Estrogen replacement therapy (ERT) prevents fractures and relieves vasomotor symptoms, but it increases the risk of endometrial cancer. Previous studies and national prescribing patterns show that physicians are conservative in their approach to this therapy. The authors interviewed physicians and perimenopausal women to assess their utilities for the various health outcomes of estrogen replacement therapy. On all outcomes, physicians rated illness episodes followed by recovery as being closer to perfect health than did perimenopausal women. Physicians, in judging which outcomes were most important to women, estimated relief of symptoms above fracture prevention, whereas women rated fracture prevention above symptom relief. These results emphasize the need to assess patients' utilities directly, particularly when utilities for the outcome of a particular therapy may influence the choice of a therapeutic regimen.

Adult↗

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Amniocentesis use and risk awareness: comparison of knowledge and beliefs among older gravida.

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Adult↗

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Hormonal replacement therapy: analysis of clinical strategies used by residents.

The authors investigated strategies employed by resident physicians to decide whether to prescribe hormonal replacement therapy (HRT) for menopausal women, a matter of continuing clinical controversy. Verbal protocols were obtained from 21 residents in three specialties as they responded to 12 brief case descriptions. The cases incorporated three levels of cancer risk and two levels of osteoporosis risk in a 3 x 2 factorial design with two replications in each cell. Substantial variation in willingness to prescribe HRT was observed. By clustering subjects with relatively similar approaches to the problem, three treatment strategies were formulated that accounted for the decisions of 20 subjects. Each strategy is a simplified representation of the conflicting considerations in this clinical dilemma that facilitates rapid decision making. The differences between these representations and formal decision-analytic models help to explain why observed clinical decisions were inconsistent with expected utility maximization.

Breast Neoplasms↗

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Attitudes of obstetricians and gynecologists toward hormone replacement therapy.

OBJECTIVE: To determine the attitudes of obstetricians and gynecologists toward hormone replacement therapy (HRT), and the beliefs and intuitions that affected those attitudes. DESIGN: A questionnaire was sent to 1,000 gynecologists in the United States; 328 replies were received. The questionnaire asked about effects of HRT, practices concerning HRT, and decisions in hypothetical scenarios. RESULTS: The respondents strongly favored HRT, and they were well informed about its effects on osteoporosis, cardiovascular disease, and breast cancer. They were aware of conflicting findings concerning breast cancer. The strength of their recommendation of HRT was sensitive to patient differences in risk factors. The respondents also showed four biases hypothesized to cause resistance to HRT: omission bias (more concern about harmful acts than harmful omissions); proportionality bias (attention to relative risk rather than risk differences); naturalness bias (preference for the natural); and ambiguity (avoiding options with missing information). Proportion bias, naturalness bias, and (weakly) omission bias were related to less favorable attitudes toward HRT. CONCLUSION: Although specialists are highly favorable toward HRT in general, some negativity toward HRT may result from decision biases.

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