No room for kinkiness in a public healthcare system.
Explore the source record for details and available documents.
Delivery of Health Care↗
Biomedical subjects
Jack Dowie
Publications and source records attributed to Jack Dowie.
Why cost-effectiveness should trump (clinical) effectiveness: the ethical economics of the South West quadrant.
In many health decision making situations there is a requirement that the effectiveness of interventions, usually their 'clinical' effectiveness, be established, as well as their cost-effectiveness. Often indeed this is effectively a prior requirement for their cost-effectiveness being investigated. If, however, one accepts the ethical argument for using a threshold incremental cost-effectiveness ratio (ICER) for interventions that are more effective but more costly (i.e. fall in the NE quadrant of the cost-effectiveness plane), one should apply the same decision rule in the SW quadrant, where the intervention is less effective but less costly. This implication is present in most standard treatments of cost-effectiveness analysis, including recent stochastic versions, and had gone relatively unquestioned within the discipline until the recent suggestion that the ICER threshold might be 'kinked'. A kinked threshold would, O'Brien et al. argue, better reflect the asymmetrical individual preferences found in empirical studies of consumer's willingness to pay and willingness to accept and justify different decision rules in the NE and SW quadrants. We reject the validity of such asymmetric preferences in the context of public health care decisions and consider and counter the two main 'ethical' objections that probably underlie the asymmetry in this case--the objection to 'taking away' and the objection to being required to undergo treatment that is less effective than no treatment at all.
Clinical Trials as Topic↗
Research implications of science-informed, value-based decision making.
In 'Hard' science, scientists correctly operate as the 'guardians of certainty', using hypothesis testing formulations and value judgements about error rates and time discounting that make classical inferential methods appropriate. But these methods can neither generate most of the inputs needed by decision makers in their time frame, nor generate them in a form that allows them to be integrated into the decision in an analytically coherent and transparent way. The need for transparent accountability in public decision making under uncertainty and value conflict means the analytical coherence provided by the stochastic Bayesian decision analytic approach, drawing on the outputs of Bayesian science, is needed. If scientific researchers are to play the role they should be playing in informing value-based decision making, they need to see themselves also as 'guardians of uncertainty', ensuring that the best possible current posterior distributions on relevant parameters are made available for decision making, irrespective of the state of the certainty-seeking research. The paper distinguishes the actors employing different technologies in terms of the focus of the technology (knowledge, values, choice); the 'home base' mode of their activity on the cognitive continuum of varying analysis-to-intuition ratios; and the underlying value judgements of the activity (especially error loss functions and time discount rates). Those who propose any principle of decision making other than the banal 'Best Principle', including the 'Precautionary Principle', are properly interpreted as advocates seeking to have their own value judgements and preferences regarding mode location apply. The task for accountable decision makers, and their supporting technologists, is to determine the best course of action under the universal conditions of uncertainty and value difference/conflict.
Bayes Theorem↗
Decision validity should determine whether a generic or condition-specific HRQOL measure is used in health care decisions.
When a HRQOL measure is needed in health care decision making should it be a generic measure (a GEN), intended to cover the entire domain of health, a condition-specific measure (a CSM) intended to embrace those aspects of health associated with the condition concerned, or both? This paper proposes that it will never be appropriate to use both a CSM and a GEN for the same decision; that a GEN alone will probably be the appropriate measure in the majority of decisions; that a CSM alone will sometimes be appropriate; and that whether it is a GEN alone or a CSM alone that is appropriate depends entirely on the structure of the decision. The argument rests on the distinction between knowledge validity and decision validity. But it has a supplementary basis in rejection of the widespread (but unjustifiable) belief that CSMs are more "sensitive" or "responsive" than GENs and hence can detect "small but important changes" that GENs always or often miss.
Consumer Behavior↗
The role of patients' meta-preferences in the design and evaluation of decision support systems.
The arrival of new analysis-based decision technologies will necessitate a profound rethinking both of the nature of the patient-doctor relationship and of the way aids and support systems designed to improve decision-making within that relationship are designed and evaluated. One-dimensional typologies of the traditional 'paternalist/shared/informed' sort do not provide the complexity called for by the heterogeneity of patient's 'meta-preferences' regarding their relationship with a doctor on the one hand and regarding the analytical level of judgement and decision-making on the other. A multidimensional matrix embodying this distinction is proposed as a framework of the minimal complexity required for the design and evaluation of the full range of decision aids and decision modes. Essentially aids should be conceived of and evaluated cell-specifically and the search for universally satisfactory decision support systems abandoned. 'shared' and'informed' are best interpreted as attributes which may or not be in line with a patient's meta-preferences. Future research should focus on the higher level goal of better decision-making, a goal that will need to respect and reflect these meta-preferences.
Counseling↗
Women's views of two interventions designed to assist in the prophylactic oophorectomy decision: a qualitative pilot evaluation.
INTRODUCTION: A qualitative pilot evaluation of two different decision interventions for the prophylactic oophorectomy (PO) decision: a Decision Chart and a computerized clinical guidance programme (CGP) was undertaken. The Decision Chart, representing current practice in decision interventions, presents population-based information. The CGP elicits individual values to allow for quality-adjusted life years to be calculated and an explicit guidance statement is given. Prophylactic oophorectomy involves removal of the ovaries as an adjunct to hysterectomy to prevent ovarian cancer. The decision is complex because the operation can affect a number of long-term outcomes including breast cancer, coronary heart disease and osteoporosis. METHODS: Both interventions were based on the evidence and were administered by a facilitator. The Decision Chart is a file, which progressively reveals information in the form of bar charts. The CGP is a decision-analysis based program integrating the results from a cluster of Markov cycle trees. The research evidence is incorporated with woman's individual risk factors, values and preferences. A purposive sample of 19 women awaiting hysterectomy used the decision interventions (10 CGP, nine Decision Chart). In-depth semi-structured interviews were undertaken. Interviews were transcribed and analysed to derive themes. RESULTS: Reactions to the different decision interventions were mixed. Both were seen as clarifying the decision. Some women found some of the tasks difficult (e.g. rating health status). Some were surprised by the "individualized" guidance, which the CGP offered. The Decision Chart provided some with a sense of empowerment, although some found that it provided too much information. CONCLUSIONS: Women were able to use both decision interventions. Both provided decision clarification. Problems were evident with both interventions, which give useful pointers for future development. These included the possibility for women to see how their individual risks of different outcomes are affected in the Decision Chart and enhanced explanation of the CGP tasks. Future design and evaluation of decision aids, will need to accommodate differences between patients in the desire for amount and type of information and level of involvement in the decision-making process.
Adult↗
Decision makers' needs as capacities to benefit.
Explore the source record for details and available documents.
Decision Making, Organizational↗