Education Committee Launches 'Canned Talk' Drive

Bioethics: Managed Care

Technology -- Fibrinolytic Therapy Guided by Decision Analysis: The Experience of a Rural CCU

Physician and Patient Decision-making: A Research Agenda for the New Millennium?

Did You Know?

President's Column

By Doug Owens

In this column, I'd like to discuss our long-term strategic plans. First, however, an update on a few other activities. The transition of our editorial office at Medical Decision Making is going smoothly. Frank Sonnenberg will begin accepting manuscripts in spring, as Arthur Elstein winds down his superb tenure as our Editor-in-Chief. In addition, we have made substantial progress toward publishing the journal online, thanks to the work of Frank, Ida Sim, the publications committee, and our publisher, Hanley and Belfus. Because our publishing contract expires soon, the publications committee, with the help of Kathy McDonald, is seeking proposals from Hanley and Belfus and other publishers. Finally, we've selected the San Diego Sheraton as the site for the 2001 meeting. The Sheraton is in a terrific location. Our thanks to Dan Reichard and Deborah Karpowicz for scouting potential sites, and for negotiating our contract with the Sheraton. In short, we are making good progress in all of these activities; my thanks to all of the people who have helped.

In October, the Board held a two-day meeting to discuss the long-term goals and strategy of SMDM. The impetus for our discussion was that many members of the Board believe that despite the remarkable success of the members of SMDM, the Society itself has not had as much influence and visibility as we desire. I agree, and I strongly believe that we now have an opportunity to consider a long-term plan to address these issues. Although each of us has a slightly different list of concerns, the common themes are that we would like to increase the influence and visibility of the journal and the Society, to ensure that SMDM is useful to our members and to others, to attract fresh ideas, to ensure long-term financial viability, and to ensure sufficiently large membership that we can realize our other goals. The reason to increase the visibility of MDM and SMDM is to enable the work of the members to reach a broader audience, and to have the influence that the work warrants.

Although the discussion absorbed most of two days, let me summarize our view of the central alternatives. Steve Pauker helped us to frame these choices by leading the Board through a structured process. One alternative is to grow and expand, which would enable us to increase our influence, visibility, and financial stability. A second alternative is to stay small, which would help us preserve the character and feel of the Society that many of us like. I would note that at a time when our field has grown substantially in influence, size and visibility, SMDM has not. My view is that moderate growth would help us reach a broader audience, and would also help provide the resources to engage in initiatives that we believe are important. Currently, our ability to do that is quite limited, primarily for financial reasons.

In view of the alternatives I've described, an obvious question is whether there are strategies that might help us both increase SMDM's influence, and yet preserve the aspects of the Society that we like. I believe there are. Based on the Board's discussions, our plan is to try to reach other potential constituents for SMDM, and to investigate whether affiliation with other organizations may be useful. Other constituencies that may be interested in our work include our colleagues in public health, in industry and pharmacoeconomics, and in locations outside of North America. Organizations that are candidates for affiliation include the American College of Physicians, the Society for General Internal Medicine, and the International Society for Technology Assessment in Health Care. Over the next 6 months, we will explore whether affiliation has sufficient advantages that we should consider that strategy further. I will discuss these options as we learn more. I would appreciate your feedback, as would the entire Board, about how we can best accomplish SMDM's goals.

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Education Committee Launches 'Canned Talk' Drive

By Nananda Col and Joel Tsevat

The Education Committee of the Society for Medical Decision Making has come up with a great idea that could save each of us hours of time. We would like to create an electronic lending library of short didactic talks (i.e., "canned talks") that SMDM members could draw upon when they are called upon to give didactic lectures.

To create this repository, we need to collect 1-hour versions of talks that you have given (we are looking for PowerPoint slide files only, not video or audio at this time) and are willing to share. These canned talks will be posted at the SMDM web site for members to draw upon at will, with acknowledgement of the contributor. We will organize these talks by contributor and topic and will summarize their content, level, and target audience. We hope to be able to post feedback from users, as well. There should be no financial imposition on donors or borrowers as all transactions will be electronic. Unfortunately, we cannot offer any financial inducements for contributing your talks other than the inherent value that creating such a library may offer you in the future when you may need to draw upon it.

This library could serve as a valuable outreach for the Society, but will only work if we can collect a critical mass of talks. Fortunately, several members of the Education Committee have already offered to post their talks on introductory topics at this site. If you have any 1-hour educational talks that you feel have worked well and would be willing to share the file with your colleagues, please let Nananda know. We are interested in a broad range of topics at this time as we are just getting started on this exciting project.

If you have any questions, suggestions, or slides, feel free to contact Nananda (617-636-2398 or nananda.col@es.nemc.org). The Education Committee looks forward to hearing from you!

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Bioethics: Managed Care

By Jonathan Baron

Each year, 2% more Americans are enrolled in managed care plans, in which medical decisions are subject to review on grounds of cost. Most medical decisions in the U.S. are either reviewed in this way or made by providers who are rewarded for reducing costs. The resulting ethical problems are not peculiar to the U.S. Some have been faced, or avoided, by other countries, and developing countries will face them in the near future.

These problems are the occasion for conflicts not only among interests but also among analytic approaches. Economists see problems of over-provision resulting from moral hazard, in which old-fashioned medical insurance provided little reason for patient or provider to internalize costs.

Ethicists - those who appeal to a growing body of doctrine published in medical ethics - tend to see the world in terms of principles such as autonomy, beneficence, and non-interference. Autonomy makes informed consent critically important. Acting on someone without consent is a violation of autonomy, and consent requires full information about alternatives. Gag rules thus violate this principle, even when the rules are of a subtle form that simply encourages providers to keep patients happy. The principle of beneficence is most usually interpreted as applying to the provider's fiduciary obligation toward the patient. It would seem to conflict with any consideration of cost.

A third perspective that might enrich this discussion is that of decision theory and "behavioral decision theory," especially utility theory and the descriptive theory of deviations from it. As yet, few studies have taken this approach to problems of managed care. Many questions suggest themselves.

One question is how providers reconcile their conflicting obligations. We can classify their motives into self-interest, concern for their patient, and concern for others (e.g., payers, other patients). An example of patient/others conflict is the decision to recommend antibiotics that may promote the evolution of antibiotic-resistant strains. Self/others conflicts happen when providers have an incentive to over-provide, and self/patient conflicts arise with capitation and other incentives to reduce costs. Optimal health care strikes a balance among the three motives. The conflicts that arise from managed care may lead to distortions away from this ideal. Of course, other distortions may arise from the alternatives to managed care. Character may reduce such distortions. Altruistic concern for patients may, for example, limit the distorting effect of excessive incentives to reduce costs. Can we rely on character in the long run? Do current rules require a kind of character that the rules themselves are driving out of the health professions?

Whatever the answer, behavioral decision theory may help in answering questions about what kinds of incentives are best. For example, under capitation, the benefit-maximizing strategy is marginal cost-effectiveness. A treatment should be provided if its marginal benefit/cost ratio is above some cutoff, with the cutoff chosen so as to aim at a certain total expenditure over the group of patients covered. Individual providers might, however, interpret the incentive differently. They might, for example, adopt a two-step rule, with a very lax criterion up to a certain expenditure per patient and a much stricter criterion beyond that, as if to compromise between the cost-effectiveness rule and another rule in which "each patient gets her share."

Another issue worthy of study is the role of rules vs. individual judgment. Efforts to control costs have usually relied on rules, whether they consist of specific treatment plans for certain categories of diagnosis, specific funding limits, or limits on coverage. The Oregon Health Plan, for example, sets coverage according to condition-treatment pairs. Critics of such rules say that they are inflexible, unable to take into account the specifics of a given case. A treatment that is not cost-effective in general may be cost-effective for a given patient.

The psychology of judgment has found repeatedly that simple rules are superior to human judgment. Human judges make errors that lead to different treatment of identical cases, and rules do not. Even if judges are superior to rules in other ways, this superiority is typically outweighed by error reduction from the use of rules. On the other hand, there must be limits to this effect. The psychological evidence is from situations in which a criterion is monotonically predicted by several cues. Medical diagnosis is typically not like that. Some ethicists have argued that, if physicians and nurses can learn to make case-by-case judgments that take costs (i.e., the needs of those other than their patients) into account, rather than seeing themselves as one-sided advocates for their patients, then the benefits of human judgment can be obtained. Such an attitude among health providers would head off excessive, and excessively crude, regulation, or, worse, imposition of the case-by-case human judgment of a case manager who is less knowledgeable and less familiar with the case at hand.

(Full reference citations are available by contacting the author at baron@psych.upenn.edu.)

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Technology -- Fibrinolytic Therapy Guided by Decision Analysis: The Experience of a Rural CCU

By John Kellett, MD

Several large trials have shown that fibrinolytic therapy can improve survival after acute myocardial infarction (MI). However, fibrinolytic drugs also increase the risk of a major bleeding episode or stroke, leaving the physician with a potentially difficult choice - to give fibrinolytic therapy and take the risk of precipitating a stroke, or withhold it and take the risk of preventable death from MI. The decision to administer fibrinolytics would not be too difficult if all patients were similar to those who fulfilled the admission criteria for the large clinical trials: that is middle aged, with definite acute MI, presenting shortly after symptom onset and with no particular risk factors for stroke or bleeding, and if not fibrinolysed, would have a mortality of around 10%. Unfortunately, such patients may not always be encountered by physicians in everyday practice. In real life, both the time of symptom onset and the diagnosis of MI are often far from certain, and individual patients may have hypertension, low body weight, advanced age, or other factors that expose them to increased risk of bleeding, stroke, and death. It is not surprising, therefore, that the proportion of patients with acute infarction actually given fibrinolytic therapy may be as low as 20%, and that up to 6% of patients without infarction may be inappropriately fibrinolysed. It is possible however, to determine explicitly the risks and benefits of fibrinolysis by decision analysis, provided the probabilities of MI, death from MI, and stroke can be estimated.

As far as I know, Nenagh CCU is the first to use a decision analysis model to guide fibrinolytic therapy (Clin. Cardiol. 1998;21:93-98). We have used two approaches to determine the chance of acute MI: one based on the patient's presenting ECG, and the other on a logistic regression model. Both give excellent, and comparable results (Canad. J. Card. 1997;13:1033-38). Logistic regression models are also used to determine the chance of stroke (Circulation 1995;92:2811-18) and death from infarction (Med. Care 1992;29:1196-1211).

The program printout does not state explicitly whether fibrinolytics should be given or not. However, it provides all the data needed to make this decision. These include the chances of death with and without treatment, as well as the "up front" risks of stroke and serious bleed. It then estimates how long the patient is likely to live with and without fibrinolysis. It also performs multiple sensitivity analyses to determine how much greater or smaller the chances of infarction, stroke, death, bleeding, time of onset etc., would have to be before the preferred treatment option changes. The physician can decide if he thinks the likely life expectancy gain from fibrinolysis is worth the "up front" risk of stroke. The physician can also decide, based on the data provided, which fibrinolytic regimen should be used. Accelerated tPA is not only riskier than streptokinase, it is also substantially more expensive. In Nenagh CCU, we have decided not to give tPA is it costs more than IR£10,000 per extra year of life saved. This not because we do not think our patients' lives are worth less than IR£10,000 per year, but because once the cost-effectiveness of tPA over streptokinase reaches this level, it starts to rise very rapidly in a very short time. Thus, by the time the accelerated tPA regimen is set up it is no longer cost-effective.

Development of the program started in 1989, and was first reported in 1992 (MD Computing 1992;3:157-164). The decision tree (Med. Decis. Making 1995;15:297-310) has been constantly updated since first published in 1991. During the early development of the program CCU staff were blinded to its results (i.e. there was no printout). Of the 262 patients treated during this phase the overall infarct mortality was 21.4%, and 2.2% of patients without infarction were inappropriately fibrinolysed. As of September 1998, 518 patients have been managed with decision analysis support, with an overall infarct mortality of 13.9%, and only 0.9% of those without infarction inappropriately fibrinolysed. Confirmation of these encouraging findings will require a larger study performed over a shorter time, thereby ensuring that the results are not confounded by other changes in CCU management. I would welcome collaboration with any interested colleague(s). Demonstration versions of the program are available from me via e-mail at kellett@iol.ie.

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Physician and Patient Decision-making: A Research Agenda for the New Millennium?

By Margaret Holmes-Rovner and Hilary Llewellyn-Thomas

At the October 1998 SMDM meeting, approximately 60 registrants attended the Past Presidents' session "Why Do Clinicians Act That Way? / Why Do Patients Act That Way?" The aim of the workshop was to gain a rapid overview of the relevant empirical literature, then based on this overview, to "brainstorm" about a research agenda for future investigations of clinician / patient decision-making.

An Overview of the Literature *

Bearing in mind the risk of greatly oversimplifying, Margaret Holmes-Rovner outlined how the literature suggests clinicians and patients sometimes act non-normatively, and how various strategies to change clinician and patient behavior have resulted in the following broad generalizations:

• Calibration interventions do not change provider behavior and have not been tried with patients.
• Academic detailing changes provider behavior, but is not cost-effective. The closest parallel directed at patients is direct marketing, which does sell drugs.
• Reminders change provider behavior if the providers are already in agreement with the behavior change. Reminders in the patient adherence studies have been shown to be effective. No one strategy appears superior.
• Practice guidelines have been relatively ineffective in changing provider behavior. Patients comply with screening guidelines less well than with medications.
• Decision supports work like reminders with providers. They appear to make patients less interventionist. Is this related to improved calibration?
• Incentives work with providers, but the magnitude of change is small. Incentives have been widely used among patients. Future moves to away from employer-purchased health care may change the experience of patients.

Next, Hilary Llewellyn-Thomas outlined the fundamental and applied research perspectives that have generated these observations:

• The major theories range from the most economic to the most psychological (see Hammond et al). These include Economic Decision Theory (includes expected utility), Behavioral Decision Theory, Psychological Decision Theory (includes prospect theory), Social Judgement Theory, Information Integration Theory, and Attribution Theory.
• The key topics include preferences for health states, treatments, and time periods, the perception and comprehension of probabilities; decision participation roles and decisional conflict; and the definition and measurement of "effective" decision making.
• The primary research methods include: non-risky and risky techniques to measure values and utilities for health states; measuring attitudes towards treatments with formal decision analysis, the analytic hierarchy process, videodiscs, decision boards, balance scales, and the treatment trade-off technique; time techniques including QALYs, healthy years equivalents, maximal endurable time; graphic, verbal, and nested numeric scales to present probabilities; scales for decision participation, conflict, effectiveness, and satisfaction.
• Some pressing research issues involve matching the research question, the technique, and the respondent population; the validity of descriptions for states and treatments; anticipatory, experienced, and retrospective assessments of states and treatments; sequencing, anchoring, and framing effects; ethical issues; cross-cultural comparisons; health research/policy implications; and improving the health care encounter.

• More cross-cultural development and application of decision measures (25%).
• Assess which decision support systems work with which patients in what kinds of contexts (21%).
• More studies on the doctor/patient relationship rather than either alone (19%).
• Address whether preference techniques lead to "improved" individual care. Determine which theories & methods are most informative (14%).
• Increase health policy research (13%).
• Increase economic policy research (05%).
• Address whether specific clinician / patient decision making guidelines are appropriate, possible, effective (03%).

• References are left as an exercise for the reader. For examples, see the 1998 Short Course in Physician Decision Making by Smith, Poses, et al., & the annotated bibliography about Patients' Decision Support Systems by O'Connor, et al., www.lri.ca/programs/ceu/ohdec/annotated.htm

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Did You Know?

Kauf Joins GlaxoWellcome. Theresa Kauf, Ph.D., recently left the School of Pharmacy at the University of North Carolina at Chapel Hill to join GlaxoWellcome as a Senior Health Outcomes Scientist. Theresa's new email: tlk99136@glaxowellcome.com. Congratulations, Theresa!

Clinical research at the University of Washington Department of Psychology and Stanford University Medical Informatics leads to the development of DatStat.com. DatStat.com provides Web-based data collection and analysis services. Services include developing paper-based and Web-based data collection form(s), collecting data from clients, patients, study participants, or customers over the Internet, and/or conducting customized statistical analyses. For more information visit www.datstat.com, email lizza@datstat.com, or call toll free: 1-888-DATSTAT (328-7828).

VA Establishes New Information Resource Center. Researchers with the U.S. Department of Veterans Affairs (VA) seeking information about VA's various data bases now have a new place to turn, thanks to the establishment of VIREC, or the VA Information Resource Center. This national referral center will provide researchers with a centralized infrastructure to understand how to access the Department's vast medical and researcher data sources. For more information, contact Joseph D. Kubal at (708) 343-7200, ext. 4269.

TreeAge Releases DATA 3.5. In January, TreeAge Software, Inc. released DATA 3.5, a new version of our decision analysis software, together with a special edition of the user's manual dedicated to medical decision making. Any MDM members with earlier versions of DATA who did not receive an upgrade notice should contact TreeAge by e-mail at info@treeage.com or by telephone at (413) 458-0104.

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