MDM Policy and Practice最新文献

Introduction. Reducing hospital waiting lists for elective procedures is a policy concern in the National Health Service (NHS) in England. Following growth in waiting lists after COVID-19, the NHS published an elective recovery plan that includes an aim to prioritize patients from deprived areas. We use a previously developed model to estimate the health and health inequality impact under hypothetical targeted versus universal policies to reduce waiting time. Methods. We use a Markov model to estimate the health impact of waiting, by index of multiple deprivation quintile group, for 8 elective procedures. We estimate patients' remaining quality-adjusted life-years (QALYs) with baseline waiting times and under 2 hypothetical policy scenarios: 1) a universal policy in which all patients receive an equal reduction in wait and 2) a targeted policy in which patients living in the most deprived quintile are prioritized. We estimate individual and population level health under each of the 2 policies and compare it with baseline. We also estimate how health inequality changes from baseline using the slope index of inequality, reflecting the difference in health between the least and most deprived quintile based on QALYs. Results. A universal reduction in waiting time is estimated to improve overall population health but increase health inequality. A targeted reduction would achieve nearly the same overall health gain and would also increase population-level health inequalities but to a lesser extent than the universal policy would. Discussion. If the NHS is successful in prioritizing patients on waiting lists from the most deprived areas, this may result in smaller increases in health inequalities while maintaining a similar level of overall health gain compared with a universal policy.

Highlights: The NHS elective recovery plans include prioritizing patients who live in the most deprived areas of England.Evaluating a hypothetical targeted wait time reduction policy against a universal wait time reduction policy suggests almost the same level of population health gain could be achieved while lessening the negative impact on health inequality.Expected outcomes of government health policies should be quantified to explore the impact on both health maximization and health inequality minimization, as both represent legitimate policy concerns.

Introduction. Many organizations recommend structured communication processes, including formal shared decision making (SDM), for patients undergoing lung cancer screening (LCS) using low-dose computed tomography (LDCT). We sought to understand if concordant and shared LCS decision making was associated with decisional conflict. Methods. In this prospective, observational study, we enrolled patients from 3 medical centers (2 Veterans Health Administration, 1 academic facility) after a decision-making interaction about undergoing LCS but before receiving the LDCT. We included patients who indicated they accepted or declined to undergo the LDCT. We evaluated preferred and actual decision-making roles and used multivariable linear and logistic regression models to measure the association of concordant (congruence between actual and preferred roles) and shared LCS decision making with decisional conflict to report adjusted odds ratios (AOR). Results. Of the 409 participants with nonmissing information, 83% reported LCS decision-making role concordance. In addition, 223 (58%) reported an indeterminate level and 56 (14%) reported decisional conflict. LCS decision-making role concordance was not associated with decisional conflict (AOR = 0.86, 95% confidence interval [CI]: 0.38-1.94, P = 0.71) compared with role discordance. Participant-reported actual LCS SDM role was not associated with decisional conflict (AOR = 0.99, 95% CI: 0.51-1.93, P = 0.98) compared with patient- or provider-controlled roles. Conclusions. LCS decisional conflict was uncommon, although many patients reported an indeterminate level of decisional conflict. Neither concordant nor shared LCS decision-making role was associated with decisional conflict. Clinicians may be unable to decrease LCS decisional conflict using efforts to enhance decision-making interactions.

Highlights: We evaluated patients' preferred and actual decision-making role and decisional conflict following a decision-making interaction about lung cancer screening (LCS).Concordant decision-making preference was not associated with decisional conflict.Actual decision-making role was also not associated with decisional conflict.Efforts to enhance decision-making interactions may not decrease LCS decisional conflict.

Introduction. Diminishing marginal lifespan utility (DMLU) implies that a particular lifespan increment (e.g., 1 life-year) confers lesser marginal utility if added to longer lifespans (e.g., 90 y to 91 y) than to shorter lifespans (e.g., 60 y to 61 y) if quality of life is unchanged. Because DMLU is difficult to disambiguate from discounting, risk attitude, and other elements of utility "curvature," it is poorly characterized. However, the imperative to consider equity in cost-effectiveness analysis (CEA) renders its characterization more important. Methods. I add certainty to the characterization of DMLU through literature review and illustrative example. The literature review synthesizes stated preference studies of utility curvature that exclude risk or probability. The example compares alternative valuations of approaches to reduce inequality in cystic fibrosis outcomes between US centers serving mostly White patients and centers serving mostly non-Black Hispanic patients, with versus without DMLU. Results. The existence of DMLU is likely, and empirical data support its relevance over typical CEA time horizons. The imperative to consider equity in CEA magnifies the importance of DMLU for several reasons. First, intergenerational CEAs require lower discount rates that are less likely to incidentally absorb DMLU. Second, DMLU is incompatible with the use of absolute measures of inequality aversion. Third, DMLU may bias the interpretation of relative measures of inequality aversion toward prioritarianism. Finally, not considering DMLU implicitly biases life-year-based metrics against equity. Conclusion. DMLU is likely to exist, can benefit from additional characterization, and may merit inclusion in CEA alongside discounting. Omitting consideration of DMLU will sometimes confer an antiequity bias and may affect the interpretation of CEAs incorporating inequality aversion.

Highlights: Diminishing marginal lifespan utility (DMLU) means that the value of extending lifespan may differ based on the duration of life already lived.DMLU is not typically considered in cost-effectiveness analyses.Not considering DMLU may bias cost-effectiveness analyses against equity.Not considering DMLU may reduce the accuracy of distributive cost-effectiveness analyses and other approaches to consider equity along with efficiency.

Background. COVID-19 tremendously disrupted the global health system. People of all ages were at risk of becoming infected. Frequent school closures raised concerns about both the physical and mental health of school-age children. Many studies discussed the effectiveness of various interventions, while few focused on optimizing such interventions. Methods. This study aimed to optimize the usage of random screening tests and masking requirements within K-12 schools. We simulated the disease transmission within a school setting and sought to find the most efficient schedules for schools to arrange their weekly screening tests and mask mandates. The goal was to minimize the number of the end-of-semester infections as well as to use the minimum number of resources. We applied the nondominated sorting genetic algorithm, NSGA-II, to solve this multiobjective optimization problem. We also compared results when polymerase chain reaction (PCR) versus rapid antigen tests were used. Results. The NSGA successfully found Pareto solutions when optimizing the end-of-semester infections, the total number of tests, and the total number of weeks masking. The screening tests and masks can serve as alternatives to one another when prioritizing minimizing the number of infections. In addition, due to the faster return of testing results and lower accuracy, the rapid antigen tests had a similar effect as PCR tests. Conclusion. Our study provides policy makers in K-12 schools with valuable insights. The conclusions derived from this research can serve as a solid foundation for making informative decisions regarding random screening tests and universal masking policies.

Highlights: Our simulation optimization framework was used to design weekly schedules for random screening tests and masking within K-12 schools to mitigate COVID-19 infections.We considered multiple objectives and applied the NSGA-II algorithm to find a Pareto solution set.Based on local context and preferences, decision makers can trade off testing and masking to achieve a similar number of end-of-semester infections.When a few weeks of masks are mandated, it is best to use them at the beginning of a semester.

Introduction. Many breast cancer survivors experience cancer-related fatigue (CRF), and several interventions to treat CRF are available. One way to tailor intervention advice is based on patient preferences. In this study, we explore preference heterogeneity regarding between-attribute and within-attribute preferences. In addition, we propose simple decision rules to match preferences to interventions. Methods. Nine attributes were included with dichotomized levels. Participants selected their preferred level per attribute and ranked the attributes using best-worst scaling. Between-attribute and within-attribute preferences were determined, together with their heterogeneity. Using decision rules, matching scores were calculated for a hypothetical intervention. Results. Sixty-seven breast cancer survivors completed the survey. They were on average 52 y old, 4.5 y after diagnosis, experienced CRF (6.5-7.2/10) on 3 dimensions (physical, mental, and emotional), and 43% already followed an intervention for CRF. Overall, participants ranked costs highest. Next to costs, proven effectiveness and type of intervention were also frequently ranked first. Only 13 participants (19%) shared the most common preference pattern of shorter interventions, daily sessions, shorter session time, a psychosocial intervention, no anonymity, and contact with a therapist and peers. Matching scores for a hypothetical intervention with attributes corresponding with the overall within-attribute preferences varied from 44% to 100%. Conclusion. A large heterogeneity in preferences of breast cancer survivors for CRF intervention attributes was demonstrated. Using simple decision rules, the effect of this heterogeneity on linking preferences to interventions with matching scores was demonstrated. Implications. Personalization of intervention advice is necessary due to preference heterogeneity. Tailored advice can result in higher involvement of patients in decision making, intervention adherence and satisfaction, and subsequently a potential higher quality of life after breast cancer.

Highlights: Many breast cancer survivors experience cancer-related fatigue for which many interventions exist.Our results show large preference heterogeneity in breast cancer patients' preferences for attributes of eHealth interventions.Based on this preference heterogeneity, intervention advice for cancer-related fatigue after breast cancer can be personalized, ultimately improving quality of life after breast cancer.

Introduction. Consumption of sugar-sweetened beverages (SSBs) contributes to weight gain, obesity, and diabetes. Soda tax has been proposed to reduce consumption of SSBs. What remains unclear is whether the soda tax has an effect on health and health care costs. We evaluated the cost-effectiveness of a 1-cent-per-ounce soda tax on obesity and diabetes in California. Methods. A microsimulation state-transition model was used to evaluate the cost-effectiveness of the soda tax. Health outcomes were measured in quality-adjusted life-years (QALYs). Health care costs were projected from 2015 to 2035. Results. In a simulated cohort of Californian adults, the soda tax policy prevented 2.28 million cases of overweight (95% confidence interval [CI] -0.06 to 6.63) and 0.49 million cases of obesity (95% CI -0.19 to 1.18). From the health care perspective, the incremental cost-effectiveness ratio of the soda tax was $124,839 dollars per QALY (95% CI -1,151,983 to 557,660). From the health care perspective, the soda tax policy was cost-effective 80% of the time in the probabilistic sensitivity analysis using a willingness-to-pay threshold of $100,000 per QALY. Conclusions. The 1-cent-per-ounce soda tax reduced the number of obesity cases, diabetes cases, and related complications. In addition, the soda tax policy implemented in California was cost-effective most of the time.

Highlights: Question: What remains unclear is whether the soda tax has an effect on health and health care costs.Findings: The 1-cent-per-ounce soda tax reduced the number of obesity cases, diabetes, and related complications. In addition, the soda tax policy brought large amounts of revenue.Meaning: This study provides additional evidence regarding the health care costs and cost-effectiveness related to the implementation of a soda tax.

Background. The time between booking an appointment and the appointment taking place, known as lead time, has been identified as a predictor of cancellation and no-show probability in health care settings. Understanding the impact of reducing permissible lead times, that is, the booking horizon, at a policy level in an outpatient care setting is important when mitigating costly cancellation and no-show rates. Few studies have researched this in an observational or experimental setting. Methods. We leveraged longitudinal observational data from an outpatient pediatric rehabilitation organization in Ontario, Canada, consisting of 73,482 visits between June 2021 and October 2023. This organization reduced its booking horizon at the policy level from 12 to 4 wk in February 2023. Using 2 interrupted time-series approaches, we estimated the change in level, slope, and variance of the weekly combined last-minute cancellation and no-show rate associated with the policy change. Results. It is estimated that reducing the booking horizon is associated with an absolute reduction in the weekly rate of last-minute cancellations and no-shows of 1.02% to 1.85% (a relative reduction of 8.07%-15.70%). Furthermore, the variance dropped by 48.18%. Conclusion. Reducing the appointment booking horizon is associated with a significant reduction in the rate and variance of costly last-minute cancellations and no-shows. The reduced variance can also help enable effective usage of strategies such as overbooking for organizations seeking further approaches to mitigating the negative effects of no-shows.

Highlights: This study uses interrupted time-series approaches to assess the effects of reducing the appointment booking horizon at a policy level on last-minute cancellations and no-shows in a pediatric outpatient care setting.Reducing the permissible booking horizon from up to 3 mo to up to 4 wk is associated with a significant reduction in the rate of last-minute cancellations and no-shows.The shortened booking horizon policy is associated with a significant drop in the variance of last-minute cancellations and no-show rates, which is valuable in settings where overbooking occurs.

Introduction. The Centers for Medicare and Medicaid Services mandate that clinicians use a shared decision-making interaction to provide information about the harms and benefits of lung cancer screening (LCS). Methods. We enrolled patients from 3 geographically diverse medical centers after a decision-making interaction about undergoing LCS but before receiving a low-dose computed tomography (CT) scan. We performed the primary analysis based on the primary knowledge question, "Which of these conditions do you think that the CT scan screens for?" We used the knowledge summary score in secondary analyses. We evaluated LCS care experience by using validated instruments to measure participant-reported communication quality (Consultation Care Measure), perception of the primary LCS clinician (Consumer Assessment of Health Care Providers and Systems), and decision conflict (Decisional Conflict Scale). Results. Of the 409 participants, 44% correctly answered the primary LCS knowledge question. Clinician communication quality was rated positively by 93% of participants. Most (93%) participants rated their LCS clinician as good. Only 14% reported decision conflict. Correctly answering the primary LCS knowledge question was associated with higher patient-clinician communication quality scores (b = 0.4; 95% confidence interval [CI] [0.1, 0.7]; R ² change = 0.03) and higher LCS clinician ratings (b = 0.4; 95% CI [0.0, 0.7]; R ² change = 0.02) but not with decision conflict. In secondary analyses, higher total LCS knowledge score was associated with lower Decisional Conflict Scale scores (b = -2.2; 95% CI [-3.4, -0.9]; R ² change = 0.24), indicating lower decision conflict. Conclusions. After an LCS decision-making interaction, many patients do not retain basic knowledge about LCS but nevertheless had low levels of decision conflict. Primary LCS knowledge may be important but insufficient to ensure high-quality, patient-centered LCS care.

Highlights: Survey of patients with a lung cancer screening (LCS) decision-making interaction.Only 44% of patients correctly answered the knowledge question about LCS.Primary LCS knowledge was not associated with decision conflict.Patient knowledge about LCS may not equate to high-quality patient-centered care.

Introduction. Financial hardship is prevalent among Black prostate cancer survivors and exacerbates health disparities. Characterizing and sharing cost information with patients can facilitate well-informed treatment decision making. Our research explored the direct and indirect costs associated with prostate cancer treatment among Black men and their caregivers. Direct costs included out-of-pocket and insurance-related fees, and indirect costs included the unforeseen costs of care, including patient time, caregiver time, lost wages, and transportation. Methods. We conducted semi-structured interviews with Black prostate cancer survivors and their caregivers to learn about the experience of direct and indirect costs. The interview guide and data analysis were informed by the Measures of Financial Wellbeing framework to gain a better understanding of the material, behavioral, and psychosocial aspects of care-related costs. Guided by a qualitative descriptive approach, we used inductive and deductive coding for our thematic analysis. Results. Eleven prostate cancer survivors with a median age of 68 y (interquartile range [IQR] 62.0-71.5 y) and 11 caregivers with a median age of 64 y (IQR 58.5-70.5 y) participated. We grouped themes into 3 domains and their intersections (i.e., material, behavioral, psychosocial). Participants reported their work and insurance had a significant influence on their finances, treatment costs required rearranging of household budgets, and the weight of indirect costs varied. Ultimately, participants emphasized the significant impact of care costs and the adjustments needed to adapt to them. Discussion. The complexities of material, behavioral, and psychosocial domains of direct and indirect costs of prostate cancer are critical to address when supporting those diagnosed with prostate cancer when making preference-sensitive treatment decisions. The interconnectedness between indirect costs highlights the wide-ranging impact financial well-being has on prostate cancer survivors and caregivers.

Highlights: Direct and indirect costs have a wide-ranging impact on the material, behavioral, and psychosocial aspects of financial well-being of Black prostate cancer survivors and their caregivers.These results emphasize the need for sharing cost information to support medical decision making.Future research should focus on the design of cost-sharing interventions that target the complexities of direct and indirect costs collectively, rather than separately.