational policy, professional-family relations, resuscitation, Unite 999-1002 12(10) 5 2008-11-14T18:50:37Z true 2008-09-22T14:01:11Z 2005-09-01 318 1 46(3) 5 2009-08-31T20:45:03Z true 2008-09-22T14:01:11Z 2005-07-01 <p>BACKGROUND: People's treatment decisions are often influenced by anecdotal rather than statistical information. This can lead to patients making decisions based on others' experiences rather than on evidence-based medicine. OBJECTIVE: . To test whether the use of a quiz or pictograph decreases people's reliance on anecdotal information. DESIGN: . Two cross-sectional survey studies using hypothetical scenarios. Participants read a scenario describing angina and indicated a preference for either bypass surgery or balloon angioplasty. The cure rate of both treatments was presented using prose, a pictograph, a quiz, or a pictograph and quiz combination. Participants read anecdotes from hypothetical patients who described the outcome of their treatment; the number of successful anecdotes was either representative or unrepresentative of the cure rates. Setting and Participants. Prospective jurors at the Philadelphia County Courthouse and travelers at the Detroit-Wayne County Metropolitan Airport. Measurements. Proportion of respondents preferring bypass over balloon angioplasty. RESULTS: . In study 1, when statistical information was presented in prose, treatment choices were influenced by anecdotes, with 41% of participants choosing bypass when the anecdotes were representative and only 20% choosing it when the anecdotes were unrepresentative (x(2) = 14.40, P &lt; 0.001). When statistics were reinforced with the pictograph and quiz, anecdotes had no significant influence on treatment decisions (38% choosing bypass when anecdotes were representative v. 44% when unrepresentative, x(2) = 1.08, P &gt; 0.20). In study 2, the tradeoff quiz did not reduce the impact of the anecdotes (27% v. 28% choosing bypass after receiving or not receiving the quiz, x(2) &lt; 1, P &gt; 0.20). However, the pictograph significantly reduced the impact of anecdotes, with 27% choosing bypass after receiving no pictograph and 40% choosing bypass after receiving a pictograph (x(2) = 6.44, P &lt; 0.001). CONCLUSIONS: . Presenting statistical information using a pictograph can reduce the undue influence of anecdotal reasoning on treatment choices.</p> 161 64 adult, aged, angina pectoris surgery, balloon angioplasty, attitude to health, coronary artery bypass, decision making, female, humans, male, Michigan, middle aged, Philadelphia, questionnaires, statistics http://mdm.sagepub.com/cgi/reprint/25/4/398 398-405 25(4) 5 2008-11-14T18:48:58Z true 2008-09-22T14:01:11Z 2005-07-01 <p>Patients with chronic health conditions often rate their quality of life (QoL) significantly higher than non-patients. One explanation for this discrepancy is that non-patients focus on the negative aspects of the onset of a condition, especially the early difficulties people face when they first experience a debilitating condition, without considering that patients can adapt to it over time. To test this hypothesis, we had 359 people perform person tradeoff (PTO) elicitations in an online survey, varying whether the treatment programs under consideration saved the lives of patients (a) with pre-existing paraplegia; or (b) who would experience new onset of paraplegia. Half of each group completed an adaptation exercise which encouraged them to consider their own ability to emotionally adapt to negative events in general and specifically to having paraplegia. The adaptation manipulation increased the value participants placed on pre-existing paraplegia (p=0.03) and on new onset paraplegia (p=0.05), relative to saving healthy lives. Moreover, the adaptation exercise dramatically reduced the differences between evaluations of pre-existing and new onset paraplegia to values within 2% of each other. Our findings suggest that asking non-patients to do an adaptation exercise before giving QoL ratings may help close the gap in ratings between patients and citizen non-patients.</p> 160 84 psychological adaptation, adult, chronic disease psychology, cost-benefit analysis, data collection, female, health status indicators, humans, male, middle aged, paraplegia physiopathology, quality of life http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6VBF-4FBW5RJ-5-1&_cdi=5925&_user=99318&_orig=search&_coverDate=07%2F31%2F2005&_qd=1&_sk=999389997&view=c&wchp=dGLbVtz-zSkWA&md5=b25326ca88f12c9a1922a2d31831dad2&ie=/sdarticle.pdf 267-277 61(2) 5 2008-11-14T17:52:32Z true 2008-09-22T14:01:11Z 2005-07-01 <p>Background: Recent proposals to reform cost-effectiveness analysis (CEA) by weighting health benefits [(Quality-adjusted life-years) QALYs] by recipients' age are based on studies examining age-related preferences in life-saving contexts. We investigated whether the perceived importance of age in resource allocation decisions differs among intervention-types.Methods: 160 individuals were recruited from a cafeteria of a university medical centre and asked to choose between hypothetical health care programmes. Scenario A described two programmes treating life-threatening conditions and Scenario B two programmes providing palliative care. Programmes were identical except in average patient age (35 versus 65). Respondents also directly rated the importance of age for allocating resources for six types of interventions.Results: Responses for the life-saving scenario favoured younger age groups while those for the palliative care scenario showed no age preference. The difference between scenarios was statistically significant. When directly rating the importance of age in allocating treatment resources, people placed greatest importance on age in treating infertility and life-saving, and least importance in treating depression.Discussion: The importance people place on age as a resource allocation criterion depends on the clinical context. As QALYs serve as a common measure of health benefits for all intervention types, age weighting of QALYs is premature.</p> 159 25 adult, age factors, aged, attitude to health, cost-benefit analysis, female, health care rationing economics, health care surveys economics, health priorities economics, health services economics, humans, male, middle aged, quailty-adjusted life years http://www3.interscience.wiley.com/cgi-bin/fulltext/109716461/PDFSTART 669-678 14(7) 5 2008-11-14T17:51:45Z true 2008-09-22T14:01:11Z 2005-06-01 <p>Editorial/review/commentary</p> 158 44 552-553 20 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2005-06-01 <p>Reports of randomized clinical trials often use survival curves to summarize clinical outcomes over time and graphically demonstrate evidence of treatment effectiveness. Survival curves can also be used in patient communications to display how health risks accumulate over time. In a randomized survey experiment, administered online, we tested whether people viewing survival curves appropriately adjust their risk perceptions to account for the duration shown. Internet users (N= 864) were recruited from a demographically balanced U.S. panel. Participants read about a hypothetical disease and then viewed one of four survival graphs that displayed mortality risks with and without treatment. Survival graphs showed either a visually large or visually small difference between treatments and were labeled to represent either 5-year or 15-year risk statistics. Participants then provided ratings of disease seriousness, as well as treatment effectiveness for each possible treatment. Variations in ratings corresponded more with visual dissimilarity than with changes in the statistical risk exhibited, with participants perceiving somewhat greater disease seriousness and significant differences in treatment effectiveness in large visual difference graphs. We conclude that when people interpret survival curves, they often fail to sufficiently account for the timeframe represented and perceive more risk and larger differences when identical risks are displayed over longer periods of time. We recommend that all presentations of survival graphics, whether to patients, physicians, or scientists, emphasize duration information (e.g., in the title) and remind readers that attending to graph axis labels is the only way to pierce these visual illusions.</p> 155 79 data collection, data display, humans, perception, randomized controlled trials statistics & numerical data, risk, survival analysis, time factors http://www.blackwell-synergy.com/doi/abs/10.1111/j.1539-6924.2005.00626.x?cookieSet=1 589-595 25(3) 5 2008-11-14T17:50:39Z true 2008-09-22T14:01:11Z 2005-06-01 <p>Counseling women about breast cancer risks has been found to decrease screening compliance. We investigated whether women's reactions to risk information are an artifact of requiring women to estimate the risk of breast cancer prior to receiving risk information. Three hundred and fifty-six women were randomized to either make or not make a risk estimate prior to receiving risk information. Outcome measures were participants' estimates of the average woman's breast cancer risk and their emotional response to the risk information. Women overestimated the lifetime risk of breast cancer (M = 46%). Women who made risk estimates felt more relieved about the risk and perceived the risk as being lower than women who did not make estimates (p's &lt; 0.001). Asking people to estimate risks influenced their subsequent perceptions of the risk of breast cancer.</p> 154 71 http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6TBC-4D99M00-2-1&_cdi=5139&_user=99318&_orig=search&_coverDate=06%2F30%2F2005&_qd=1&_sk=999429996&view=c&wchp=dGLbVlb-zSkWA&md5=027937a87be018226162e3781d4513d9&ie=/sdarticle.pdf 294-299 57(3) Women overestimate breast cancer risk 5 2008-11-14T17:53:38Z true 2008-09-22T14:01:11Z 2005-04-01 151 93 psychological adaptation, adult, affect, attention, climate, disabled persons psychology, female, humans, illusions, life changing events, male, personal satisfaction, questionnaires 111-123 11 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2005-04-01 <p> </p> 150 77 activities of daily living, cross-sectional studies, disability evaluation, female, follow-up studies, happiness, health status, humans, male, middle aged, quailty of life psychology, socioeconomic factors 663-666 16 Money may buy happiness if you're sick 5 2008-11-06T23:45:25Z true 2008-09-22T14:01:11Z 2005-04-01 149 28 psychological adaptation, chronic disease psychology, decision making, delivery of health care, disabled persons psychology, humans, imagination, patient participation psychology, quality of life, United States S57-S62 24(4 Suppl) 5 2008-11-14T18:47:49Z true 2008-09-22T14:01:11Z 2005-02-01 <p>Healthy people generally underestimate the self-reported well-being of people with disabilities and serious illnesses. The cause of this discrepancy is in dispute, and the present study provides evidence for 2 causes. First, healthy people fail to anticipate hedonic adaptation to poor health. Using an ecological momentary assessment measure of mood, the authors failed to find evidence that hemodialysis patients are less happy than healthy nonpatients are, suggesting that they have largely, if not completely, adapted to their condition. In a forecasting task, healthy people failed to anticipate this adaptation. Second, although controls understated their own mood in both an estimation task and a recall task, patients were quite accurate in both tasks. This relative negativity in controls' estimates of their own moods could also contribute to their underestimation of the moods and overall well-being of patients.</p> 147 43 psychological adaptation, adolescent, adult, affect, awareness, environment, female, health status, humans, chronic kidney failure physiopathology, chronic kidney failure therapy, male, middle aged, quality of life, questionnaires, renal dialysis psycholo http://bll.epnet.com/citation.asp?tb=0&_ug=sid+7C2479C7%2D19AD%2D4CC4%2DACAF%2DD5019B11BC1D%40sessionmgr4+38AA&_us=hd+False+SLsrc+ext+40D5&_usmtl=ftv+True+137E&_uso=hd+False+db%5B0+%2Dpdh+33B8&bk=S&EBSCOContent=ZWJjY8bb43ePp7Vrtdvha6Gmr4CPp7eFo6a5e6WWxpjDpfKDp62ygaSmrbjQ3%2B151N7uvuMA&rn=&fn=&db=pdh&an=xge13413&sm=&cf=1 3-9 134 5 2008-11-14T18:42:31Z true 2008-09-22T14:01:11Z 2005-02-01 146 87 http://www.ama-assn.org/ama/pub/category/14561.html np 7 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2005-01-01 <p>OBJECTIVE: To examine the association between questionnaire length and response rate in a mailed survey of generalist physicians randomly selected from the American Medical Association master file. STUDY DESIGN AND SETTING: In a pilot study, otherwise similar questionnaires of 30 different lengths (849 to 1,867 words) were mailed to 192 physicians in April 1999. In the main study, questionnaires of 16 different lengths (564 to 988 words) were mailed to 1,700 physicians between June 1999 and January 2000. RESULTS: In the pilot study, response rate decreased from 60% for questionnaires 849 words in length to 16.7% for questionnaires over 1,800 words in length. Logistic regression revealed an odds ratio of 0.887 (95%CI 0.813, 0.968; p=0.006) for word count, expressed in units of 100 words. In the main study, response rate varied between 51.5% and 71.4%. Logistic regression showed no association between response and word count (OR 0.988; 95%CI 0.896, 1.090; p=0.81). CONCLUSION: There appears to have been a threshold in these studies of approximately 1,000 words. Questionnaires above the threshold had lower response rates than those below it (38.0% vs. 59.4%).</p> 145 39 health care surveys methods, humans, logistic models, motivation, family physicians psychology, pilot projects, postal service, questionnaires, research design http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6T84-4F79HJM-J-1&_cdi=5076&_user=99318&_orig=search&_coverDate=01%2F01%2F2005&_qd=1&_sk=999419998&view=c&wchp=dGLbVlz-zSkWW&md5=2aef5c883898eeb190a4d40f9bf7d093&ie=/sdarticle.pdf 103-5 58 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2005-01-01 <p>In this symposium, three speakers describe research that examines ways in which people's decision-making is affected by emotions. In his paper, Dr. Loewenstein describes research on the properties and effects of projection bias, the tendency to allow one's immediate, often transient, preferences to influence decisions in the future when one's preferences will be predictable different. Over-shopping on an empty stomach or failing, when not addicted, to appreciate one's future helplessness in the face of drug craving, are examples. Dr. Schwarz focuses on how experiences that accompany the thought process can influence the ease of access to information or the fluency with which new information can be processed. These meta-cognitive experiences can affect decisions. For example, recalling many risk-increasing behaviors is more difficult than recalling only a few. Drawing on this difficulty, people who recall many risk-increasing behaviors infer that they are at lower risk than people who recall merely a few risk-increasing behaviors, in contrast to what the content of recall would suggest. Finally, Dr. Bodenhausen clarifies what is meant by stereotyping, considers how stereotypes might influence decision-making processes, and discuss why this influence often might not be very desirable. He then describes research about factors that amplify the biasing impact of stereotypes in decision making processes. The authors provide examples, discuss implications of their findings for medical decision-making, and describe strategies that we might employ to minimize or eliminate the biases that might be introduced into decision-making processes.</p> 144 64 http://mdm.sagepub.com/cgi/reprint/25/1/95 95-6 25 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2004-12-01 143 87 http://www.ama-assn.org/ama/pub/category/14285.html np 6 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2004-11-01 <p>BACKGROUND: Patient-centered care requires clinicians to recognize and act on patients' expectations. However, relatively little is known about the specific expectations patients bring to the primary care visit. OBJECTIVE: To describe the nature and prevalence of patients' specific expectations for tests, referrals, and new medications, and to examine the relationship between fulfillment of these expectations and patient satisfaction. DESIGN: Prospective cohort study. SETTING: VA general medicine clinic. PATIENTS/PARTICIPANTS: Two hundred fifty-three adult male outpatients seeing their primary care provider for a scheduled visit. MEASUREMENTS AND MAIN RESULTS: Fifty-six percent of patients reported at least 1 expectation for a test, referral, or new medication. Thirty-one percent had 1 expectation, while 25% had 2 or more expectations. Expectations were evenly distributed among tests, referrals, and new medications (37%, 30%, and 33%, respectively). Half of the patients who expressed an expectation did not receive one or more of the desired tests, referrals, or new medications. Nevertheless, satisfaction was very high (median of 1.5 for visit-specific satisfaction on a 1 to 5 scale, with 1 representing excellent). Satisfaction was not related to whether expectations were met or unmet, except that patients who did not receive desired medications reported lower satisfaction. CONCLUSIONS: Patients' expectations are varied and often vague. Clinicians trying to implement the values of patient-centered care must be prepared to elicit, identify, and address many expectations.</p> 141 44 aged, ambulatory care facilities, communication, humans, internal medicine, male, middle aged, North Carolina, patient participation, patient satisfaction, phsycian's practice patterns, physician-patient relations, drug prescriptions, primary health care http://www.blackwell-synergy.com/links/doi/10.1111/j.1525-1497.2004.30436.x/full/ 1080-1087 19 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2004-09-01 <p>This study examines the public's and physicians' willingness to support deception of insurance companies in order to obtain necessary healthcare services and how this support varies based on perceptions of physicians' time pressures. Based on surveys of 700 prospective jurors and 1617 physicians, the public was more than twice as likely as physicians to sanction deception (26%versus 11%) and half as likely to believe that physicians have adequate time to appeal coverage decisions (22%versus 59%). The odds of public support for deception compared to that of physicians rose from 2.48 to 4.64 after controlling for differences in time perception. These findings highlight the ethical challenge facing physicians and patients in balancing patient advocacy with honesty in the setting of limited societal resources.</p> 506 111 53-59 4 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2004-04-01 <p>OBJECTIVES: This study investigated the attitudes of the transplant community toward the current policy of altruistic organ donation and 6 alternative policies offering incentives to the donor family. METHODS: Two hundred forty-nine transplant surgeons, 143 transplant coordinators, and 134 critical-care nurses rated the moral appropriateness and success of the current policy of altruistic donation, rated the moral appropriateness of the alternative policies, judged whether donation would increase or decrease under each alternative policy, and decided whether each alternative policy should be put into effect. RESULTS: All 3 professions believed the current policy of altruistic organ donation to be morally appropriate and most of the alternative policies to be morally appropriate or morally neutral. All 3 professions believed the current policy to be at best only moderately successful and judged most or all of the alternative policies to be likely to increase donation. All 3 professions favored implementing a policy offering donor recognition; approximately one half of the surgeons and one half of the coordinators also advocated implementing a policy offering 1500 US dollars toward funeral expenses. In all 3 professions, respondents' decisions to implement the alternative policies were more frequently related to those policies' moral appropriateness than to their likelihood of increasing organ donation. CONCLUSIONS: Specific incentives varied in their acceptability to the transplant community. Attitudes of the transplant community toward incentives were not in accord with published criticisms of incentives.</p> 136 62 adult, altruism, analysis of variance, attitude of health personnel, attitude to health, critical care, organizational decision making, female, funeral rites, health knowledge attitudes practice, health policy, humans, logistic models, male, hospital medi 378 42(4) 5 2008-11-14T16:14:55Z true 2008-09-22T14:01:11Z 2004-04-01 <p>Can person tradeoff (PTO) value judgments be elicited by a computer, or is a face-to-face interview needed? The authors randomly assigned 95 subjects to interview or computer methods for the PTO, a valuation measure that is often difficult for subjects. They measured relative values of foot numbness, leg paralysis, and quadriplegia (all 3 pairs) at 2 reference group sizes (10 or 100). Relative values did not differ between computer and interview. Overall, 21% of responses were equality responses, 13% were high extreme values, and 5% violated ordinal criteria. The groups did not differ in these measures. The authors also assessed consistency across reference group size (10 v. 100). Although relative values were significantly lower for 100 than for 10, mode did not influence the size of this effect. Subjects made, on average, equally consistent judgments for the 3 comparisons. A computerized PTO elicitation protocol produced results of similar quality to that of a face-to-face interview.</p> 135 64 demography, humans, interviews, Philadelphia, user-computer interface 170-180 24(2) 5 2008-11-14T16:34:23Z true 2008-09-22T14:01:11Z 2004-04-01 <p>Choices of health care providers can become inconsistentwhen people lack sufficient context to assess the value ofavailable information. In a series of surveys, general populationsamples were randomized to read descriptions of either 2possible health care providers or a single provider. Some informationabout providers was easy to consider (e.g., traveltime), but some was difficult to interpret without additionalcontext (e.g., success rates). Ratings of the described healthcare providers varied significantly by whether options wereevaluated independently or concurrently. For example, onefertility clinic (33% success rate, 15 min away) was ratedhigher than a 2nd (40% success rate, 45 min away) wheneach clinic was considered separately (7.1 v. 6.2, P = 0.046),but preferences reversed in joint evaluation (5.9 v. 6.7, P =0.051). The results suggest that clinicians and developers ofpatient information materials alike should consider informationevaluability when deciding how to present health careoptions to patients.</p> 134 64 http://saturn.bids.ac.uk/cgi-bin/ds_deliver/1/u/d/ISIS/10695991.1/sage/j501/2004/00000024/00000002/art00004/6DF964E4081967BA10813613881BDBB28B23C3D83B.pdf?link=http://www.ingenta.com/de/ingenta%3Bid=526rqh6ce9750.crescent&format=pdf 142-148 24(2) 5 2008-11-14T16:35:42Z true 2008-09-22T14:01:11Z 2004-04-01 <p>Purpose: Racial/ethnic disparities in the utilization of definitive therapy for prostate cancer are well recognized in the United States. The effect of race on the use of contemporary definitive therapies, including brachytherapy, and the assessment of Hispanic men with regard to racial/ethnic disparity has not been fully characterized. Materials and Methods: We evaluated treatment patterns using Surveillance, Epidemiology and End Results registry data on 142,340 localized/regional stage cases between 1992 and 1999 in white, black and Hispanic American men. Definitive therapy was defined as radical prostatectomy, external beam radiation, brachytherapy or combinations thereof. Logistic regression models were constructed to determine the odds of receiving definitive treatment, adjusting for age, marital status, tumor grade, and Surveillance, Epidemiology and End Results site. Results: Black and Hispanic men were less likely to receive definitive therapy than white men (p &lt;0.001). Higher tumor grade was associated with decreasing odds of definitive therapy for black and Hispanic men (p &lt;0.001) compared to white men. The racial/ethnic disparities in the use of definitive therapy decreased between 1992 and 1999 with the greatest decrease in Hispanic men. Conclusions: Hispanic and black men were less likely than white men to receive definitive therapy. The disparity in the use of definitive therapy between 1992 and 1999 decreased significantly in Hispanic men, although a significant disparity in the use of definitive therapy persisted in black men. Our observation of an association between tumor grade and the racial/ethnic disparity in definitive therapy ties together relevant biological and social factors that may contribute to the observed racial/ethnic disparity in mortality.</p> 133 56 African continental ancestry group, aged, aged 80 and over, cohort studies, European continental ancestry group, Hispanic Americans, humans, male, middle aged, prostatic neoplasms therapy, SEER program http://www.jurology.com/pt/re/juro/pdfhandler.00005392-200404000-00027.pdf;jsessionid=B0T2ENwYzPIlenROLmniw8tx6qOAcaLq4wCkKjNyrQGDr93ELFfg!113108930!-949856032!9001!-1 1504-1507 171(4) 5 2008-11-14T18:38:27Z true 2008-09-22T14:01:11Z 2004-04-01 <p>Transplant centers may game the severity of listed patients to increase their patients' likelihood of receiving transplantable organs. Recent lawsuits allege gaming at some centers, and listing policies were modified in 1999 to clarify listing criteria. We tested for gaming and its relationship to heart transplant center competition. We found that increased competition resulted in more patients listed in the most severe illness category (p &lt; .01), consistent with the gaming hypothesis. Gaming was mitigated after the 1999 policy change (p &gt; .05), which suggests that the new rules were effective. Continued monitoring is warranted, given prior gaming and recent accusations.</p> 131 24 heart transplantation, humans, tissue and organ procurement, United States, waiting lists http://gateway.proquest.com/openurl?url_ver=Z39.88-2004&res_dat=xri:pqd&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&genre=article&rft_dat=xri:pqd:did=000000579316801&svc_dat=xri:pqil:fmt=text&req_dat=xri:pqil:pq_clntid=17822 191-198 23(2) 5 2008-11-14T16:18:47Z true 2008-09-22T14:01:11Z 2004-03-22 <p>Scarcity is increasingly common in health care, yet many physicians may be reluctant to acknowledge the ways that limited health care resources influence their decisions. Reasons for this denial include that physicians are unaccustomed to thinking in terms of scarcity, uncomfortable with the role that limited resources play in poor outcomes, and hesitant to acknowledge the influence of financial incentives and restrictions on their practice. However, the denial of scarcity serves as a barrier to containing costs, alleviating avoidable scarcity, limiting the financial burden of health care on patients, and developing fair allocation systems.In this report, we speculate about why some physicians are unwilling to acknowledge the presence of scarcity or the influence that it has on their practice. We then discuss the potential consequences of this denial on patients and the health care system. To set the stage for this discussion, we begin with 3 examples that illustrate physicians' denial of scarcity.</p> 132 13 health care rationing economics, humans, resource allocation economics, United States, waiting lists http://archinte.ama-assn.org/cgi/content/full/164/6/593 593-596 164(6) 5 2008-11-14T16:32:40Z true 2008-09-22T14:01:11Z 2003-12-01 <p>BACKGROUND: Based on a series of clinical trials showing no difference in the effectiveness or tolerability of most major classes of antihypertensive medications, the Joint National Commission on High Blood Pressure Treatment recommends that physicians prescribe beta-blockers or diuretics as initial hypertensive therapy unless there are compelling indications for another type of medication. Nevertheless, many physicians continue to favor more expensive medications like angiotensin-converting enzyme (ACE) inhibitors and calcium channel blockers as first line agents. The persistent use of these agents raises questions as to whether physicians perceive ACE inhibitors and calcium channel blockers to be better than beta-blockers and diuretics. METHODS: We surveyed 1,200 primary care physicians in 1997, and another 500 primary care physicians in 2000, and asked them to estimate the relative effectiveness and side effects of 4 classes of medication in treating a hypothetical patient with uncomplicated hypertension: ACE inhibitors, beta-blockers, calcium channel blockers, and diuretics. In addition, we asked them to indicate whether they ever provided free samples of hypertension medications to their patients. RESULTS: Perceptions of the relative effectiveness and side effects of the 4 classes of hypertension medications did not significantly change over the 3 years, nor did prescription recommendations. Physicians perceive that diuretics are less effective at lowering blood pressure than the other 3 classes (P &lt;.001). They also perceive that beta-blockers are less tolerated than the other 3 classes (P &lt;.001). In a multivariate model, perceptions of effectiveness and tolerability displayed significant associations with prescription preference independent of background variables. The only other variable to contribute significantly to the model was provision of free medication samples to patients. CONCLUSIONS: Despite numerous clinical trials showing no difference in the effectiveness or side-effect profiles of these 4 classes of drugs, most physicians believed that diuretics were less effective and beta-blockers were less tolerated than other medications. Moreover, their prescription practices were associated with their provision of free samples provided by pharmaceutical representatives, even after adjusting for other demographic characteristics. Efforts to increase physicians' prescribing of beta-blockers and diuretics may need to be directed at overcoming misunderstandings about the effectiveness and tolerability of these medicines.</p> 127 44 adrenergic beta-antagonists therapeutic use, adult, analysis of variance, angiotensis-converting enzyme inhibitors therapeutic use, calcium channel blockers therapeutic use, chi-square distribution, diuretics therapeutic use, drug utilization trends, fema http://www.blackwell-synergy.com/links/doi/10.1111/j.1525-1497.2003.20414.x/full/ 977-983 18(12) 5 2008-11-14T16:36:54Z true 2008-09-22T14:01:11Z 2003-11-01 <p>BACKGROUND: For patients with chronic illnesses, it is hypothesized that effective patient-provider collaboration contributes to improved patient self-care by promoting greater agreement on patient-specific treatment goals and strategies. However, this hypothesis has not been tested in actual encounters of patients with their own physicians. OBJECTIVE: To assess the extent to which patients with type 2 diabetes agree with their primary care providers (PCPs) on diabetes treatment goals and strategies, the factors that predict agreement, and whether greater agreement is associated with better patient self-management of diabetes. DESIGN: One hundred twenty-seven pairs of patients and their PCPs in two health systems were surveyed about their top 3 diabetes treatment goals (desired outcomes) and strategies to meet those goals. Using several measures to evaluate agreement, we explored whether patient characteristics, such as education and attitudes toward treatment, and patient-provider interaction styles, such as shared decision making, were associated with greater agreement on treatment goals and strategies. We then examined whether agreement was associated with higher patient assessments of their diabetes care self-efficacy and self-management. RESULTS: Overall, agreement on top treatment goals and strategies was low (all kappa were less than 0.40). In multivariable analyses, however, patients with more education, greater belief in the efficacy of their diabetes treatment, and who shared in treatment decision making with their providers were more likely to agree with their providers on treatment goals or strategies. Similarly, physician reports of having discussed more content areas of diabetes self-care were associated with greater agreement on treatment strategies. In turn, greater agreement on treatment goals and strategies was associated both with higher patient diabetes care self-efficacy and assessments of their diabetes self-management. CONCLUSION: Although patients and their PCPs in general had poor agreement on goals and strategies for managing diabetes, agreement was associated with higher patient self-efficacy and assessments of their diabetes self-management. This supports the hypothesis that enhancing patient-provider agreement on both overall treatment goals and specific strategies to meet these goals may lead to improved patient outcomes.</p> 124 44 adult, type 2 diabetes mellitus therapy, female, goals, humans, male, middle aged, patient acceptance of health care psychology, patient education methods, physician-patient relations, family physicians psychology, self care, self efficacy, treatment outc http://www.blackwell-synergy.com/links/doi/10.1046/j.1525-1497.2003.21132.x/full/ 893-902 18(11) Patient-physician agreement on diabetes treatment goals and strategies 5 2008-11-14T16:38:47Z true 2008-09-22T14:01:11Z 2003-10-01 <p>PURPOSE: To explore public attitudes toward the incorporation of cost-effectiveness analysis into clinical decisions. METHODS: The authors presented 781 jurors with a survey describing 1 of 6 clinical encounters in which a physician has to choose between cancer screening tests. They provided cost-effectiveness data for all tests, and in each scenario, the most effective test was more expensive. They instructed respondents to imagine that he or she was the physician in the scenario and asked them to choose which test to recommend and then explain their choice in an open-ended manner. The authors then qualitatively analyzed the responses by identifying themes and developed a coding scheme. Two authors separately coded the statements with high overall agreement (kappa = 0.76). Categories were not mutually exclusive. RESULTS: Overall, 410 respondents (55%) chose the most expensive option, and 332 respondents (45%) choose a less expensive option. Explanatory comments were given by 82% respondents. Respondents who chose the most expensive test focused on the increased benefit (without directly acknowledging the additional cost) (39%), a general belief that life is more important than money (22%), the significance of cancer risk for the patient in the scenario (20%), the belief that the benefit of the test was worth the additional cost (8%), and personal anecdotes/preferences (6%). Of the respondents who chose the less expensive test, 40% indicated that they did not believe that the patient in the scenario was at significant risk for cancer, 13% indicated that they thought the less expensive test was adequate or not meaningfully different from the more expensive test, 12% thought the cost of the test was not worth the additional benefit, 9% indicated that the test was too expensive (without mention of additional benefit), and 7% responded that resources were limited. CONCLUSIONS: Public response to cost-quality tradeoffs is mixed. Although some respondents justified their decision based on the cost-effectiveness information provided, many focused instead on specific features of the scenario or on general beliefs about whether cost should be incorporated into clinical decisions.</p> 121 64 adult, cost-benefit analysis, cross-sectional studies, decision making, female, health care rationing economics, humans, male, mass screening economics, middle aged, neoplasms diagnosis, neoplasms economics, physician's practice patterns ecnomics, public 369-378 23(5) 5 2008-11-14T16:41:42Z true 2008-09-22T14:01:11Z 2003-09-01 <p>Three experiments on the World Wide Web asked subjects to rate the severity of common health disorders such as acne or arthritis. People who had a disorder ("Haves") tended to rate it as less severe than people who did not have it ("Not-haves"). Two explanations of this Have versus Not-have discrepancy were rejected. By one account, people change their reference point when they rate a disorder that they have. More precise reference points would, on this account, reduce the discrepancy, but, if anything, the discrepancy was larger. By another account, people who do not have the disorder focus on attributes that are most affected by it, and the discrepancy should decrease when people make ratings on several attributes. Again, if anything, the discrepancy increased when ratings were on separate attributes (combined by a weighted average). The discrepancy varied in size and direction across disorders. Subjects also thought that they would be less affected than others.</p> 575 64 http://mdm.sagepub.com/cgi/reprint/23/5/422 422-434 23(5) 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2003-09-01 <p>There is often a discrepancy between quality of life estimates from patients and the general public. These discrepancies are of concern to the disability community, who worry that the public does not understand how valuable life can be for people with disabilities; policy planners, who must decide whose quality of life estimates to use in economic analysis; and practitioners and patients facing difficult medical decisions, who may have to worry that people have difficulty imagining unfamiliar health states. We outline several factors that may contribute to these discrepancies. Discrepancies might occur because patients and the public interpret health state descriptions differently--for example, making different assumptions about the recency of onset of the health state, or about the presence of comorbidities. Discrepancies might also arise if patients adapt to illness and the public does not predict this adaptation; because of response shift in how people use quality of life scales; because of a focusing illusion whereby people forget to consider obvious aspects of unfamiliar health states; because of contrast effects, whereby negative life events make people less bothered by less severe negative life events; and because of different vantage points, with patients viewing their illness in terms of the benefits that would result from regaining health, while the public views the illness in terms of the costs associated with losing good health. Decisions about whose values to measure for the purposes of economic analyses, and how to measure discrepancies, should take these potential contributing factors into account.</p> 119 78 psychological adaptation, cost-benefit analysis, disabled persons psychology, humans, patient satisfaction, public opinion, quality of life, United States, value of life http://content.kluweronline.com/article/5107167/fulltext.pdf 599-607 12 5 2008-11-14T16:46:43Z true 2008-09-22T14:01:11Z 2003-08-01 <p>OBJECTIVE: To investigate the nature of public preferences in the allocation of donor liver grafts for transplantation. DESIGN: A qualitative study based upon the transcripts of four focus groups. SETTING: Derby, Derbyshire, UK. PARTICIPANTS: Twenty-two members of the public in the Derby locality, recruited to one of four focus groups through local community groups. MAIN OUTCOME MEASURES: The views of focus group members as to the importance (or otherwise) of several potential discriminating factors which could be used in the prioritization of patients on the waiting list for liver transplantation were ascertained. The factors included were expected posttransplantation prognosis, the age of the patient, whether the patient was personally responsible for their illness, the time spent on the waiting list, re-transplantation or primary transplant and the social background of the patient. Results and CONCLUSIONS: Group members explored the criteria from a number of perspectives, and made some unexpected linkages between the criteria and wider moral principles. They did not come to firm conclusions about the relative desirability of the criteria, but their approach was notably flexible and thoughtful, with the exception of a few instances where they appeared to resort to arguments based on what is 'obvious' and 'natural'. The results of these discussions suggest that members of the public would be able and willing to respond positively to a more open and consultative system of donor liver prioritization than exists presently within the UK.</p> 117 60 adult, focus groups, Great Britain, humans, liver transplantation psychology, patient selection http://www3.interscience.wiley.com/cgi-bin/fulltext/106593845/PDFSTART 878-880 9(8) 5 2008-11-14T16:48:19Z true 2008-09-22T14:01:11Z 2003-07-28 576 13 1637-1641 163 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2003-03-18 <p>BACKGROUND: Some physicians seem to be willing to sanction deception of insurance companies. Little is known about public attitudes regarding this practice. OBJECTIVE: To assess public attitudes regarding physician deception of insurance companies. DESIGN: Cross-sectional survey using clinical vignettes. SETTING: Philadelphia County Courthouse, Philadelphia, Pennsylvania. PARTICIPANTS: Convenience sample of 700 prospective jurors. MEASUREMENTS: Participants were asked whether, in response to restriction of health care, a physician should 1) accept restriction, 2) appeal restriction, or 3) misrepresent a patient's condition to obtain the desired service. The proportion of respondents reporting that the physician should misrepresent a patient's condition was determined. RESULTS: 26% of respondents sanctioned deception, 70% supported appealing, and 4% supported accepting the insurance company decision. Among the 27% of respondents believing physicians have inadequate time to appeal coverage decisions, 50% sanctioned deception. CONCLUSIONS: Sanctioning of deception was substantial in this sample of prospective jurors. Preferences regarding insurance company deception are related to perceptions of physician workload and may further pressure physicians struggling to balance advocacy with honesty.</p> 109 12 adult, aged, aged 80 and over, cross-sectional studies, deception, humans, insurance claim reporting, health insurance, male, middle aged, Pennsylvania, physicians, professional misconduct, public opinion http://www.annals.org/cgi/reprint/138/6/472.pdf 472-475 138 Patients' views on doctors lying to insurance companies 5 2008-11-14T16:54:08Z true 2008-09-22T14:01:11Z 2003-02-01 <p>Physicians are increasingly asked to use cost-effectiveness information when evaluating alternative health care interventions. Little is known about how the way such information is presented can influence medical decision making. We presented physicians with hypothetical screening scenarios with multiple options, varying the type of cost-effectiveness ratios provided as well as whether the scenarios described cancer screening settings that were familiar or unfamiliar. Half the scenarios used average cost-effectiveness ratios, as commonly reported, calculating benefits and costs relative to a no-screening option. The other half used the preferred incremental cost-effectiveness ratios, with each option's benefits and costs calculated relative to the next best alternative. Relative to average cost-effectiveness ratios, incremental cost-effectiveness information significantly reduced preference for the most expensive screening strategies in two of three unfamiliar scenarios. No such difference was found for familiar scenarios, for which physicians likely have established practice patterns. These results suggest that, in unfamiliar settings, average cost-effectiveness ratios as reported in many analyses reported in the literature can hide the often high price for achieving incremental health care goals, potentially causing physicians to choose interventions with poor cost effectiveness.</p> 581 79 81-89 23 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2003-01-01 577 54 1464-1472 30 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2002-09-01 587 128 12-14 6 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2002-09-01 <p>BACKGROUND: The validity of the results of mailed surveys is often threatened by nonresponse bias, which is made more likely when response rates are low. However, the effectiveness and cost-effectiveness of several strategies to increase response rates are uncertain. OBJECTIVES: To assess three strategies to increase response rates to mailed physician surveys: including a 10 dollars versus a 5 dollars cash incentive in the initial mailing, including a mint candy or not, and using a large versus small outgoing envelope. RESEARCH DESIGN AND SUBJECTS: Using a 2 x 2 x 2 factorial design, a randomized trial of these strategies was conducted in a survey of 1200 physicians randomly selected from the American Medical Association's Master File. RESULTS: Including a 10 dollars incentive yielded a significantly higher response rate (60.5% vs. 52.8%) (P = 0.009). The mailing and incentive costs per completed response were 12.24 dollars (95% CI, 11.75 dollars, 13.64 dollars) in the 5 dollars group and 18.48 dollars (95% CI, 17.77 dollars, 20.69 dollars) in the 10 dollars group. Each additional response obtained in the 10 dollars group came at an incremental cost of 61.26 dollars (95% CI, 36.98 dollars, 200.80 dollars). Neither inclusion of a mint nor use of a large envelope influenced the response rate. CONCLUSIONS: Investigators may increase response rates by including more money in the initial questionnaire packet, but there may be diminishing returns to serial increments in incentives greater than 5 dollars. Including smaller incentives in more questionnaires may maximize total responses.</p> 586 62 834-839 40 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2002-08-01 <p>BACKGROUND: The person trade-off (PTO) has been advocated by some as an alternative measure for the purposes of cost-effectiveness analyses. However, the measurement properties of PTO elicitations are still being defined. METHODS: We presented subjects with two PTO scenarios. In the pre-existing paraplegia scenario, they were asked how many paraplegics' lives would have to be saved to be just as important as saving 100 'normal' people's lives. In the paraplegia onset scenario, they were asked how many patients who would experience the onset of paraplegia need to be saved to equal the benefit of saving 100 'normal' lives. We varied the order of the two scenarios across subjects to test whether PTO elicitations are susceptible to order effects. In addition, we varied whether subjects were required to provide a numerical response to the first elicitation. RESULTS: Subjects' PTO indifference points for the two scenarios varied dramatically depending on the order with which they received the scenarios, and according to whether the first elicitation required a numerical response. For those subjects providing numerical responses to both elicitations, median PTO responses varied by a factor of close to two in the pre-existing paraplegia scenario and by a factor of eight in the paraplegia onset scenario. However, the magnitude of the order effect was significantly reduced when subjects were not asked to provide a numerical response to the first PTO elicitation. CONCLUSION: PTO elicitations are susceptible to order effects. These order effects are partly due to numerical anchoring. However, other cognitive factors contribute to the order effect. Further research should clarify whether these order effects can be reduced.</p> 95 27 adult, attitude to health, cost-benefit analysis methods, data collection, decision making, female, health care rationing economics, humans, male, paraplegia economics, Philadelphia, quality-adjusted life years, questionnaires, social values, value of lif http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V8X-463XN53-1&_coverDate=08%2F31%2F2002&_alid=170228024&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=5882&_sort=d&view=c&_acct=C000007678&_version=1&_urlVersion=0&_userid=99318&md5=04c87abd2fc9ab77e62ca858facaefbb 189-199 61 5 2008-11-14T17:59:29Z true 2008-09-22T14:01:11Z 2002-06-01 <p>BACKGROUND: Mutations in the breast cancer susceptibility genes BRCA1 and BRCA2 are found in less than 1/1,000 women in the general population. Experts and professional organizations recommend targeting testing to women with risk factors for carrying a mutation. Over the next decade, BRCA1/2 testing is likely to become substantially less expensive and to move into primary care practice where pretest counseling may be limited. METHODS: The objective of the study was to investigate the factors associated with interest in BRCA1/2 testing among primary care patients receiving only limited information about testing. The design was a cross-sectional mailed survey. The setting was a University-based health system in the metropolitan Philadelphia region. The participants were 400 adult women cared for in a faculty General Internal Medicine practice. RESULTS: Two hundred forty-two women (71%) completed surveys; 53% of respondents were aware of BRCA1/2 testing and 58% were interested in undergoing testing if it was both convenient and affordable. Thirty-one percent were both aware of and interested in testing. Awareness of testing was inversely associated with African-American race (OR 0.56, 95% CI 0.38-0.83) and positively associated with college education (OR 2.21, 95% CI 1.23-3.94). Interest in testing was inversely associated with a family history of breast cancer (OR 0.45, 95% CI 0.23-0.92) and increasing age (OR 0.97, 95% CI 0.95-0.99). The inverse association between family history and interest in testing persisted in the subgroup of women who were aware of testing (OR 0.55, 95% CI 0.30-0.98). CONCLUSIONS: Among a primary care population, African-American women are less aware of BRCA1/2 testing and, when provided only limited information about BRCA1/2 testing, women at lowest risk of carrying a mutation are most interested in undergoing BRCA1/2 testing. Challenges of moving BRCA1/2 testing into primary care practice include both limiting indiscriminate use by the "worried well" and, as proven cancer prevention strategies become available, ensuring access to all high-risk women regardless of race. Copyright 2002 Elsevier Science (USA).</p> 592 75 590-595 34 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2002-03-01 518 13 1134-1139 162 5 2008-11-14T18:06:23Z true 2008-09-22T14:01:11Z 2002-01-01 583 70 1110-1118 89 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2001-07-01 <p>BACKGROUND: People sometimes object to the results of cost-effectiveness analysis when the analysis produces a ranking of options based on both cost and benefit. We suggest 2 new reasons for these objections: the prominence effect, in which people attend mostly to a more prominent attrbute (benefit as opposed to cost), and distortion of utility judgments. METHOD: We simulated the production of a cost-effectiveness ranking list in 3 experiments using questionnaires on the World Wide Web. Subjects rated the utility of 16 health benefits using either rating scale or person trade-off elicitation methods. In some experiments, subjects were asked to rate the utility of the health benefits with attention also to the cost of achieving the benefits. In all experiments, at the end, subjects were shown a priority list based on their own utility judgments and were asked whether they wanted to move any of the health benefits up or down the list. RESULTS: In all experiments, subjects wanted to give higher priority to treatments with higher benefit, even when they also had higher cost. They thus wanted to give less weight to high cost (which would, by itself, lead to lower ranking) and more weight to benefit than the weight implied by their own prior judgments. The desire for revision was reduced when subjects made their utility judgments after indicating whether the utility was above or below the midpoint of the scale (a manipulation previously found to reduce distortion). CONCLUSION: The desire to change cost-effectiveness rankings is in part a preference reversal phenomenon that occurs because people attend mainly to the benefit of health interventions as opposed to cost, when they examine the ranking. People should be wary of tinkering with priority lists by examining the lists themselves.</p> 605 64 278-287 21 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2001-07-01 <p>BACKGROUND: Patients often face medical decisions that involve outcomes that occur and change over time. Survival curves are a promising communication tool for patient decision support because they present information about the probability of an outcome over time in a simple graphic format. However, previous studies of survival curves did not measure comprehension, used face-to-face explanations, and focused on a VA population. METHODS: In this study, 246 individuals awaiting jury duty at the Philadelphia County Courthouse were randomized to receive one of two questionnaires. The control group received a questionnaire describing two hypothetical treatments and a graph with two survival curves showing the outcomes of each treatment. The practice group received the same questionnaire preceded by a practice exercise asking questions about a graph containing a single curve. Subjects' ability to interpret survival from a curve and ability to calculate change in survival over time were measured. RESULTS: Understanding of survival at a single point in time from a graph containing two survival curves was high overall, and was improved by the use of a single curve practice exercise. With a practice exercise, subjects were over 80% accurate in interpreting survival at a single point in time. Understanding of changes in survival over time was lower overall, and was not improved by the use of a practice exercise. With or without a practice exercise, subjects were only 55% accurate in calculating changes in survival. CONCLUSION: The majority of the general public can interpret survival at a point in time from self-administered survival curves. This understanding is improved by a single curve practice exercise. However, a significant proportion of the general public cannot calculate change in survival over time. Further research is necessary to determine the effectiveness of survival curves in improving risk communication and patient decision making.</p> 599 44 544-549 16 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2001-07-01 598 91 17-34 14 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2001-05-01 <p>BACKGROUND: In previous studies, the authors found that most people, given a fixed budget, would rather offer a less effective screening test to 100% of a Medicaid population than a more effective test to 50% of the population. In a subsequent study, the authors found that the number of people preferring the less effective screening test was dramatically reduced when the percentage of Medicaid enrollees receiving it was less than 100. In this article, 2 new studies are reported that explore whether people's preferences for equity versus efficiency are susceptible to a framing effect. METHODS: In 2 studies, the authors presented subjects with multiple scenarios involving screening tests that vary in the proportion of people who could receive the tests within a budget constraint and the number of people whose lives each test would save. Across scenarios, the proportion of Medicaid enrollees who could receive each test was varied, as was the question of whether scenarios involved Medicaid enrollees from the same or a different state. In addition, the authors varied the order in which subjects received the scenarios. RESULTS: In the 1st study, people's preferences for equity over efficiency varied significantly depending on the way situations were framed. Preference for equity was stronger when the more widely distributed choice covered the entire population than when it covered only half the population (P < 0.001). In addition, people's preferences were susceptible to order effects, with preference for equity being significantly stronger when the 1st scenario received by subjects involved 1 screening test that could be offered to the entire population (P < 0.001). In the 2nd study, preferences for equity over efficiency diminished even when the different framings were descriptions of identical circumstances--preference for equity was significantly reduced when the population to be screened was framed broadly, in terms of the percentage of patients across 2 states who could receive testing rather than narrowly, in terms of the percentages of patients in 1 state who could receive testing (P = 0.04). CONCLUSION: Policy planners should be careful about accepting public preferences for equity over efficiency at face value, because such preferences can be dramatically influenced by framing effects and order effects.</p> 607 64 180-189 21 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2001-05-01 <p>BACKGROUND: A number of studies show that the general public often estimates that the quality of life (QOL) associated with various health conditions is worse than patients say it is. These studies raise the possibility that people overestimate the impact that unfamiliar health conditions will have on their quality of life. One possible reason people overestimate this is because they are susceptible to a focusing illusion--when asked to imagine themselves in unfamiliar circumstances, people overestimate the emotional impact of those features of their life that would change. METHODS: The authors surveyed members of the general public to test the hypothesis that their QOL ratings of hypothetical health conditions would be higher (indicating a better quality of life) after thinking about how the health condition would affect a broad range of life domains. Across 3 experiments, the authors varied the health conditions people were asked to consider (either paraplegia, below-the-knee amputation, or partial blindness), the life domains they were asked to consider, the response mode with which they evaluated how each health condition would affect each life domain, whether subjects rated the health condition before and after considering life domains or only after, and whether subjects rated their own current quality of life first. RESULTS: Across 3 experiments, using 10 different questionnaire versions, only 1 instance was found in which subjects' ratings were significantly higher after thinking about the effect of the health condition on life domains than before, and the magnitude of this increase was small. CONCLUSION: It could not be established that a focusing illusion contributes significantly to the discrepancy in QOL ratings of patients and nonpatients. Further research should explore other factors that could contribute to the discrepancy or other ways of testing for the influence of a focusing illusion.</p> 606 64 190-199 21 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2001-02-01 <p>Physicians are often asked to be "gatekeepers," determining their patients' access to medical therapies and technologies. At the same time, most physicians have been taught that they should act as patient advocates, pursuing patients' best interests regardless of cost. This paper reviews moral arguments ethicists have made for and against "bedside rationing." It argues that healthcare rationing is appropriate in order to help control healthcare costs, and that rationing decisions made at the bedside by physicians must be part of the rationing system. A system that attempts to control costs by mandating an elaborate set of rules would be burdensome, and many physicians would find ways</p> 602 30 10-21 2 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2001-01-01 <p>BACKGROUND: New medications for treating HIV/AIDS are effective, but expensive, and funding shortfalls have led many state AIDS Drug Assistance Programs (ADAPs) to ration these drugs. Little is known about the views of those most directly affected by rationing policies. This study explores attitudes of patients with HIV and the general public toward specific rationing strategies. METHODS: A Likert-style, self-administered questionnaire about rationing expensive HIV medications in the context of a budget shortfall was administered to patients with HIV and shopping mall patrons in central Pennsylvania. Subjects were asked how much they agreed or disagreed with seven drug rationing policies. RESULTS: In all, 100 patients and 101 shoppers completed the survey (response rate = 89%). A majority in both groups "strongly" or "somewhat" disagreed with six of the seven rationing policies described, and patients more strongly disagreed with the policies than did the public. The five policies actually used by state ADAPs (first come first serve, limiting expensive medicines, limiting new patient enrollment, giving the expensive medicines to the sickest, using a spending cap) lacked support in either group. CONCLUSIONS: HIV drug rationing policies currently in use do not reflect the preferences of patients and the public. Integrating the views of those affected by the rationing decisions would raise difficult challenges to current programs.</p> 610 36 56-62 26 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2001-01-01 <p>BACKGROUND: Decision aids often provide statistical information and patient testimonials to guide treatment choices. This raises the possibility that the testimonials will overwhelm the statistical information. METHODS: Prospective jurors in Philadelphia County were presented with hypothetical statistical information about the percentage of angina patients who benefit from angioplasty and bypass surgery (50% and 75%, respectively). They were also given written testimonials from hypothetical patients who had benefited or not benefited from each of the two treatments. The numbers of patients benefiting and not benefiting were varied to be either proportionate to the statistical information or disproportionate. In study 1, all participants received 1 testimonial from a patient who had benefited from angioplasty and 1 from a patient who had not. Participants receiving the proportionate questionnaire version were also given 3 testimonials from patients who benefited from bypass surgery and 1 from a patient who did not, coinciding with the hypothetical statistical information. In contrast, participants receiving the disproportionate questionnaire version received only 1 testimonial from a patient who benefited from surgery and 1 from a patient who did not. In study 2, all participants received 2 examples of patients who benefited from angioplasty and 2 who did not. Participants with the proportionate questionnaire version received the same testimonials regarding surgery as in study 1. Those receiving the disproportionate questionnaire version received 2 testimonials from patients who benefited from bypass and 2 from patients who did not. Finally, a separate set of participants in study 2 received a questionnaire with no testimonials. RESULTS: In study 1, 30% of participants receiving the disproportionate questionnaire version chose bypass surgery versus 44% of those receiving the proportionate questionnaire (P = 0.002 by chi2). In study 2, 34% of participants receiving the disproportionate questionnaire version chose bypass surgery versus 37% of those receiving the proportionate questionnaire (P = 0.59 by chi2). Of those receiving no patient testimonials, 58% chose bypass surgery. CONCLUSIONS: The inclusion of written patient testimonials significantly influenced hypothetical treatment choices. Efforts to make the mix of positive versus negative testimonials proportionate to statistical information may, under some circumstances, affect choices in ways that cannot automatically be assumed to be optimal.</p> 609 64 60-68 21 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2001-01-01 512 44 185 16(Suppl. 1) 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2000-11-01 <p>Over the last decade there have been major advances in all aspects of liver transplantation with the consequence that the number of patients who could benefit from the procedure is increasing. As a result, the number of patients listed for liver transplantation is growing while the donor pool is remaining constant or even falling. The effect of this donor shortage is seen clearly both in Europe and in North America. For example, in North America data from UNOS shows that between 1988 and 1997 the number of cadaveric donor liver transplants rose from 1,713 to 4,100. The number of patients waiting for transplant rose over the same time from 616 to 9,647. This shortage of organs has tragic consequences. Although the proportion of patients dying on the waiting list is falling, the number of patients dying on the liver transplant waiting list increased from 196 to 1,129 over this same period of time.</p> 611 85 1411-1413 70(10) 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2000-09-09 <p>OBJECTIVE: Before cost-effectiveness analysis (CEA) can fulfill its promise as a tool to guide health care allocation decisions, the method of incorporating societal values into CEA may need to be improved. DESIGN: The study design was a declarative exposition of potential fallacies in the theoretical underpinnings of CEA. Two values held by many people-preferences for giving priority to severely ill patients and preferences to avoid discrimination against people who have limited treatment potential because of disability or chronic illness-that are not currently incorporated into CEA are discussed. CONCLUSIONS: Traditional CEA, through the measurement of quality-adjusted life years (QALYs), is constrained because of a "QALY trap." If, for example, saving the life of a person with paraplegia is equally valuable as saving the life of a person without paraplegia, then current QALY methods force us to conclude that curing paraplegia brings no benefit. Basing cost-effectiveness measurement on societal values rather than QALYs may allow us to better capture public rationing preferences, thereby escaping the QALY trap. CEA can accommodate a wider range of such societal values about fairness in its measurements by amending its methodology.</p> 617 62 892-901 38 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2000-09-01 613 40 230-235 11 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2000-08-01 <p>BACKGROUND: While lying is morally problematic, physicians have been known to use deception with their patients and with third parties. Little is known, however, about the use of deception between physicians. OBJECTIVES: To determine the likelihood that resident physicians say they would deceive other physicians in various circumstances and to examine how variations in circumstances affect the likelihood of using deception. METHODS: Two versions of a confidential survey using vignettes were randomly distributed to all internal medicine residents at 4 teaching hospitals in 1998. Survey versions differed by introducing slight variations to each vignette in ways we hypothesized would influence respondents' willingness to deceive. The likelihood that residents say they would use deception in response to each vignette was compared between versions. RESULTS: Three hundred thirty surveys were distributed (response rate, 67%). Of those who responded, 36% indicated they were likely to use deception to avoid exchanging call, 15% would misrepresent a diagnosis in a medical record to protect patient privacy, 14% would fabricate a laboratory value to an attending physician, 6% would substitute their own urine in a drug test to protect a colleague, and 5% would lie about checking a patient's stool for blood to cover up a medical mistake. For some of the scenarios, the likelihood of deceiving was influenced by variations in the vignettes. CONCLUSIONS: A substantial percentage of internal medicine residents report they would deceive a colleague in various circumstances, and the likelihood of using deception depends on the context. While lying about clinical issues is not common, it is troubling when it occurs at any time. Medical educators should be aware of circumstances in which residents are likely to deceive, and discuss ways to eliminate incentives to lie.</p> 618 13 2317-2323 160 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2000-07-01 <p>BACKGROUND: Postmenopausal hormone replacement therapy (HRT) decreases the risks of coronary heart disease and osteoporosis, but increases the risk of breast cancer. Although only 20-30% of postmenopausal women in the United States take HRT, the relationship between breast cancer risk perception and use of HRT is not known. OBJECTIVE: To assess the impact of belief that HRT increases breast cancer risk and high perceived risk of breast cancer on the use of HRT. DESIGN: Cross-sectional mailed survey. PARTICIPANTS: 189 randomly selected postmenopausal women from a general internal medicine practice in the Philadelphia area. MAIN RESULTS: Of the 268 women (67%) who returned surveys, 189 were postmenopausal; 70 (37%) were currently using HRT and 21 (11 %) had previously used HRT. Respondents' mean age was 59.6 years; 64% were Caucasian, and 33% had completed college. Fifty-nine women (33%) thought HRT increased the risk of breast cancer, 22 (12%) thought it did not, and 100 (55%) were unsure. Mean perceived lifetime risk of breast cancer was 31% (range 0%-100%). After multivariate adjustment, current use of HRT was inversely associated with age (OR 0.96 for each one-year increase, 95% CI 0.940.98), and positively associated with Caucasian race (OR 2.73, 95% CI 1.40-5.32). Use of HRT was not associated with belief that HRT increases the risk of breast cancer, breast cancer risk perception, or perceived severity of breast cancer. CONCLUSIONS: Belief that HRT increases the risk of breast cancer and high perceptions of breast cancer risk may not be important barriers to use of HRT. Efforts to improve decision making about HRT should focus on previously established barriers, such as perceptions of menopause and lack of physician discussion, rather than misconceptions about breast cancer risk.</p> 615 64 308-313 20 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2000-04-01 <p>BACKGROUND: In a previous study we showed that within a budget constraint, most people would rather offer a less effective screening test to 100% of a Medicaid population, thereby saving 1,000 lives, than a more effective test to 50% of the population, thereby saving 1,100 lives. We present here a study exploring whether this preference for equity over efficiency persists when neither test can be offered to the entire population. METHODS: Members of Physicians' Online and prospective jurors at the Philadelphia County Courthouse randomly received 1 of 3 questionnaires (Q1, Q2, or Q3) describing a limited budget to screen Medicaid enrollees for colon cancer. In all questionnaires, test 1 was said to save 1,000 lives, and test 2, a more effective and more expensive test, was said to save 1,100. In Q1, test 1 was offered to 100% and test 2 to 50% of the population. In Q2, the 2 tests could be offered to 50% and 25%, respectively; in Q3, to 90% and 40%, respectively. Respondents indicated which test they recommended and provided justification. RESULTS: The majority of physicians (59%) and the general public (56%) receiving Q1 favored the less effective screening test However, of those receiving Q2, only 26% of physicians and 27% of the general public recommended the less effective screening test. And of those receiving Q3, only 38% of physicians and 28% of the general public recommended the less effective test. Justifications for these recommendations were based largely on concerns for equality of treatment among those who chose the less effective test and concerns for saving the most lives among those who preferred the more effective test. CONCLUSIONS: Although most respondents show a preference for equity over efficiency when equity means that 100% of a population can receive a service, many fewer respondents maintain this preference when equity is no longer absolute. This result suggests that the preference for equity is sometimes "all or none."</p> 621 62 366-373 38 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2000-04-01 614 24 206-211 19 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2000-03-01 <p>In a previous paper, it was argued that Societal Value measurement through person trade-off (PTO) elicitation offers a way to include the values of both general public and patients into cost-effectiveness analysis (CEA). It was said that patients' values could be used to estimate the effect that various health care dimensions have on health-related utility and that public values could be used to estimate the Societal Value of these changes in utility. However, this previous proposal still creates opportunities for the public to misvalue the benefit of health care interventions because of bias or misunderstanding about what the health-related utility really is of various illnesses or disabilities. A procedure that combines patient and public values into CEA to partially correct for this bias is suggested in this paper. In addition, it is pointed out that, although Societal Value measurement offers a role for distinctly public preferences in CEA, it still does not answer the question of whose utilities ought to be included in CEA.</p> 620 126 127-136 9 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 2000-01-01 <p>BACKGROUND: Important discrepancies between clinical practice and health policy may be related to the ways in which physicians and others make decisions about individuals and groups. Previous research has found that physicians and laypersons asked to consider an individual patient generally make different decisions than those asked to consider a group of comparable patients, but this discrepancy has not been observed in more recent studies. This study was designed to explore possible reasons for these findings. METHODS: Prospective jurors (N = 1,013) each made a recommendation regarding a risky treatment for an incurable blood condition. Perspective (individual vs group) was crossed with uncertainty frame (probability vs frequency) and response wording (original vs revised) in a 2 x 2 x 2 between-participants design. RESULTS: When the strength of participants' recommendations was considered, the effects of perspective, uncertainty frame, and response wording were not statistically significant. When recommendations were dichotomized, participants in the revised-response-wording conditions were more likely to recommend treatment to the group than to the individual. CONCLUSIONS: These results conflict with previous findings for this scenario and suggest that reported differences between decisions for individuals and decisions for groups are not robust.</p> 619 64 39-44 20 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1999-11-01 <p>OBJECTIVE: To determine if a mailed patient education brochure (addressing demonstrated reasons for vaccination refusal) would result in a higher rate of influenza vaccination than a mailed postcard reminder without educational content. DESIGN: Randomized, controlled trial. SETTING: Urban, predominantly African-American, low-income community. PARTICIPANTS: There were 740 community-dwelling individuals aged 65 years and older in the study. MEASUREMENTS: Receipt of influenza vaccination and beliefs about influenza and influenza vaccination were measured by telephone survey self-report. MAIN RESULTS: We successfully contacted 202 individuals (69.9%) who received the postcard reminder and 229 individuals (71.1%) who received the educational brochure. People receiving the educational brochure were more likely to report influenza vaccination during the previous vaccination season than those who received the postcard reminder (66.4% vs 56.9%, p =.04). They also reported more interest in influenza vaccination in the coming year. (66.5% vs 57.1%, p =.05). CONCLUSIONS: A mailed educational brochure is more effective than a simple reminder in increasing influenza vaccination rates among inner-city, elderly patients.</p> 623 44 695-697 14 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1999-10-01 <p>BACKGROUND: Previous studies have suggested that people favor allocating resources to severely ill patients even when they benefit less from treatment than do less severely ill patients. This study explores the stability of people's preferences for treating severely ill patients. METHODS: This study surveyed prospective jurors in Philadelphia and asked them to decide how they would allocate scarce health care resources between a severely ill group of patients who would improve a little with treatment and moderately ill patients who would improve considerably with treatment. Subjects were randomized to receive one of six questionnaire versions, which altered the wording of the scenarios and altered whether subjects were given an explicit option of dividing resources evenly between the two groups of patients. RESULTS: Four hundred and seventy nine subjects completed surveys. The preference subjects placed on allocating resources to severely ill patients depended on relatively minor wording changes in the scenarios. In addition, when given the explicit option of dividing resources evenly between the two groups of patients, the majority of subjects chose to do so. CONCLUSION: People's preferences for allocating resources to severely ill patients can be significantly decreased by subtle wording changes in scenarios. However, this study adds to evidence suggesting that many people place priority on allocating resources to severely ill patients, even when they would benefit less from treatment than others.</p> 48 84 adult, attitude to death, attitude to health, chi-square distribution, decision making, ethics, female, health care rationing, health priorities, health resources, humans, male, Pennsylvania, public opinion, quality-adjusted life years, questionnaires, so http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6VBF-3WY9S8G-4-1&_cdi=5925&_orig=search&_coverDate=10%2F31%2F1999&_qd=1&_sk=999509992&view=c&wchp=dGLbVlz-zSkzS&_acct=C000007678&_version=1&_userid=99318&md5=41f207491416f8fa9586726e103bab17&ie=f.pdf 895-903 49 5 2008-11-06T23:55:05Z true 2008-09-22T14:01:11Z 1999-09-01 628 23 7-15 29 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1999-08-01 <p>OBJECTIVE: To study the attitudes of preclinical and clinical medical students toward the importance of telling patients they are students, and to compare their attitudes with those of patients. METHODS: We conducted a cross-sectional survey of medical students from five Philadelphia medical schools, and a longitudinal follow-up in one medical school, to assess the importance students place on telling patients they are medical students before interacting with them. We asked similar questions of 100 general medical outpatients from two academically affiliated hospitals. MAIN RESULTS: In total, 2,603 students (58%) responded to the cross-sectional survey, 74 (50%) responded to the longitudinal survey, and 100 patients responded to our interview survey (94% response rate). In the cross-sectional survey, there were negligible differences in the importance that patients and medical students placed on informing alert patients that they are interacting with students in nonsurgical settings. In surgical settings involving anesthetized patients, patients placed significantly more importance on being informed of students' roles in their surgery than did students, and preclinical students placed more importance on this than did clinical students. Results from the cross-sectional survey were supported by the longitudinal survey, in which fourth-year medical students placed significantly less importance on informing patients of their student status than the same cohort had done 2 years previously. CONCLUSIONS: Medical students place less importance on informing patients about their student status than patients desire, especially in surgical settings in which the patient is to be anesthetized. Medical students already having completed a clinical rotation stray further from patient ideals than preclinical medical students. These findings suggest that, as medical students advance in their training, they suffer an erosion in their attitudes about telling patients they are students.</p> 627 44 481-487 14 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1999-02-01 <p>The paper addresses some limitations of the QALY approach and outlines a valuation procedure that may overcome these limitations. In particular, we focus on the following issues: the distinction between assessing individual utility and assessing societal value of health care; the need to incorporate concerns for severity of illness as an independent factor in a numerical model of societal valuations of health outcomes; similarly, the need to incorporate reluctance to discriminate against patients that happen to have lesser potentials for health than others; and finally, the need to combine measurements of health-related quality of life obtained from actual patients (or former patients) with measurements of distributive preferences in the general population when estimating societal value. We show how equity weights may serve to incorporate concerns for severity and potentials for health in QALY calculations. We also suggest that for chronically ill or disabled people a life year gained should count as one and no less than one as long as the year is considered preferable to being dead by the person concerned. We call our approach 'cost-value analysis'.</p> 630 126 25-39 8 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1999-01-01 631 14 57-68 13 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1998-10-01 633 67 933-934 73 5 2008-11-14T20:04:36Z true 2008-09-22T14:01:11Z 1998-09-01 664 2 933-934 73(9) 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1998-07-01 634 20 329-334 70 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1998-01-01 640 8 64-68 104 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1998-01-01 <p>OBJECTIVES: The effects of incentive size on physicians' response rates to a mail survey were determined. METHODS: One thousand US primary care physicians were assigned randomly to receive a survey with either a $5 bill or a $2 bill as an incentive. For each of the two incentive groups, the overall response rate for three mailing waves, the total cost, and the total cost per usable response were measured. RESULTS: The response rate among those receiving the $5 bill (61%) was 32% higher than the response rate among those receiving the $2 bill (46%); overall costs were slightly higher in the $5 group, but the cost per response for each group was similar ($15.46 versus $14.93). For the same cost, a higher response rate could have been achieved in the $2 group if costs saved from foregoing the third mailing were instead used to increase the incentive for a portion of the subjects. CONCLUSIONS: A $5 bill incentive yielded a higher response rate among the physicians in this study than did a $2 bill incentive. Moreover, the powerful effect of the incentive size, combined with the consequent decline in the costs of subsequent mailing waves, suggests that resources in a fixed survey budget are allocated more efficiently to increasing the initial incentive rather than to providing a third wave to nonresponders.</p> 639 62 95-99 36 5 2008-11-14T20:31:45Z true 2008-09-22T14:01:11Z 1997-12-01 <p>PURPOSE: To explore how preliminary trial data affect the general public's stated willingness to enter a randomized clinical trial. METHODS: We asked 165 prospective jurors to imagine that their physicians wanted them to enroll in a clinical trial. We then presented them with scenarios portraying preliminary trial results--for example, 9 out of 10 patients get better with drug A and 5 out of 10 get better with drug B--and asked after each scenario, whether they would choose to be part of the trial. We designed the scenarios to test how stated willingness to enter the trial would be influenced by: 1) the difference in effectiveness of the 2 treatments based on the patients enrolled thus far; and 2) by the chance that the difference in effectiveness was random (i.e., the P value). The subjects' willingness to enter the trial at various decision points was analyzed using logistic regression. RESULTS: Fewer subjects were willing to enter the trial as preliminary data indicated either an increasing difference in the effectiveness of the two treatments or an increasing statistical significance of that difference. For example 75% of subjects were willing to enter the research trial before any preliminary data were presented, but this number fell to 49% when subjects were presented with preliminary data showing that 9 out of 10 patients improved with one treatment and 5 out of 10 with the other. Multivariable logistic regression revealed that higher P values (odds ratio = 4.29; P < 0.001; 95% CI: 2.22-8.28) and smaller differences in effectiveness (odds ratio = 0.02; P < 0.001; 95% CI: 0.00-0.07) implicit in preliminary data presented to subjects made subjects less likely to agree to enter clinical trials. After adjustment for other relevant variables, male gender was associated with increased willingness to enter the trial. CONCLUSION: A subjects' willingness to enter the hypothetical trial was influenced by preliminary data. Fewer subjects were willing to enter the trial as the differences in benefit between 2 treatment groups increased. However, the majority of subjects were willing to enter the hypothetical trial even when preliminary evidence strongly favored one treatment over another. Given the importance of informed consent in entering patients in clinical trials, these results should be confirmed in actual trial settings.</p> 637 49 561-566 45 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1997-11-01 <p>OBJECTIVE: To explore how U.S. medical students doing clinical rotations are physically identified to patients via their name tags, and how patients interpret the educational status conveyed by those name tags. MEASUREMENTS AND MAIN RESULTS: A letter was sent to the dean of students at all 141 medical school campuses in the United States, requesting a photocopy of the name tag distributed to third-year students on clinical rotations. We then surveyed a convenience sample of 100 general medicine outpatients at the Hospital of the University of Pennsylvania and the Philadelphia Veterans Affairs Medical Center and presented them with examples of four ways medical students were identified on name tags we received: "medical student," "student physician," "student doctor," and "MD student." Patients were then asked to rank these, and three other identifiers ("faculty physician," "resident physician," and "house staff"), from least experienced to most experienced. Patients were told that some of the identifiers might denote the same level of experience. Fifty-three percent of the medical school name tags we received identified the medical student as "medical student," 11% as "student," 6% as "student physician," 2% as "student doctor," and 1% as "MD student." Four percent of name tags had only the student's name, and 18% had only the student's name and university affiliation. Patients thought that the four student descriptors ("medical student," "student physician," "student doctor," and "MD student") on medical student name tags indicated less experience than the other three descriptors. However, of the four student descriptors, patients thought "medical student" indicated less experience than the other three (p < .0001). CONCLUSIONS: There is great variation in how medical schools identify medical students on the name tags used during their clinical rotations. These different ways of identifying medical students are not interpreted as being identical to many patients.</p> 641 44 669-671 12 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1997-08-01 <p>OBJECTIVES: The point system used to distribute scarce transplantable kidneys places great emphasis on antigen matching. This contributes to increased waiting times for African Americans, who have a disproportionate share of rare antigens. We conducted a pilot study to explore the understanding and attitudes of kidney transplant candidates toward the way the transplant allocation system trades off between antigen matching and waiting time. MEASUREMENTS AND MAIN RESULTS: We performed semi-structured interviews of a convenience sample of 33 patients awaiting transplants in Philadelphia and its surrounding suburbs. Patients had a number of misconceptions about the transplant allocation system. Many incorrectly thought, for example, that quality of life and financial status influence which patients on the waiting list receive available organs. Despite these and other misconceptions, the majority of patients thought the allocation system was fair. However, many African Americans thought the system was biased against them because of their race. After hearing about how the transplant system factors antigen matching and waiting time into organ allocation, the majority of subjects still felt the system was fair. After hearing that the emphasis on antigen matching causes African Americans to wait twice as long as whites, a larger number of subjects thought the system was unfair. Nevertheless, few thought the system should be changed. Even African American patients who felt the system was unfair still approved of the emphasis on antigen matching out of a desire to have a successful kidney transplant. CONCLUSIONS: We found that most of the interviewed patients awaiting kidney transplant thought the system should continue to emphasize antigen matching. Although attitudes toward the allocation system differed by race, with African American patients more suspicious of the system, the importance patients placed on antigen matching did not appear to differ by race.</p> 643 44 478-484 12 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1997-06-01 644 67 1668-1671 336 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1997-03-01 <p>BACKGROUND: Health insurance fraud committed by patients may be an increasing problem given the number of underinsured and uninsured people in the United States. Physicians recognizing acts of health insurance fraud perpetrated by patients face an ethical dilemma: should they disclose the incident to the insurance company, or protect patient confidentiality? OBJECTIVE: To explore physicians' attitudes toward the reporting of patient-initiated health insurance fraud. METHODS: Three hundred seven physician members of the American College of Physicians returned a mailed questionnaire that presented 6 case vignettes (3 variables) of patients who used a relative's insurance to obtain health care in the past. For each vignette, respondents were asked whether the treating physician should report insurance fraud to the health insurance carrier. RESULTS: Sixty-three respondents (20.7%) indicated that physicians should report all the patients presented in the vignettes, while 45 (14.8%) indicated none should be reported; the rest indicated that the decisions to-report should be based on the characteristics presented, with acute vs terminal illness (P < .001), history of fraud (P < .001), and wealth of the patient (P < .001) all causing physicians to be more likely to report the patient to the health insurance carrier. Multivariate analysis demonstrated that type of practice (P = .04) and respondents' experiences with insurance fraud (P = .03) had significant effects on the willingness to report patients. CONCLUSIONS: Physicians are divided about whether to report patients who have committed insurance fraud. Their decisions to report insurance fraud are influenced by their attitudes and demographic features, as well as by patient factors.</p> 645 13 501-504 157 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1997-01-01 <p>Under increasing pressure to contain medical costs, physicians find themselves wondering whether it is ever proper to ration health care at the bedside. Opinion about this is divided, but one thing is clear; Whether physicians should ration at the bedside or not, they ought to be able to recognize when they are doing so. This paper describes three conditions that must be met for a physician's action to quality as bedside rationing. The physician must 1) withhold, withdraw, or fail to recommend a service that, in the physician's best clinical judgment, is in the patient's best medical interests; 2) act primarily to promote the financial interests of someone other than the patient (including an organization, society at large, and the physician himself or herself); and 3) have control over the use of the beneficial service. This paper presents a series of cases that illustrate and elaborate on the importance of these three conditions. Physicians can use these conditions to identify instances of bedside rationing; leaders of the medical profession, ethicists, and policymakers can use them as a starting point for discussions about when, if ever, physicians should ration at the bedside.</p> 649 12 74-80 126 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1996-10-01 651 86 2975-2980 28 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1996-08-01 <p>BACKGROUND: The system to allocate scarce transplantable livers has been criticized for not giving enough weight to the prognoses of the patients receiving the transplants, but little research has been done looking at how the public weights the relative importances of efficacy and equity in distributing the organs. METHODS: This study was an experimental survey of prospective jurors asked to distribute transplantable livers among transplant candidates grouped according to their prognoses. The relative prognoses of the transplant candidates were varied across survey versions. RESULTS: As the prognostic difference between transplant groups increased, the subjects became less likely to distribute the organs equally between them (p < 0.005). However, the subjects' willingness to base allocation on prognosis was moderated by a number of factors, including their understanding of how to use prognostic information and their attitudes toward using prognostic information for individuals versus groups. Thus, even when the relative prognoses of transplant groups differed by 60%, less than a fourth of the subjects were willing to give all the organs to the better-prognosis group. CONCLUSION: Many subjects feel that prognosis is an important consideration in allocating scarce livers. However, few are willing to base allocation purely on maximizing survival. Policies that base allocations purely on outcomes will violate the values of a significant portion of the public.</p> 19 64 adult, age factors, attitude to health, child, choice behavior, female, health care rationing standards, health policy, humans, liver transplantation, male, middle aged, patient selection, Pennsylvania, prognosis, questionnaires, resource allocation, soci 234-241 16 5 2008-11-06T23:57:37Z true 2008-09-22T14:01:11Z 1996-07-01 653 7 293-297 2 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1996-05-01 <p>BACKGROUND: One of the promises of cost-effective analysis is that it can demonstrate how to maximize health benefits attainable within a specific limited budget. Many people argue, however, that when there are budget limitations, the use of cost-effectiveness analysis leads to health care policies that are inequitable. METHODS. We asked prospective jurors, medical ethicists, and experts in medical decision making to choose between two screening tests for a population at low risk for colon cancer. One test was more cost effective than the other but because of budget constraints was too expensive to be given to everyone in the population. With the use of the more effective test for only half the population, 1100 lives could be saved at the same cost as that of saving 1000 lives with the use of the less effective test for the entire population. RESULTS. Fifty-six percent of the prospective jurors, 53 percent of the medical ethicists, and 41 percent of the experts in medical decision making recommended offering the less effective screening test to everyone, even though 100 more lives would have been saved by offering the more expensive test to only a portion of the population. Most of the study participants justified this recommendation on the basis of equity. A smaller number stated either that it was not politically feasible to offer a test to only half the population or that the additional benefit of the more expensive test (100 more lives saved) was too small to justify offering it to only a portion of the public. CONCLUSIONS. People place greater importance on equity than is reflected by cost-effectiveness analysis. Even many experts in medical decision making -- those often responsible for conducting cost-effectiveness analyses -- expressed discomfort with some of its implications. Basing health care priorities on cost effectiveness may not be possible without incorporating explicit considerations of equity into cost-effectiveness analyses or the process used to develop health care policies on the basis of such analyses.</p> 652 67 1174-1177 334 5 2008-11-14T20:25:14Z true 2008-09-22T14:01:11Z 1996-04-01 <p>The transplant system has been criticized for not paying enough attention to efficiency in distributing scarce organs. But little research has been done to see how the general public views tradeoffs between efficiency and equity. We surveyed members of the general public to see how they would distribute organs among patients with varying chances of benefiting from them. In addition, we asked subjects to explain their decisions and to tell us about any other information they would have liked in order to make the decisions. We found that the public places a very high value on giving everyone a chance at receiving scarce resources, even if that means a significant decrease in the chance that available organs will save people's lives. Our results raise important questions about whether the aims of outcomes research and cost-effective studies agree with the values of the general public.</p> 656 84 1049-1055 42 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1996-04-01 <p>OBJECTIVE. To test whether cost-effectiveness analysis and present methods of eliciting health condition "utilities" capture the public's values for health care rationing. DESIGN. Two surveys of economics students. The first survey measured their utilities for three states of health, using either analog scale, standard gamble, or time tradeoff. The second survey measured their preferences, in paired rationing choices of the health states from the first survey and also compared with treatment of acutely fatal appendicitis. The rationing choices each subject faced were individualized according to his or her utility responses, so that the subject should have been indifferent between the two conditions in each rationing choice. RESULTS. The analog-scale elicitation method produced significantly lower utilities than the time-tradeoff and standard-gamble methods for two of the three conditions (p < 0.001). Compared with the rationing choices, all three utility-elicitation methods placed less value on the importance of saving lives and treating more severely ill people compared with less severely ill ones (p < 0.0001). The subjects' rationing choices indicated that they placed values on treating severely ill people that were tenfold to one-hundred-thousand-fold greater than would have been predicted by their utility responses. However, the subjects' rationing choices showed internal inconsistency, as, for example, treatments that were indicated to be ten times more beneficial in one scenario were valued as one hundred times more beneficial in other scenarios. CONCLUSIONS. The subjects soundly rejected the rationing choices derived from their utility responses. This suggests that people's answers to utility elicitations cannot be easily translated into social policy. However, person-tradeoff elicitations, like those given in our rationing survey, cannot be substituted for established methods of utility elicitation until they can be performed in ways that yield acceptable internal consistency.</p> 654 64 108-119 16 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1995-11-01 658 44 624-630 10 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1995-11-01 <p>PURPOSE: To measure the relative importance people place on prognosis and retransplantation status in allocating scarce transplantable livers. METHODS: 138 subjects were asked to distribute scarce livers amongst transplant candidates with either a 70% chance or a 30% chance of surviving if transplanted. In one group of subjects, the prognostic difference was based on the presence or absence of a 'blood marker.' In the other group, the prognostic difference was based on whether candidates had been previously transplanted or not, with retransplant candidates having a 30% chance of surviving if transplanted. RESULTS: Subjects answering the retransplantation survey gave a higher percentage of organs to the better prognostic group than subjects answering the blood marker survey, with a mean of 71.6% versus 65.0%, although this difference fell just short of statistical significance (P = 0.0581). Retransplantation survey respondents were significantly less likely to want to ignore prognostic information than were blood marker respondents (P = 0.026). Subjects in both survey groups were equally unwilling to abandon the poor prognostic group, with only 18% in each group choosing to give all the available organs to the better prognostic group. CONCLUSIONS: Respondents reacted more strongly to prognostic differences when they were due to retransplant status than to the results of a blood test. However, most people were not solely interested in the aggregate medical benefit brought by different allocation systems, but were also interested in the amount of benefit brought to the worst off.</p> 657 27 145-151 34 5 2008-09-22T14:01:11Z true 2008-09-22T14:01:11Z 1995-09-25 <p>A local internist is in the process of ordering an intravenous pyelogram for a patient she suspects of having kidney problems, when a medical student shadowing her in clinic interrupts. The student wants to know why the physician is not ordering a low-osmolality contrast agent for the patient, having read that they are less likely to cause serious side effects than high-osmolality contrast agents. The physician realizes that the medical student is correct, but rejects the suggestion, telling the student that "low-osmolality contrast agents are the standard of care for low-risk patients."</p> 11 13 psychology conflict, cost control economics, cost control legislation & jurisprudence, cost control, cost-benefit analysis economics, cost-benefit analysis legislation & jurisprudence, medical ethics, health care rationing economics, health care rationing 1837-1842 155 5 2008-11-06T23:51:56Z true 2008-09-22T14:01:11Z 1995-06-01 9 8 communication, humans, physician-patient relations, medical technology, wit and humor http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6TDC-40SFTJX-7B-1&_cdi=5195&_orig=search&_coverDate=06%2F30%2F1995&_qd=1&_sk=999019993&view=c&wchp=dGLbVzb-zSkWA&_acct=C000007678&_version=1&_userid=99318&md5=e78e96590c686a5815080a115d553211&ie=f.pdf 587-588 98 5 2008-11-06T23:54:08Z true 2008-09-22T14:01:11Z 1993-04-01 662 33 487-502 8(4) 5 2008-09-22T14:01:11Z