MDM Policy and Practice最新文献

Objectives. Health utility estimates from the current era of HIV treatment, critical for cost-effectiveness analyses (CEA) informing HIV health policy, are limited. We examined peer-reviewed literature to assess the appropriateness of commonly referenced utilities, present previously unreported quality-of-life data from two studies, and discuss future implications for HIV-related CEA. Methods. We searched a database of cost-effectiveness analyses specific to HIV prevention efforts from 1999 to 2016 to identify the most commonly referenced sources for health utilities and to examine practices around using and reporting health utility data. Additionally, we present new utility estimates from the Centers of Disease Control and Prevention's Medical Monitoring Project (MMP) and the INSIGHT Strategies for Management of Anti-Retroviral Therapy (SMART) trial. We compare data collection time frames, sample characteristics, assessment methods, and key estimates. Results. Data collection for the most frequently cited utility estimates ranged from 1985 to 1997, predating modern HIV treatment. Reporting practices around utility weights are poor and lack details on participant characteristics, which may be important stratifying factors for CEA. More recent utility estimates derived from MMP and SMART were similar across CD4+ count strata and had a narrower range than pre-antiretroviral therapy (ART) utilities. Conclusions. Despite the widespread use of ART, cost-effectiveness analysis of HIV prevention interventions frequently apply pre-ART health utility weights. Use of utility weights reflecting the current state of the US epidemic are needed to best inform HIV research and public policy decisions. Improved practices around the selection, application, and reporting of health utility data used in HIV prevention CEA are needed to improve transparency.

Purpose. To understand the medical decision support needs specific to adolescents and young adults (AYAs) with ulcerative colitis (UC) and inform development of a decision support tool addressing AYAs' preferences. Methods. We conducted focus groups with AYAs with UC and mentors from a pediatric inflammatory bowel disease clinic's peer mentoring program. Focus groups were led by a single trained facilitator using a semistructured guide aimed at eliciting AYAs' roles in medical decision making and perceived decision support needs. All focus groups were audio recorded, transcribed, and coded by the research team. Data were analyzed using content analysis and the immersion crystallization method. Results. The facilitator led six focus groups: one group with peer mentors aged 18 to 24 years, three groups with patients aged 14 to 17 years, and two groups with patients aged 18 to 24 years. Decision timing and those involved in decision making were identified as interacting components of treatment decision making. Treatment decisions by AYAs were further based on timing, location (inpatient v. outpatient), and family preference for making decisions during or outside of clinic. AYAs involved parents and health care providers in medical decisions, with older participants describing themselves as "final decision makers." Knowledge and experience were facilitators identified to participating in medical decision making. Conclusions. AYAs with UC experience changes to their roles in medical decisions over time. The support needs identified will inform the development of strategies, such as decision support tools, to help AYAs with chronic conditions develop and use skills needed for participating in medical decision making.

[This corrects the article DOI: 10.1177/2381468319868968.].

Purpose. The radial forearm free flap (RFFF) is considered the gold standard for gender affirming phalloplasty. Ideally, a nondominant forearm flap is used to minimize the risk of functional morbidity. However, many transmasculine individuals have tattooed forearms, which can affect decision making. The purpose of this study was to understand the prevalence of forearm tattoos among transmasculine patients seeking phalloplasty and how and whether tattoos affected decision making about flap source. Methods. Participants were 50, consecutive, adult, transmasculine patients seeking phalloplasty. The presence and location of tattoos were assessed using consult notes in the electronic medical record. A one-tailed test of proportions was used to test whether forearm tattoos increased the likelihood of alternative flap choice. Results. More than half of patients (56%) had tattoos on either one or both forearms (n = 28), 75% on their nondominant arm (n = 21). Among the patients with forearm tattoos, the presence of tattoos affected the flap site decision for 46% of patients (n = 13). For the patients that chose an alternative flap site, 46% chose a dominant forearm RFFF (n = 6) and 54% an anterolateral thigh flap (n = 7). The percentage of patients whose records indicated that they were planning on using an alternative flap due to a tattoo on their nondominant forearm was significantly higher than the percentage of patients without such tattoos, indicating the desire for an alternate flap (P < 0.01). Conclusion. Many transmasculine patients seeking phalloplasty have tattoos on either one or both of their forearms. Because of this, a substantial fraction of patients may choose flap donor sites that are less ideal. Providers from all disciplines may wish to educate young transmasculine patients about how tattoo placement may affect surgical options earlier during transition.

Purpose. Assess patient preferences for aspects of breast cancer treatments to evaluate and inform the usual assumptions in scoring rubrics for value frameworks. Methods. A discrete-choice experiment (DCE) was designed and implemented to collect quantitative evidence on preferences from 100 adult female patients with a self-reported physician diagnosis of stage 3 or stage 4 breast cancer. Respondents were asked to evaluate some of the treatment aspects currently considered in value frameworks. Respondents' choices were analyzed using logit-based regression models that produced preference weights for each treatment aspect considered. Aggregate- and individual-level preferences were used to assess the relative importance of treatment aspects and their variability across respondents. Results. As expected, better clinical outcomes were associated with higher preference weights. While life extensions with treatment were considered to be most important, respondents assigned great value to out-of-pocket cost of treatment, treatment route of administration, and the availability of reliable tests to help gauge treatment efficacy. Two respondent classes were identified in the sample. Differences in class-specific preferences were primarily associated with route of administration, out-of-pocket treatment cost, and the availability of a test to gauge treatment efficacy. Only patient cancer stage was found to be correlated with class assignment (P = 0.035). Given the distribution of individual-level preference estimates, preference for survival benefits are unlikely to be adequately described with two sets of preference weights. Conclusions. Although value frameworks are an important step in the systematic evaluation of medications in the context of a complex treatment landscape, the frameworks are still largely driven by expert judgment. Our results illustrate issues with this approach as patient preferences can be heterogeneous and different from the scoring weights currently provided by the frameworks.

Background. Metamodels can simplify complex health policy models and yield instantaneous results to inform policy decisions. We investigated the predictive validity of linear regression metamodels used to support a real-time decision-making tool that compares infant HIV testing/screening strategies. Methods. We developed linear regression metamodels of the Cost-Effectiveness of Preventing AIDS Complications Pediatric (CEPAC-P) microsimulation model used to predict life expectancy and lifetime HIV-related costs/person of two infant HIV testing/screening programs in South Africa. Metamodel performance was assessed with cross-validation and Bland-Altman plots, showing between-method differences in predicted outcomes against their means. Predictive validity was determined by the percentage of simulations in which the metamodels accurately predicted the strategy with the greatest net health benefit (NHB) as projected by the CEPAC-P model. We introduced a zone of indifference and investigated the width needed to produce between-method agreement in 95% of the simulations. We also calculated NHB losses from "wrong" decisions by the metamodel. Results. In cross-validation, linear regression metamodels accurately approximated CEPAC-P-projected outcomes. For life expectancy, Bland-Altman plots showed good agreement between CEPAC-P and the metamodel (within 1.1 life-months difference). For costs, 95% of between-method differences were within $65/person. The metamodels predicted the same optimal strategy as the CEPAC-P model in 87.7% of simulations, increasing to 95% with a zone of indifference of 0.24 life-months ( ∼ 7 days). The losses in health benefits due to "wrong" choices by the metamodel were modest (range: 0.0002-1.1 life-months). Conclusions. For this policy question, linear regression metamodels offered sufficient predictive validity for the optimal testing strategy as compared with the CEPAC-P model. Metamodels can simulate different scenarios in real time, based on sets of input parameters that can be depicted in a widely accessible decision-support tool.

Background. Shared decision making is a cornerstone of an informed consent process for cancer treatment, yet there are often many physician and patient-related barriers to participation in the process. Decisions in cancer care are often perceived as relating to a discrete, treatment decision event, yet there is evidence that decisions are longitudinal in nature and reflect a multifactorial experience. Objective. To explore patient and caregiver perceptions of the choices and decision-making opportunities within cancer care. Design. Qualitative in-depth interviews with 37 cancer patients and 7 caregivers carried out as part of an evaluation of a cancer center's effort to improve patient experience. Results. Participants described decision making related to four distinct phases in complex cancer care, with physicians leading, and often limiting, decisions related to disease assessment and treatment options and access, and patients leading decisions related to physician selection. Though physicians led many decisions, patients had a moderating influence on treatment, such that if patients did not like options presented, they would reconsider their options and sometimes switch physicians. Patients had various strategies for dealing with uncertainty when faced with decisions, such as seeking additional information to make an informed choice or making a conscious choice to defer decision making to the physician. Limitations. Patients were sampled from one academic cancer center that serves a predominantly Caucasian, Asian, and Hispanic/Latino population and received complex treatment. Conclusion. Because of the complexity of cancer treatment, many patients felt as though they were a "passenger" in decision making about care and did not lead many of the decisions, though many patients trusted their doctors to make the best decisions and were comforted by their expertise.

[This corrects the article DOI: 10.1177/2381468320914310.].

This study systematically examines the diffusion of the discrete event simulation (DES) approach in health services and health care management by examining relevant factors such as research areas, channels with the objective of promoting the application of DES in the health field. We examined 483 journal papers referencing this approach that were published in 230 journals during 1981 to 2014. The application of DES has extended from health service operational research evaluation to the assessment of interventions in diverse health arenas. The increase in the number of adopters (paper authors) of DES and the increase in number of related channels (journals publishing DES-related articles) are highly correlated, which suggests an increase of DES-related publications in health research. The same conclusion is reached, that is, an increased diffusion of DES in health research, when we focus on the temporal trends of the channels and adopters. The applications of DES in health research cover 22 major areas based on our categorization. The expansion in the health areas also suggests to a certain extent the rapid diffusion of DES in health research.

Purpose. There is no gold-standard health literacy measure. The Single Item Literacy Screener (SILS) and Subjective Literacy Screener (SLS) ask people to self-report ability to understand health information. They were developed in older adults, before common use of electronic health information. This study explored whether the SILS and SLS related to objective literacy, numeracy, and comprehension among young adults, and whether specifying "online" or "paper-based" wording affected these relationships. Methods. Eligible individuals (18-35 years of age, English-speaking, US residents) from an online survey company were randomized to 1) original measures; 2) measures adding "paper-based" to describe health information/forms; or 3) measures adding "online" to describe health information/forms. We examined how each measure related to e-Health Literacy (eHEALS), subjective numeracy (SNS), objective numeracy (ONS), and comprehension of a short passage. Results. A total of 848/1342 respondents correctly answered attention-checks and were analyzed. The validated SILS related to comprehension (P = 0.003), eHEALS (P = 0.04), and ONS (P < 0.001) but not SNS (P = 0.44). When adding "paper-based," SILS related to eHEALS (P < 0.001) and ONS (P = 0.003) but did not relate to comprehension (P = 0.25) or SNS (P = 0.35). When adding "online," SILS related to comprehension (P < 0.001), eHEALS (P < 0.001), ONS (P = 0.005), and SNS (P = 0.03). The validated SLS related to comprehension (P < 0.001), eHEALS (P < 0.001), ONS (P < 0.001), and SNS (P < 0.001). When adding "paper-based," the SLS only related to eHEALS (P = <0.001) and comprehension (P = 0.03) but did not relate to ONS (P = 0.13) or SNS (P = 0.33). When adding "online," the SLS related to comprehension (P < 0.001), eHEALS (P < 0.001), and SNS (P = 0.03) but not ONS (P = 0.06). Conclusions. Young adults might interpret subjective health literacy measures differently when prompted to think about electronic or paper-based information. Researchers should consider clearer instructions or modified wording when using these measures in this population.