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Biomedical subjects

D C Hadorn

Publications and source records attributed to D C Hadorn.

10 recordsLinked to original sources
PubMed1992

The problem of discrimination in health care priority setting.

Increasingly stringent fiscal restrictions on the scope of medical services available to patients have resulted in calls for explicit health care priority setting. Several commentators have called for the application of decision-analytic principles to such efforts, which would assign services priority based on the extent to which they produce preferred health outcomes. The Oregon Medicaid exercise is an example of such a process. An important challenge to these utilitarian efforts is the need to avoid discrimination against people with medical disabilities. Both of the key elements entailed by decision-analytic approaches to priority setting--estimation of outcomes and assignment of values to those outcomes--are vulnerable to charges of discrimination, primarily because both the medical outcomes expected in disabled individuals and the values they place on those outcomes may differ from the general public. Priority-setting efforts must proceed carefully to avoid the appearance (and reality) of discrimination.

Civil Rights↗
PubMed1992

An annotated algorithm approach to clinical guideline development.

The Urinary Incontinence in Adults Guideline Panel facilitated the ready elucidation of its guideline's management recommendations through the use of an annotated algorithm approach. The algorithms created as part of this guideline differ from previous algorithms in two ways: (1) they employ systematic annotation to link explicitly the algorithms' recommendations to the literature, and (2) they contain patient counseling and decision nodes to depict the major preference-dependent decision or branch points in the algorithm. We believe that these two innovations can help ensure the clinical validity of guidelines' algorithms while preserving appropriate clinical flexibility and respecting patient preferences.

Algorithms↗
PubMed1992

Cross-validation performance of mortality prediction models.

Mortality prediction models hold substantial promise as tools for patient management, quality assessment, and, perhaps, health care resource allocation planning. Yet relatively little is known about the predictive validity of these models. We report here a comparison of the cross-validation performance of seven statistical models of patient mortality: (1) ordinary-least-squares (OLS) regression predicting 0/1 death status six months after admission; (2) logistic regression; (3) Cox regression; (4-6) three unit-weight models derived from the logistic regression, and (7) a recursive partitioning classification technique (CART). We calculated the following performance statistics for each model in both a learning and test sample of patients, all of whom were drawn from a nationally representative sample of 2558 Medicare patients with acute myocardial infarction: overall accuracy in predicting six-month mortality, sensitivity and specificity rates, positive and negative predictive values, and per cent improvement in accuracy rates and error rates over model-free predictions (i.e., predictions that make no use of available independent variables). We developed ROC curves based on logistic regression, the best unit-weight model, the single best predictor variable, and a series of CART models generated by varying the misclassification cost specifications. In our sample, the models reduced model-free error rates at the patient level by 8-22 per cent in the test sample. We found that the performance of the logistic regression models was marginally superior to that of other models. The areas under the ROC curves for the best models ranged from 0.61 to 0.63. Overall predictive accuracy for the best models may be adequate to support activities such as quality assessment that involve aggregating over large groups of patients, but the extent to which these models may be appropriately applied to patient-level resource allocation planning is less clear.

Discriminant Analysis↗
PubMed1992

Improving task comprehension in the measurement of health state preferences. A trial of informational cartoon figures and a paired-comparison task.

Information concerning people's relative preferences for health care outcomes is usually obtained using questionnaires which ask subjects to imagine health states of various kinds. When using illness- or treatment-specific states, elaborate descriptions of patients' quality of life may adequately convey to the rater a sense of the real situation. Such descriptions are not possible with generic questionnaires, which frame outcomes in general terms, such as pain, limits on activities, etc. This study evaluated two methods for facilitating task comprehension with generic preference-assessment instruments: (1) use of informational figures that provide visual representations of the described health state, and (2) measurement of preferences by means of a paired-comparison task. The use of figures did not change rating variance or the number of counter-intuitive ratings, but did improve one-week test-retest reliability. Paired comparisons had reliability comparable to the direct rating tasks and reduced the number of counter-intuitive ratings, although not to a statistically significantly extent.

Adult↗
PubMed1992

Emerging parallels in the American health care and legal-judicial systems.

The structure and principal decision-making processes of the American health care system have, in recent years, evolved to closely resemble those of the legal-judicial system. This transformation reflects important common values that underlie both systems, including the values of life and liberty. This Article analyzes quasi-legal features of the health care system and draws conclusions about how those features might be used to address the problem of health care rationing. It concludes that coverage rules, if properly developed, can provide the sort of objective framework necessary to evaluate claims of health care needs. This Article also demonstrates that by defining legitimate health care needs, society can thereby potentially eliminate or forestall the need to ration necessary care. This can be achieved by using carefully developed coverage rules, rather than the informal rules currently in place, in conjunction with already existing due process methods for interpreting and implementing those rules.

Decision Making↗
PubMed1991

The health care resource allocation debate. Defining our terms.

The problem of health care distribution in the United States demands immediate action. Many different solutions have been proposed to slow rising health care costs and to improve access to care for the poor and uninsured. Debate among proponents of these various proposals might be advanced if a common language were adopted with regard to certain key terms instead of the various meanings currently assigned to these terms. For this reason, we propose and defend the following three definitions: (1) rationing is the societal toleration of inequitable access to health services acknowledged to be necessary by reference to necessary-care guidelines; (2) health care needs are desires for services that have been reasonably well demonstrated to provide significant net benefit for patients with specified clinical conditions; and (3) basic benefit plans are insurance packages that provide for all and only acknowledged health care needs, again by reference to appropriate clinical guidelines.

Comprehensive Health Care↗
PubMed1991

Setting health care priorities in Oregon. Cost-effectiveness meets the rule of rescue.

The Oregon Health Services Commission recently completed work on its principal charge: creation of a prioritized list of health care services, ranging from the most important to the least important. Oregon's draft priority list was criticized because it seemed to favor minor treatments over lifesaving ones. This reaction reflects a fundamental and irreconcilable conflict between cost-effectiveness analysis and the powerful human proclivity to rescue endangered life: the "Rule of Rescue." Oregon's final priority list was generated without reference to costs and is, therefore, more intuitively sensible than the initial list. However, the utility of the final list is limited by its lack of specificity with regard to conditions and treatments. An alternative approach for setting health care priorities would circumvent the Rule of Rescue by carefully defining necessary indications for treatment. Such an approach might be applied to Oregon's final list in order to achieve better specificity.

Cost-Benefit Analysis↗
PubMed1991

The role of public values in setting health care priorities.

Public values must play a substantial role in any attempt to deal with the health care resource allocation problem. This article examines how preferences for the health outcomes of care (e.g. improved or worsened physical suffering) can provide a coherent basis upon which set explicit health care priorities. Preferences for health outcomes could be mapped onto information concerning the outcomes expected from the specific health services when used for particular clinical conditions. These 'preference-weighted' outcomes would determine the relative priority given to health services for each specific condition. Generic outcome measures would be used in order to permit comparison of benefits and harms across different services. It is argued herein that allocation rules cannot be based on individual patients' preferences. Instead, average population preferences should be used to evaluate the relative importance of services--as occurs in other insurance contexts--despite theoretical concerns about the aggregation of preferences. Patients' preferences might also be estimated by reference to relevant demographic factors, but only if population subgroups are identified with relatively homogeneous preference patterns and if the use of such subgroups is deemed socially acceptable. Concerns about stereotyping and discrimination might limit the tractability of this approach.

Biomedical Research↗
PubMed1991

Multitrait-multimethod analysis of health-related quality-of-life measures.

Interest in health-related quality of life (HRQOL) is burgeoning and there has been a proliferation of self-report measures of HRQOL. However, only two instruments available for measuring HRQOL have been calibrated using empirically derived preferences; both are long and complex. This study tested a brief survey designed to concurrently assess HRQOL and preferences for different HRQOL states. Multitrait-multimethod (MTMM) analysis was used to evaluate the construct validity of the survey in a convenience sample of 116 persons. Two methods were used to assess six aspects of HRQOL: general health perceptions, meaningful activities, outlook on life, physical suffering, self-care activities, and social relationships. HRQOL preferences were assessed using two methods similar to those used for self-reports, as well as one additional method. The construct validity of self-reported HRQOL was supported. On the other hand, substantial method variance and little valid trait variance was observed for the HRQOL preferences. Results are discussed in terms of their implications for evaluating and measuring HRQOL and related preferences.

Factor Analysis, Statistical↗