Society for Medical Decision Making

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News from SMDM: Summer 1999

Ready to Take a Gamble? Join Us in Reno

1999 SMDM Short Courses Break New Ground

Bioethical Debate: Peter Singer

President's Column

Highlights from the Board of Trustees Spring Meeting, May 2, 1999

VIReC: Resource for Medical Decision Makers

Electronic Publication Survey Results

Did You Know?

Ready to Take a Gamble? Join Us in Reno

by Bob Byrg

The program committee of the 21st Annual Meeting of the Society of Medical Decision Making would like to invite you to exciting Reno to present your new research, renew old friendships and then practice your level of risk taking or risk aversion at the Reno Hilton and Casino.

The meeting is scheduled to start on Sunday, October 3rd with 16 short courses arranged by Les Lenert. These range from the standard Basic and Advanced Decision Analysis courses that run for a full day to a course on the Theoretic Foundations of Utility Theory taught by David Paltiel and Aaron Stinnett. Starting Sunday evening, there is a welcome reception and poster session. Monday features the top abstracts submitted in a plenary session as well as the evening social event: The Lake Tahoe Sunset Dinner Dance Cruise. On Tuesday, there is a symposium on: "Managed Care: Where Did We Come from and Where Are We Going?" Several nationally known speakers are scheduled for this symposium. The conference will conclude on Wednesday at 10:30 AM in time to catch flights back east out of Reno Tahoe International Airport.

The meeting will be held in the Reno Hilton, the largest hotel to host this convention. At 2001 rooms, it is almost a small city. In addition to the bed towers, there is a 100,000 square foot casino featuring games of skill and chance. The table games of 21 (Blackjack) and craps are ever popular. The roulette wheels are constantly spinning, luring gamblers to take a chance on red or black. For the well to do, Baccarat also lures gamblers. For people who are intimidated by the table games, the slot machines beckon. Megabucks is a multi-casino progressive slot that currently has a jackpot of over $17,000,000. This would be enough to fund anybody's research for many years to come. Unfortunately, the payline is significantly lower than current NIH grants. For those who can't think this big, smaller slots including
Video Poker abound around the floor. This meeting will be a great place to demonstrate how risk tolerant or risk averse the membership of this Society is.

Inside and out, abundant non-gaming entertainment is present on site. In the lower level, there is a shopping mall, 2 movie theaters, and laser tag. On the first level, there is a 50-lane bowling alley. Outdoors, there is a Golf Driving Range into the Hilton Lake and the "Ultimate Experience" ride where one swings from a 200 foot tower, similar to bungee jumping.

Unlike other years, a wealth of restaurants awaits inside the hotel itself. For the frugal, Subway sandwiches and Round Table Pizza are available. As in all Nevada casinos, there is the ever-present buffet, offering wide selections at reasonable prices, since the hotel figures they will get your money in the casino sooner or later. On the high end, there is Asiana, a Pacific style restaurant blending Japanese and Chinese cuisine; the Hilton Steakhouse offering choice cuts of beef and seafood: and Chevy's offering Mexican food for the masses. A Johnny Rockets is also available.

October is one of the best times to visit the high desert of Reno and the mountains of the high Sierra. Days are warm with highs in the 70's and nights are cool, with lows in the 30's on the average. There is very little precipitation this time of year, but as with any month of the year, there is always a chance of snow. Since mornings and evenings can be brisk, we recommend bringing a jacket for those going on the Lake Tahoe Cruise.

Monday night promises to be a spectacular evening for those members and their guests that chose to join us in cruising Lake Tahoe. Leaving the hotel at approximately 5 pm, buses will take us over a high mountain pass before entering the Tahoe Valley. In this short distance, one enters one of the most beautiful valleys in the country. We will alight onto the MS Dixie Paddlewheeler for a night of food, dancing and collegiality. We return late in the evening back to the Hilton. We will cruise to Emerald Bay at sunset and be able to watch the spectacular sunset over the mountains to the West.

This meeting offers a little of everything, from intellectual stimulation, to scenic relaxation, to the excitement of testing your skills in the casino. We look forward to seeing you all come to the "Biggest Little City in the World", Reno, Nevada.

1999 SMDM Short Courses Break New Ground

by Les Lenert

I want to encourage you all to take advantage of the unique and broad range of educational opportunities offered this year through the pre-meeting Short Courses. This year's meeting features nine new courses on topics ranging from Bayesian data analysis to management of conflicts between patients and healthcare providers. As always, an important focus of our educational efforts is the improvement of our memberships' research skills. To that end, we are offer courses on the fundamental research methods underlying work presented at the Society's meeting. These include:

SC#1: Basics of Decision Analysis (full day course)

SC#2: Advanced Decision Analysis (full day course)

SC#3: Cost-Effectiveness Analysis

SC#15: Foundations of Utility Theory

The curriculum also features advanced training for the membership to open new research opportunities. Courses designed to meet this need include:

SC#4: Developing and Evaluation Patient Decision Aids

SC#5: Economic Evaluation of Clinical Trials

SC#8: Introduction to Bayesian Analysis

SC#9: Neural Networks: Advantages and Limitations

SC#13: Applying the Theory of Constraints.

SC#14: Managing Conflict in Medical Decision--Making

SC#16: Clustering and the Definition of Health States.

I have taken the liberty of putting together a few suggested "tracks" to help you choose among the 16 outstanding courses offered at this years' meeting. These tracks illustrate the potential synergies among courses in the curriculum. Tracks are given for example purposes only. You can select any combination of morning and afternoon courses. But sign up early, as space in all courses is limited.

Track A: Thought Leaders in Medical Decision Making (Select SC#4 and SC#14)

AM Session -- "Developing and Evaluating Patient Decision Aids" will be taught by Annette O'Connor, Margaret Holmes-Rovner, and Michael Barry. These distinguished investigators will discuss their work that has literally defined this field.

PM-Session -- "Applying the Theory of Constraints" taught Steve Pauker, Robert Centor, Mark Eckman, and David Matchar will
discuss a new model for evaluating and refining medical decisions.

Track B: Disease Management (Select SC#6 or SC#7 and SC#10 or SC#11)

AM Session: Choose between learning about the latest technologies to develop guidelines (SC#6 led by Gillian Sanders, Doug Owens, and Robert Nease) or learning how to apply the principles from evidenced based medicine in quality improvement (SC#7 led by Roy Poses with Juan Ruiz and Wally Smith).

PM Session: Choose courses describing how to motivate change in healthcare providers (SC #10 led by Lisa Rubenstein from the VA Center of Study of Provider Behavior and the UCLA School of Medicine) or how to motivate change in patients (SC#11 led by Allen Gifford and Kate Lorrig of the Stanford University School of Medicine).

Track C: Advanced Topics in Cost-Effectiveness Analysis (Select SC#5 and SC#12)

AM Session -- "Prospective Economic Evaluation of Clinical Trials," led by Kevin Schulman, discusses how to integrate cost and other economic measures into clinical trials

PM Session -- "Workshop in Health Index Instruments." Health Index Models are frequently applied to estimate changes in quality
adjusted life years in clinical trials. Ted Ganiats, with. Robert Kaplan, will discuss features of various health index models such as the Euroqol (ED-5D), the Health Utilities Index, and the Quality of Well Being Scale.

Track D: Advanced Topics in Patient-Centered Care (Select SC#4 and SC#14)

AM Session -- "Developing and Evaluating Patient Decision Aids." As above.

PM Session -- "Managing Conflict in Medical Decision Making." Stanford Professor Michael Fehling will lead a course on how to use decision analysis to manage conflicts among patients, physicians, and health care administration, drawing from his experience working with cancer patients through the Community Breast Health Project.

Track E: Advanced Statistical Methodologies (Select SC#7 or SC#9 and SC#16)

AM Session: Choose between learning about one of two "hot" methods for interpretation of data and get hands-on experience with that method. If Bayesian approaches to data analysis peak your interest, join SC#7 led by Dennis Fryback and learn how to use WinBugs. If you learn toward artificial intelligence-based methods, join Phillip Goodman and learn how to interpret your data using neural networks in SC#9. Bring your laptop to either of these courses.

PM Session: "Clustering and the Definition of Health States." Stanford Professor Richard Olshen leads a discussion on how to define health states and forge links between health status measures and preferences using k-means cluster analysis.

I look forward to see you all in Reno this year.

Bioethical Debate: Peter Singer

By Jonathan Baron

Professor Peter Singer, now at the Centre for Human Bioethics, Monash University, plans to move to Princeton this summer, to a chair in Bioethics at the Center for Human Values. In anticipation of his arrival in the U.S., recent protests at Princeton and editorials throughout the U.S. have charged him with "moral vacancy" and called him a Nazi. He thinks that active euthanasia should be allowed, not only for adults but also for severely disabled infants. He also favors legal abortion, in-vitro fertilization and research on human embryos.

On the other hand, he opposes most research on animals, advocates vegetarianism, and wants to protect the great apes. He thinks that letting poor people die throughout the world from malnutrition and preventable disease is roughly as bad as killing them, and he favors major increases in aid from individuals and governments.

His views are of interest to students of medical decision making. They are perhaps best laid out in "Practical Ethics" (Cambridge University Press, 2nd edition, 1993), which I have assigned to several classes. (Other relevant books are "The expanding circle" [1982] and "Rethinking life and death" [1997].) Singer's unique and apparently incongruous set of views all stem from a relentless search for reasons. He distrusts moral intuition as a guide to morality, a view that will be congenial to psychologists who believe that intuitions are often misleading.

Much of "Practical Ethics" is a search for reasons why we should not kill. It is thus a sort of multi-attribute decision analysis of the value of life. First, as the classical (and perhaps mythical) utilitarians argued, life has value because it is a vehicle for good experiences, for pleasure. Second, adult human life has additional value because we are "persons," endowed with attachments, ongoing projects and concerns. So, thinks Singer, are some apes, but not infants, other animals, fetuses, or embryos. (He may have his facts wrong about the apes.) Killing these non-persons is thus different from killing persons. Third, fetuses and infants (and embryos, and egg-sperm pairs) are also potential persons. In the end, Singer rejects the moral relevance of potential, but "Practical Ethics" carries the idea through, for the benefit of the reader who thinks it is relevant.

This analysis, together with a few assumptions about facts, generates most of the views I listed. One more assumption is needed: the distinction between acts and omissions is, in itself, morally irrelevant. This assumption leads to active euthanasia and to the obligation to help the poor.

These conclusions all follow from still deeper premises about the nature of morality and moral argument. Singer should have a hearing in the U.S. He will enrich the bioethical landscape here, and his presence may also increase his influence in our field and lead us to analyze life as a value in more nuanced ways.

President's Column

By Doug Owens

In this column, I'd like to briefly emphasize a few issues that Scott Cantor describes in his summary of the Board meeting, elsewhere in the Newsletter. As Scott notes, we are in the midst of renewing our contract for publishing Medical Decision Making. Our goals are to maintain the high quality of MDM, to increase its visibility, and to take full advantage of the opportunities for electronic publication and dissemination.

On behalf of the Board, I'd like to thank Ida Sim, Kathy McDonald, and the publications committee for their help with the contract renewal process; they've done a truly spectacular job. The proposals for new contracts range from arrangements that are similar to our current contract, to proposals that include sale of the journal to a publisher, for a substantial sum. You may be aware that academic publishing is in upheaval. The cost of many journals has increased dramatically, and the availability of electronic publishing has introduced substantial uncertainty in the publishing world. For an interesting discussion of these problems, see http://www.stanford.edu/~boyd/schol_pub_crisis.html. It is possible that the contract that is most financially beneficial to SMDM in the
short-term may not be in the long-term interest of the academic community. If you'd like to give us feedback about the journal or the contract, please contact members of the pubs committee (smdm-pubs@smi.stanford.edu), or board members.

We also continue to investigate whether strategic affiliations with other societies could be beneficial to SMDM. We are considering affiliations of two kinds. The first would be a close affiliation with a society that enables us to meet our goals of increased visibility, influence, and strong financial security. Such an affiliation might include shared administrative support, and the development of strategic initiatives on topics that are of mutual scientific or policy importance, or even a merger. I believe that for such an affiliation to be mutually beneficial, we should have strong overlapping interests, and the affiliation should enable us to reach an important audience for our work. We would also like to foster affiliations with societies that have common interests, in the form of close working relationships. We are considering ways to foster such relationships.

If you know of societies or groups that you think would be of interest to our members, or that would be interested in the work of SMDM members, please let us know. We should make every effort to reach potential consumers of our work, and to familiarize our colleagues with our research agenda. For example, SMDM has not actively fostered relationships with industry, and we believe that we have missed an important opportunity to reach a group to which our work is relevant. We hope to learn how our work can be useful to our colleagues in industry, and to learn about the topics that are of most relevance to them.

I hope to have updates on all of these initiatives by the meeting in fall. As always, I would like to hear about your thoughts on any of these topics (owens@stanford.edu).

Highlights from the Board of Trustees Spring Meeting, May 2, 1999

By Scott B. Cantor.

The spring meeting of the Board of Trustees of the Society for Medical Decision Making met in San Francisco. Highlights of the board meeting are as follows:

Administrative Report (Dan Reichard). Deborah Karpowicz resigned her position as Associate Administrator to accept a position with a corporate meeting-planning firm in Baltimore. Courtney Jones is now the Associate Administrator for the Society in the George Washing University Medical Center Office of Continuing Education in the Health Professions. Courtney can be reached by e-mail at smdm-office@smi.stanford.edu in addition to the usual SMDM phone and fax numbers. Dan suggested that all SMDM members visit the Society website on a regular basis to view the continuing enhancements, including the annual meeting information, membership directory and back issues of the journal. Dan also raised the issue of having a policy regarding the copyright and distribution of annual meeting short course materials -- these materials are available from the SMDM for a nominal fee.

Treasurer (Roy Poses) Roy presented a proposed budget for the 1999-2000 fiscal year. The Society is projecting to be "in the red" in the forthcoming years. The Board discussed alternatives for increasing revenues, given that the possibility of decreasing expenses was not an attractive option. These alternatives included raising dues, increasing fees for the annual meeting, and fundraising though industry. The budget will be voted upon at the fall meeting.

Annual Meeting (Robert Bryg). Robert reviewed the plans for the next annual meeting to be held October 3-6, 1999 in Reno, Nevada. The call for abstracts has been distributed to the membership and is available on the SMDM website. (A few board members were embarrassed to not recognize the symbolism of the Ace-Jack combination on the cover of the brochure -- it is the 21st Annual Meeting of the Society.) The Board congratulated the Reno team (Robert Bryg, David Bryg, Holly Jimison and Les Lenert) for their care in planning this exciting meeting.

Publications Committee (Ida Sim). The major issue facing the Publications Committee is the renegotiation of the publishing contract for the journal. Ida Sim presented the various options and attributes of the decision making process, including the possibility of remaining with the current publisher, Hanley and Belfus. A decision is expected before the end of the calendar year.

The transition in the Editorial Office for the journal is nearly complete. Arthur Elstein was congratulated for his fine work as Editor-in-Chief for Medical Decision Making and Frank Sonnenberg was welcomed as the new Editor-in-Chief. New manuscripts are now being received at the New Jersey address, where Sandy Tarentino will be the new Editorial Assistant.

Membership Committee (Mark Roberts). Our membership numbers have dipped this past year--we are now just below 1000 members. Attrition has been caused by (1) change in professional responsibilities, (2) non-receipt of journal issues, and (3) competition from other societies. Efforts to both recruit and retain members will be developed.

Education Committee (Joel Tsevat). The Committee has received six "canned" talks from SMDM members. It is expected that at least twelve such talks will be made available to SMDM members for their use. Most of these talks concern with methodology fundamental to medical decision making.

Nominations Committee (Bob Nease). Candidates for the SMDM officers and board members include: for President-Elect, Roy Poses and Myriam Hunink; for Vice-President-Elect, Annette O'Connor and Scott Cantor; and for Trustee, Ida Sim, David Paltiel, David Meltzer, Miriam Kuppermann, Kerry Kilbridge, and Ken Freedberg. The Board unanimously approved the slate.

Other Business. Given the two important goals of increasing the usage and impact of analytical techniques for medical decision making and the maintenance of our financial viability, Doug Owens reported on the status of potential affiliations with other professional societies. At this point, all discussions are in their very early stages. However, the Board would be interested in the opinions of the SMDM membership regarding potential alliances, both for the purposes of increasing visibility and the possibility of taking advantage of increased efficiencies of scale.

The Board also continued discussion of creating a plan for making alliances with industry. At this point, our plan is to assess the needs of SMDM and of industry to determine where joint values could be shared. Board members will make initial contacts at the International Society of Pharmacoeconomics and Outcomes Research meeting later in May, to be followed by dinner meetings during the summer. The next meeting of the Board will take place by telephone in August.

VIReC: Resource for Medical Decision Makers

By Joseph Kubal

The Department of Veterans' Affairs' VA Information Resource Center (VIReC) will mark its first anniversary on July 1, 1999. During the last year, VIReC staff developed a new resource guide for the VA's National Patient Care Database's outpatient files, wrote a variety of news and research articles for the scientific and lay press, attended and presented at several major conventions, and participated in VA informatics policy-making meetings while fielding numerous questions on VA databases. But just what is VIReC and how can this new center help medical decision-makers?

VIReC was founded under the premise that health services researchers and medical decision-makers often need assistance obtaining information regarding VA and non-VA health-related databases when developing research proposals and protocols. To accomplish this mission, the VIReC has undertaken six major objectives. These include: 1) updating the Department of Veterans Affairs Database Resource Guides and the three-volume Resource Guide: VA Long Term Care Programs and Services; 2) documenting new VA databases of key interest for health services research, including the National Patient Care Database (NPCD) and the Decision Support System (dSs); 3) developing a network of high level data experts for consulting on use of VA and non-VA databases; 4) supporting VA Health Services Research and Development (HSR&D) Service and the VA Cooperative Studies Programs (CSP) by providing their scientific review boards with evaluation of research proposals utilizing VA information systems; 5) serving as liaison between HSR&D and the VA Office of the Chief Information Officer (OCIO); and 6) evaluating the reliability and validity of current VA databases that are relevant to health services research.

VIReC investigators and staff include experts in health services research, health economics, medical demography, clinical trials, and informatics. Investigators and staff are experienced in utilizing a variety of VA and non-VA databases to address research, management, and quality improvement issues. VIReC investigators and staff are available to provide information, advice, and consultation to researchers, managers, clinicians, and other medical decision-makers about database availability, access, architecture, content, and contacts. VIReC eventually hopes to provide basic information on other federal databases, such as those maintained by the Health Care Financing Administration (HCFA).

The VIReC website located at http://www.virec.research.med.va.gov should serve as the first step for those individuals interested in obtaining information about VA databases. Whether researchers need a data dictionary, want to know the value labels of the Patient Treatment File (PTF) or the Outpatient Clinic File (OPC), need some tips about writing SAS code, or could benefit from some examples of tested computer programs, this site may provide the answers to their VA database questions. Additionally, researchers and decision-makers will find a list and brief explanation of the most frequently used data sources, links to other VA and non-VA informatics and database sites, a news page dedicated to the latest happenings; trends; and changes throughout the health care research community, and a listing of questions frequently asked by VIReC customers.

The VIReC is co-directed by Dr. Denise M. Hynes and Diane C. Cowper. More information about VIReC can be obtained by contacting Joseph D. Kubal, Center Manager, at 708-202-2413 (telephone), 708-202-2415 (fax), or virec@research.hines.med.va.gov (e-mail). The mailing address for the Center is: VA Information Resource Center (578/151V), Hines VA Hospital, P.O. Box 5000, Hines, IL 60141-5000.

Electronic Publication Survey Results

By Robert M. Hamm, Noriaki Aoki, and Ida Sim

Should the journal Medical Decision Making be available electronically? To whom should electronic access be available, and at what price (if any)? Should SMDM provide access to interactive decision analytic models, or to the code of decision analyses? The SMDM Publications Committee conducted a survey of the membership regarding these and other options for electronic publication.

The survey was published in the January 1999 issue of Medical Decision Making, and made available at a web site at Baylor College of Medicine. It was also announced in the Winter 1998 SMDM Newsletter and via the SMDM-L email list. Additionally, the MDM page with the printed version gave the address of the web version.

There were 45 responses, 40 from the web site and 5 from the questionnaire in MDM. The web questionnaire elicited many thoughtful written comments.

In brief, the respondents were interested in web access to abstracts and full text of Medical Decision Making papers, both at the time of publication and retrospectively. (Plans are underway to implement some of these features.) This is not, however, as a substitute for the paper journal. The mean amount respondents indicated they were willing-to-pay (WTP), per year, for all of the electronic services was $25. The median WTP was $9.50.

Many members were interested in having access to decision analytic models published in Medical Decision Making, although they felt providing this access should be voluntary for the authors. There was some concern about providing data for reanalysis some interest in web-based tutorials.

As for long term electronic publishing possibilities, many good points were offered regarding access to generic decision models, providing clinicians and patients access to interactive decision analytic models, and providing a service for reviewing and certifying decision analyses.

A summary of the survey is available at ftp://www.fammed.ouhsc.edu/CDM/webpubsurv/WEBQNsumm.rtf and the results for each question as well as the full set of comments are in ftp://www.fammed.ouhsc.edu/CDM/webpubsurv/WEBQNrpt.doc. Thanks to all that responded to the survey. Your input was helpful as we (the publications committee) consider electronic publications options for the future.

Did You Know?

Mark Eckman moves to Cincinnati. On July 1, Mark Eckman will be going to the University of Cincinnati Medical Center to take on the role of Chief of the Division of General Medicine and Director of the Center for Clinical Effectiveness in the Institute for

Health Policy and Health Services Research. You can reach Mark after 7/1/99 at mark.eckman@uc.edu. (Joel, congratulations on the new colleague!)

Joseph Lipscomb has been named the head of the newly-created Outcomes Research Section in the Division of Cancer Control and Population Sciences at the National Cancer Institute in Bethesda. Mailing address: NCI, DCCPS, ARB; EPN 313; 6130 Executive Blvd, MSC 7344; Bethesda, MD 20892-7344. E-mail: joseph_lipscomb@nih.gov. Phone (301) 402-3590.

A trickle of new manuscripts continues to arrive at Arthur Elstein's office, even though the editorial transition was announced in the January issue of MDM. All new manuscripts should be sent to Frank Sonnenberg at the address below. Dr. Sonnenberg's editorial assistant is Sandy Tarantino, tarantsa@umdnj.edu. Please note that updated instructions for authors are located on the MDM web site at http://www.hanleyandbelfus.com/journals/archive/info4authors/mdm.html. Please note that we are now requesting an electronic (floppy disk) copy of each manuscript at the time of submission to facilitate electronic communication with associate editors and reviewers.

Frank A. Sonnenberg, MD
Editor-in-Chief
Medical Decision Making
UMDNJ Robert Wood Johnson Medical School
125 Paterson Street
New Brunswick, NJ 08903
Phone: 732-235-7357
Fax: 732-235-7144

Email: sonnenbe@umdnj.edu