Flawed choices.

Drug treatment and reimbursement is an area of ever growing complexity in health priority setting. This paper assesses the National Registry of Growth Hormone Treatment (LRG) responsible for making prioritisation decisions in the Dutch drug reimbursement system in the treatment of growth hormone, using the framework for fairness. We used qualitative research consisting of semi-structured interviews and focus group sessions combined with quantitative methods to audit the decisions of the forum. The rationing decisions of the forum demonstrate accountability for reasonableness by the conditions for transparency, relevance, and appeal. Most rationales for the decisions are public and transparent. The patients and paediatricians see decisions made by the LRG as clinical and therefore relevant decisions. They also refer to extensive appeal procedures. The case also raises important issues regarding the legitimacy of expert-based priority setting as the cyclic nature of guideline development conflicts with the need for maintaining strict rationing criteria. In 13% of the patients, the sick funds did cover treatment as the forum advised them to do, but according to guideline criteria it may be unlikely that these patients have growth hormone deficiency. According to the LRG, however, only 2% of the decisions are inconsistent with the guidelines, as some criteria on what to do in case of more uncertainty, shifted. For the forum, it seems rather unthinkable to go against the professional norms, in spite of formal national regulations. For the Health Care Insurance Board (CVZ), it was not considered possible to go against national regulations, especially as professional norms have shifted without informing policy makers and patient representatives.

Choice Behavior↗

PubMed2006

Worksite interventions to increase stair climbing; reasons for caution.

Point-of-choice prompts to use the stairs rather than the escalator consistently increase physical activity at public access staircases such as those in shopping malls. More recently, exercise promoters have targeted stair climbing in the worksite. A review of interventions in worksites reveals little hard evidence of successful increases in stair climbing, though the increases in stair usage are encouraging. The contrast between the worksites and public access staircases, however, is not simply one of location. In a worksite, the choice is between the stairs and an elevator rather than an escalator. We reason that the availability of the elevator or the stairwell may be the major immediate determinant of stair climbing in worksites and dilute any possible effects of an intervention.

Choice Behavior↗