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Biomedical subjects

P A Ubel

Publications and source records attributed to P A Ubel.

At least 19 recordsLinked to original sources
PubMed2005

Do incentives matter? Providing benefits to families of organ donors.

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 < 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.

Adolescent↗
PubMed2001

Physicians' willingness to participate in the process of lethal injection for capital punishment.

BACKGROUND: It has been found that physicians condone colleague involvement in capital punishment. Physicians' own willingness to participate has not been explored. OBJECTIVE: To examine physicians' willingness to be involved in cases of capital punishment. DESIGN: Survey exploring physicians' willingness to participate in 10 aspects of capital punishment by lethal injection, 8 of which are disallowed by the American Medical Association. SETTING: United States. PARTICIPANTS: 1000 randomly selected practicing physicians. MEASUREMENTS: Questions assessing willingness to be involved in and attitudes toward capital punishment. RESULTS: 41% of respondents indicated that they would perform at least one action disallowed by the American Medical Association; 25% would perform five or more disallowed actions. Perceived duty to society (P < 0.001), approval of the death penalty (P < 0.001), and approval of assisted suicide (P = 0.015) correlated with increased willingness to perform disallowed actions. Only 3% of respondents knew of any guidelines on this issue. CONCLUSIONS: Despite medical society policies, many physicians would be willing to be involved in the execution of adults. The medical profession needs to be better informed about the ethical issues involved in physician participation in capital punishment.

American Medical Association↗
PubMed2001

Who will enroll? Predicting participation in a phase II AIDS vaccine trial.

BACKGROUND: The problems of underenrollment and selective enrollment may undermine AIDS vaccine trials. If prospective study subjects' stated willingness to participate (WTP) in hypothetical vaccine trials predicts future enrollment, then measuring WTP before recruitment may enhance the enrollment in, and ethics of, such trials. METHODS: We prospectively studied changes over an 18-month period in the stated WTP in, and knowledge of, a hypothetical AIDS vaccine trial among 610 Philadelphia residents at high risk for HIV infection. Of these people, 499 were subsequently recruited to participate in an actual, phase II AIDS vaccine trial. We used multivariable logistic regression and the area under the receiver-operating characteristic (ROC) curve to model predictors of actual enrollment. RESULTS: Actual enrollment rates were 8.3%, 6.8%, 15.8%, and 29.0% among those who had initially said they were "definitely not," "probably not," "probably," and "definitely" willing to participate, respectively (p =.006). The area under the ROC curve was 0.65, indicating a modest ability of stated WTP to differentiate those who enroll from those who do not. Knowledge of basic vaccine trial concepts, though unrelated to enrollment, increased over an 18-month period with repeated education sessions (p <.0001), whereas stated WTP declined over this same period (p <.0001). CONCLUSION: Although other factors not captured by stated WTP may also influence future enrollment, prospectively assessing stated WTP may augment the validity of the informed consent process, help prevent underenrollment, and clarify the population from which the study sample is drawn.

AIDS Vaccines↗
PubMed2001

Rationing HIV medications: what do patients and the public think about allocation policies?

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.

Adult↗
PubMed2001

Barriers to influenza immunization in a low-income urban population.

BACKGROUND: Although influenza immunization significantly reduces mortality from influenza, over one third of elderly Americans are not immunized each year. Low rates of immunization are particularly concerning among African-American low-income populations. Preliminary interviews suggested that fear of undisclosed ingredients in the influenza vaccine may impede vaccine acceptance in this vulnerable population. OBJECTIVES: To assess the role of concern about vaccine contents and other factors in the use of influenza immunization among a predominantly African-American low-income urban population. METHODS: Cross-sectional, health-system-population-based, telephone survey of a random sample of West Philadelphia residents aged > or =65 years. RESULTS: Of 659 eligible individuals, 486 (73.8%) were successfully interviewed. Concern about undisclosed shot contents was reported by 132 (20%) respondents and was inversely associated with vaccine receipt (OR 0. 49, 95% CI 0.26-0.91). This association was similar among African Americans and Caucasians. In addition, receipt of influenza vaccine was inversely associated with belief that immunization is inconvenient (OR 0.14, 95% CI 0.05-0.36), belief that immunization is painful (OR 0.21, 95% CI 0.08-0.54), and history of previous side effects (OR 0.33, 95% CI 0.18-0.60), and positively associated with physician recommendation (OR 3.22, 95% CI 1.76-5.93). CONCLUSIONS: In a low-income urban population, concern about undisclosed vaccine contents appears to impede acceptance of influenza immunization among both African Americans and Caucasians. Directly addressing this concern offers a new approach to increasing immunization in this vulnerable population.

Aged↗
PubMed2001

Using survival curve comparisons to inform patient decision making can a practice exercise improve understanding?

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.

Adult↗
PubMed2001

Between two worlds medical student perceptions of humor and slang in the hospital setting.

OBJECTIVE: Residents frequently use humor and slang at the expense of patients on the clinical wards. We studied how medical students react to and interpret the "appropriateness" of derogatory and cynical humor and slang in a clinical setting. DESIGN: Semistructured, in-depth interviews. SETTING: Informal meeting spaces. PARTICIPANTS: Thirty-three medical students. MEASUREMENTS: Qualitative content analysis of interview transcriptions. MAIN RESULTS: Students' descriptions of the humorous stories and their responses reveal that students are able to take the perspective of both outsiders and insiders in the medical culture. Students' responses to these stories show that they can identify the outsider's perspective both by seeing themselves in the outsider's role and by identifying with patients. Students can also see the insider's perspective, in that they identify with residents' frustrations and disappointments and therefore try to explain why residents use this kind of humor. Their participation in the humor and slang--often with reservations--further reveals their ability to identify with the perspective of an insider. CONCLUSIONS: Medical students describe a number of conflicting reactions to hospital humor that may enhance and exacerbate tensions that are already an inevitable part of training for many students. This phenomenon requires greater attention by medical educators.

Adult↗
PubMed2001

Allocation of transplantable organs: do people want to punish patients for causing their illness?

Some people believe patients with alcoholic cirrhosis should not receive equal priority for scarce transplantable organs. This may reflect a belief that these patients (1) are personally responsible for causing their own illnesses, (2) have poor transplant prognoses, or (3) are unworthy because they have engaged in socially undesirable behavior. We explore the roles that social desirability and personal responsibility have in people's judgments about transplant allocation. We presented prospective jurors with 4 scenarios, asking them to distribute 100 transplantable organs among 2 groups of 100 patients each. In each scenario, 1 group of patients, but not the other, was described as having a history of unhealthy behavior (alcohol or cigarette use) associated with a poorer prognosis. In some scenarios, alcohol or cigarette use was said to cause the organ failure. In others, it only contributed to the patients' transplant prognosis. We also obtained self-reports of subjects' own smoking status. Subjects allocated significantly fewer than half the organs to those with unhealthy behaviors and worse prognoses (33%; P <.001), but the specific behavior (alcohol versus cigarette use) was not significantly associated with subjects' allocation choices. Significantly fewer organs were allocated to patients with behavior responsible for causing their diseases than to other patients (P <.0001). Subjects who never smoked discriminated the most and current smokers discriminated the least against patients with a history of unhealthy behavior (P <.0001). The public's transplantation allocation preferences are influenced by whether patients' behaviors are said to have caused their organ failure.

Adult↗
PubMed2001

Measuring patient expectations: does the instrument affect satisfaction or expectations?

BACKGROUND: Fulfillment of patients' expectations may influence health care utilization, affect patient satisfaction, and be used to indicate quality of care. Several different instruments have been used to measure expectations, yet little is known about how different assessment methods affect outcomes. OBJECTIVE: The object of the study was to determine whether different measurement instruments elicit different numbers and types of expectations and different levels of patient satisfaction. DESIGN: Patients waiting to see their physician were randomly assigned to receive 1 of 2 commonly used instruments assessing expectations or were assigned to a third (control) group that was not asked about expectations. After the visit, patients in all 3 groups were asked about their satisfaction and services they received. SUBJECTS: The study subjects were 290 male, primary care outpatients in a VA general medicine clinic. MEASURES: A "short" instrument asked about 3 general expectations for tests, referrals, and new medications, while a "long" instrument nested similar questions within a more detailed list. Wording also differed between the 2 instruments. The short instrument asked patients what they wanted; the long instrument asked patients what they thought was necessary for the physician to do. Satisfaction was measured with a visit-specific questionnaire and a more general assessment of physician interpersonal skills. RESULTS: Patients receiving the long instrument were more likely to express expectations for tests (83% vs. 28%, P <0.001), referrals (40% vs. 18%, P <0.001), and new medications (45% vs. 28%, P <0.001). The groups differed in the number of unmet expectations: 40% of the long instrument group reported at least 1 unmet expectation compared with 19% of the short instrument group (P <0.001). Satisfaction was similar among the 3 groups. CONCLUSIONS: These different instruments elicit different numbers of expectations but do not affect patient satisfaction.

Ambulatory Care Facilities↗
PubMed2001

Physicians, thou shalt ration: the necessary role of bedside rationing in controlling healthcare costs.

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

Decision Making↗
PubMed2000

Finding a place for public preferences in liver allocation decisions.

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.

Humans↗
PubMed2000

Physicians' attitudes about involvement in lethal injection for capital punishment.

BACKGROUND: Physicians could play various roles in carrying out capital punishment via lethal injection. Medical societies like the American Medical Association (AMA) and American College of Physicians have established which roles are acceptable and which are disallowed. No one has explored physicians' attitudes toward their potential roles in this process. METHODS: We surveyed physicians about how acceptable it was for physicians to engage in 8 actions disallowed by the AMA and 4 allowed actions involving lethal injection. Questions assessing attitudes toward capital punishment and assisted suicide were included. The impact of attitudinal and demographic variables on the number of disallowed actions deemed acceptable was analyzed via analysis of variance and multiple logistic regression analysis. RESULTS: Four hundred eighty-two physicians (51%) returned questionnaires. Eighty percent indicated that at least 1 of the disallowed actions was acceptable, 53% indicated that 5 or more were acceptable, and 34% approved all 8 disallowed actions. The percentage of respondents approving of disallowed actions varied from 43% for injecting lethal drugs to 74% for determining when death occurred. All 4 allowed actions were deemed acceptable by the majority of respondents. Favoring the death penalty (P<.001) and the acceptance of assisted suicide (P<.001) were associated with an increased number of disallowed actions that were deemed acceptable. CONCLUSIONS: Despite medical society policies, the majority of physicians surveyed approved of most disallowed actions involving capital punishment, indicating that they believed it is acceptable in some circumstances for physicians to kill individuals against their wishes. It is possible that the lack of stigmatization by colleagues allows physicians to engage in such practices. Arch Intern Med. 2000;160:2912-2916

Aged↗
PubMed2000

Understanding racial variation in the use of coronary revascularization procedures: the role of clinical factors.

BACKGROUND: Black patients undergo coronary artery bypass grafting and percutaneous transluminal coronary angioplasty less often than white patients. It is unclear how racial differences in clinical factors contribute to this variation. METHODS: A retrospective cohort study was performed of 666 male patients (326 blacks and 340 whites), admitted to 1 of 6 Veterans Affairs hospitals from October 1, 1989, to September 30, 1995, with acute myocardial infarction or unstable angina who underwent cardiac catheterization. The primary comparison was whether racial differences in percutaneous transluminal coronary angioplasty and coronary artery bypass grafting rates persisted after stratifying by clinical appropriateness of the procedure, measured by the appropriateness scale developed by the RAND Corporation, Santa Monica, Calif. RESULTS: Whites more often than blacks underwent a revascularization procedure (47% vs 28%). There was substantial variation in black-white odds ratios within different appropriateness categories. Blacks were significantly less likely to undergo percutaneous transluminal coronary angioplasty (odds ratio, 0.30; 95% confidence interval, 0.14-0.63 [P<.01]) when the indication was rated "equivocal." Similarly, blacks were less likely to undergo coronary artery bypass grafting (odds ratio, 0.44; 95% confidence interval, 0.23-0.86 [P<.01]) when only coronary artery bypass grafting was indicated as "appropriate and necessary." Differences in comorbidity or use of cigarettes or alcohol did not explain these variations. Using administrative data from the Veterans Health Administration, we found no differences in 1-year (5.2% vs 7.4%) and 5-year (23.3% vs 26.2%) mortality for blacks vs whites. CONCLUSION: Among patients with acute myocardial infarction or unstable angina, variation in clinical factors using RAND appropriateness criteria for procedures explained some, but not all, racial differences in coronary revascularization use.

Adult↗
PubMed2000

Societal value, the person trade-off, and the dilemma of whose values to measure for cost-effectiveness analysis.

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.

Cost-Benefit Analysis↗
PubMed2000

Are preferences for equity over efficiency in health care allocation "all or nothing"?

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."

Adult↗
PubMed2000

Improving value measurement in cost-effectiveness analysis.

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.

Attitude to Health↗