Medical Decision Making最新文献

This article critically examines the application of minimal important differences (MIDs) to health state values or utilities. The concept of MIDs aims to guide clinical and research decisions by identifying important changes in health-related quality-of-life (HRQoL) indicators. However, this cannot be used without additional information not contained within the indicator itself, so that the MID cannot be regarded as a property of the indicator. First, MIDs defined at the individual patient level cannot be meaningfully aggregated for groups without additional context. Second, any improvement in HRQoL is important for patients themselves, so decision making using an MID also requires context, such as resource costs for effecting change. Third, health state values incorporate a measure of importance according to patient preferences, so the only change that is unimportant is zero. Calculating and reporting MIDs for health state values is not only unhelpful but also misleading.HighlightsThe minimal important difference (MID) for health-related quality of life and patient-reported outcome measures is widely used but arguably is not only of limited use but also usually misleading because it lacks context-specific meaning.MIDs for individuals cannot be aggregated without judgments about the distribution of outcomes over patient groups, and quality-of-life indicators need context; thus, the MID cannot be regarded as a property of an indicator.Quality-of-life indicators that generate health state values or utilities incorporate importance based on patient preferences, so the only unimportant change is zero.Published research into MIDs for health state values is unhelpful and even misleading.

BackgroundIndividuals commonly want diagnostic testing even after being informed the test is clinically unbeneficial and has risks. These preferences are poorly understood but may relate to beliefs that any testing information is valuable. To explore this, we examined Australian adults' attitudes toward finding harmless abnormalities using diagnostic tests and the broader beliefs related to these attitudes.MethodsData collected via survey were analyzed using mixed methods. Free text explaining attitudes to finding harmless abnormalities were analyzed using comparative content and interpretative analyses. Associations between attitudes to finding harmless abnormalities and broader beliefs and demographics were analyzed using regression.ResultsAlmost three-fifths of 655 participants considered it valuable to identify harmless abnormalities using tests. Qualitative analyses showed this attitude was driven by beliefs that identification would provide psychological reassurance, valuable biodata, and enable monitoring and management of the harmless abnormalities. These beliefs were underpinned by a skepticism that abnormalities can ever be harmless and by a range of beliefs about the broader value of diagnostic testing. Participants with negative attitudes to identifying harmless abnormalities were concerned about resultant anxiety and unnecessary health interventions. Regression showed that positive attitudes to identifying harmless abnormalities were associated with greater confidence in doctors, lesser concerns about overtreatment, and a stronger desire to know as much about their bodies as possible as well as with several demographic variables.Conclusions and ImplicationsOur study explores why people seek diagnostic tests that they know lack obvious clinical benefits. It identifies broader beliefs and psychological factors that profoundly influence testing choices. This knowledge will help overcome the limitations of existing strategies to explain the risks of tests to patients and the public.HighlightsFindings help explain why facts showing that particular diagnostic tests are ineffective or harmful fail to dissuade many Australians from seeking those tests.Many Australians value diagnostic testing for perceived reassurance, understanding one's body, and use in medical decision making.Many are skeptical that identifying incidentalomas is harmful, and are confident they can avoid unnecessarily treating them.Messages about testing risks should focus on broader beliefs and respond to psychological factors that undermine the effect of risk/benefit information.

ObjectivesDiscrete choice experiment (DCE) methods that account for nonlinear time preferences have been tested in adult EQ-5D instruments but have yet to be tested for the valuation of EQ-5D-Y instruments. The aims of this study were to test the feasibility of using DCE methods that model nonlinear time preferences for the valuation of the EQ-5D-Y-5L as well as to explore the impact of the perspective adult respondents are asked to take.MethodsA representative Australian adult general population sample completed an online survey that included 15 DCE split triplet tasks. Depending on arm assignment, respondents were asked to imagine themselves or a 10-y-old when choosing between health states. A Bayesian efficient design was used to construct DCE tasks; the design was updated 3 times. Data were analyzed using correlated mixed logit models with exponential discounting.ResultsThere were 955 and 947 respondents in the "self" and "10-y-old" arms, respectively. When nonlinear modeling is used, there is evidence of discounting in the "self" (17%) and "10-y-old" (15%) perspective. Avoiding the experience of pain and discomfort were most important in both arms. When imagining a 10-y-old, rather than "self," respondents considered being worried, sad, or unhappy to be more important. Sensitivity analysis revealed that nonparents considered a higher number of health states to be worse than dead when imagining themselves.ConclusionsThis is the first study to use a nonlinear DCE approach in the valuation of the EQ-5D-Y-5L and in pediatric health-related quality of life more generally. Nonlinear modeling methods were found to be suitable for the valuation of the EQ-5D-Y-5L.HighlightsThere is evidence that modeling for nonlinear time preferences is suitable for the valuation of adult health-related quality of life (HRQoL). It is unknown how time preferences affect the valuation of pediatric instruments, such as the EQ-5D-Y-5L, and whether this differs when adults are asked to imagine "self" versus a "10-y-old."There was evidence of nonlinear time preferences when adult respondents value health states for a 10-y-old using a discrete choice experiment (DCE) that included a duration attribute. Perspective was a strong driver of estimating states worse than dead: 42% of health states were considered worse than dead for a 10-y-old as opposed to 26% when respondents imagined themselves.Nonlinear DCE methods are feasible for the valuation of the EQ-5D-Y-5L and have advantages compared with the use of time tradeoff in valuing child HRQoL. Future studies can test whether nonlinear modeling methods are suitable for other pediatric HRQoL instruments.

PurposeWe examined how different narrative aspects related to the COVID-19 pandemic influenced unvaccinated individuals' willingness to vaccinate (WTV) against a future virus. We tested whether the stories focused on the perspective of the actor (who chose to vaccinate or not) versus the affected (affected by that decision), framing the outcome as death versus survival, and presenting an identified individual versus an unidentified group.MethodsA total of 1,545 respondents read scenarios depicting individuals' (actors') decisions to either vaccinate against COVID-19 or refuse vaccination, alongside the framing of the consequences for the affected individuals: death versus survival. The protagonists were either identified by name and photo or described as a group of unidentified people. Participants reported their emotions, perceived risk from the virus and the vaccine, and their future WTV against a new virus. They also reported their past vaccination decisions.ResultsWhen the narrative focused on affected individuals, framing outcomes in terms of death increased WTV by heightening the perceived threat of the virus. Conversely, when the focus was on the actor, the lifesaving frame was more effective, especially when the actor was identified. A concrete case of someone vaccinated who saved others evoked positive emotions, boosting WTV.LimitationsOur hypothetical scenarios and the cross-sectional methodology might limit understanding of the long-term effects.ConclusionsScenarios highlighting a person who died increase the perceived threat of the virus and enhance WTV. Conversely, information about a person who was vaccinated and saved others boosts positive emotions and increases WTV.ImplicationsPublic health campaigns can boost vaccination by sharing stories of vaccinated individuals who saved lives, evoking positive emotions. Highlighting the virus's dangers can also raise the perceived threat and motivate uptake.HighlightsVariations in narratives influence unvaccinated individuals' willingness to vaccinate.Emphasizing the death of those affected evokes greater threat perception of the virus, enhancing vaccine intent.Personal stories of vaccinated individuals saving others can boost positive emotions and vaccination willingness.

IntroductionBreast cancer survivors have a higher risk of interval cancers relative to the screening population. Patient characteristics including features of the primary cancer and its treatment can help predict interval second breast cancer risk, but patient and physician perspectives on how risk prediction tools might enhance surveillance decision making are not well characterized.DesignWe conducted a qualitative study of women with breast cancer who had completed primary treatment and multispecialty physicians recruited through Breast Cancer Surveillance Consortium registries. We conducted semi-structured focus groups with 5 to 7 breast cancer survivors and individual physician interviews. All participants were presented with information about an interval cancer risk prediction tool. We elicited participant perspectives on aspects of the tool's design, relevance, and use for surveillance decision making. Data coding, thematic analysis, and interpretation were guided by the principles of theoretical thematic analysis.ResultsForty physician interviews and 4 focus groups involving 23 breast cancer survivors were analyzed. Two prominent areas of focus emerged: 1) perspectives on how a risk prediction tool would enhance and add value to patient-centered care and 2) risk prediction tools can be a means to improve communication about risk of in-breast recurrence or new breast cancer.ConclusionsThis study provides data on breast cancer survivor and physician perceptions of a new risk prediction tool to support surveillance imaging decisions among breast cancer survivors.ImplicationsAn interval second breast cancer risk prediction tool may promote evidence-based care across an array of physicians and different clinical settings. Future research should identify care delivery settings and features that promote adoption and support use in ways that improve shared decision making and patient outcomes.HighlightsThis qualitative study of breast cancer survivors and physicians found that risk prediction tools to support surveillance decisions were perceived positively when positioned as a supplement to the patient-physician relationship.Both patients and physicians said that a tool supported by strong evidence and accessible outputs would be valuable for shared decision making.

BackgroundPrevious research suggests that physicians' inclination to refer patients for suspected cancer is a relatively stable characteristic of their decision making. We aimed to identify its psychological determinants in the presence of a risk-prediction algorithm.MethodsWe presented 200 UK general practitioners with online vignettes describing patients with possible colorectal cancer. Per the vignette, GPs indicated the likelihood of referral (from highly unlikely to highly likely) and level of cancer risk (negligible/low/medium/high), received an algorithmic risk estimate, and could then revise their responses. After completing the vignettes, GPs responded to questions about their values with regard to harms and benefits of cancer referral for different stakeholders, perceived severity of errors, acceptance of false alarms, and attitudes to uncertainty. We tested whether these values and attitudes predicted their earlier referral decisions.ResultsThe algorithm significantly reduced both referral likelihood (b = -0.06 [-0.10, -0.007], P = 0.025) and risk level (b = -0.14 [-0.17, -0.11], P < 0.001). The strongest predictor of referral was the value GPs attached to patient benefits (b = 0.30 [0.23, 0.36], P < 0.001), followed by benefits (b = 0.18 [0.11, 0.24], P < 0.001) and harms (b = -0.14 [-0.21, -0.08], P < 0.001) to the health system/society. The perceived severity of missing a cancer vis-à-vis overreferring also predicted referral (b = 0.004 [0.001, 0.007], P = 0.009). The algorithm did not significantly reduce the impact of these variables on referral decisions.ConclusionsThe decision to refer patients who might have cancer can be influenced by how physicians perceive and value the potential benefits and harms of referral primarily for patients and the moral seriousness of missing a cancer vis-à-vis over-referring. These values contribute to an internal threshold for action and are important even when an algorithm informs risk judgments.HighlightsPhysicians' inclination to refer patients for suspected cancer is determined by their assessment of cancer risk but also their core values; specifically, their values in relation to the perceived benefits and harms of referrals and the seriousness of missing a cancer compared with overreferring.We observed a moral prioritization of referral decision making, in which considerations about benefits to the patient were foremost, considerations about benefits but also harms to the health system or the society were second, while considerations about oneself carried little or no weight.Having an algorithm informing assessments of risk influences referral decisions but does not remove or significantly reduce the influence of physicians' core values.