Family health care decision making

How do families choose a health plan when offered the option of insurance or a Health Maintenance Organization (HMO)? Choices are influenced by health consumerism, decision variables, family health needs, family composition, family socioeconomic status, and knowledge about HMOs. Subjects in the research reported here chose insurance or one of four HMOs; control subjects had no HMOs available. The model is estimated with LOGIT regression, yielding a pseudoR ² of.22 for the adjusted model. Participation in the decision process, number of chronic illnesses, and knowledge about HMOs all are significantly and positively associated with choosing an HMO; also, young adults are more likely than older adults to choose HMOs. The consumerism variable fails to attain significance. LOGIT analysis of the adjusted model indicates that the model predicted 72% of plan choices correctly. Suggested research for other family forms, for the poor, and for the elderly's health plan choices are discussed.     

Building community capacity in governance and decision making

Civil society is generally understood as the realm within whichpeople can participate collectively and work toward a commoninterest. This article examines the mechanisms for involvingmarginalized groups in this process. The study focuses on parents'experiences with two of Canada's largest community-based healthpromotion programmes for children. The conclusions emphasizethe need to recognize the informal and everyday as importantsites for governance and decision making. In addition, theyadd substance to the claim that women's spaces that focus on‘women's work’ are legitimate sites from which tobuild civil society.     

Physical health decision making and decision aid preferences of individuals with severe mental illness

Individuals with severe mental illness (SMI) often suffer from comorbid physical health conditions that reduce quality of life and longevity. The integrated care movement has improved access to primary care services, but system change does not necessarily impact health behaviors. In an effort to better understand health behaviors of persons with SMI in integrated care, we explored physical health decision making and decision aid preferences. We conducted three focus groups, including two consumer groups and one mental health staff group. Data were analyzed using a grounded theory approach, employing independent coding, thematic analysis, and meaning-making processes. Data suggest that overall, the consumer groups preferred a shared decision making process, with the doctor making the final treatment decision. Staff indicated that decision making depended on a consumer’s functioning level. Consumers liked the idea of using a decision aid, and reported preferring the computerized aid. Staff felt that decision aids were dependent on consumer level of functioning. Consumers generally view primary care doctors as experts, but like the idea of using decision aids to assist in making medical decisions. Staff feel that consumers may need help in both decision making and decision aid use in primary care.     

Differences in white-nonwhite community mental health center service utilization patterns

Routinely collected computerized data were used to study the process of service delivery in terms of admission patterns, type and quantity of services rendered, and status at termination for whites and nonwhites in two community mental health centers. Social area analysis techniques were employed to control for socio-economic status, ethnicity and life style variables, and an epidemiologic model was used to analyze admission and service delivery rate differences. It was found that nonwhite admission rates were at least twice as great as white rates. Service delivery rates to the population at large were considerably greater for nonwhites than for whites. Delivery of direct services within the centers differed for whites and nonwhites, but no consistent trends emerged when types and amounts of services rendered were analyzed, controlling for sex, ethnicity, age, diagnosis and social area. Disruption of care indices were greater for nonwhites than for whites. Highlighted were some of the complexities involved in interpreting results of utilization studies.     

Fairness judgments in household decision making

The behavioral economic study of fairness was applied to household decision making. A sample of household partners judged the fairness of a number of hypothetical decisions of a household partner, varying in the context of the decision. Decisions made by the partner to make a large personal expenditure or to reduce time spent on household chores were considered by the subjects as more fair if the outcome was framed as a forgone gain then if it was framed as a straight loss. Partners’ decisions to reduce household chores were also considered as more fair in the case of overtime work than when the partner received a salary increase or windfall income. We conclude that asymmetric valuation of losses and forgone gains, and (behavioral) costs as compared with income increase of the partner, influenced the fairness judgments concerning the partner’s behavior.     

The use of evaluation models for decision making: Application to the community anti-crime program

Evaluations are typically designed to provide useful information, including measures of program effectiveness. Although this information is intended to be useful, the general literature on evaluations suggests that instances in which evaluations are explicitly used for decision making are rare. This article discusses the use of decision-theoretic evaluation models, and their applicability in practice as well as in principle. A case study is presented from the evaluation of LEAA's Community Anti-Crime Program, in which a decision analysis based on a decision-theoretic evaluation model influenced a programmatic decision which arose during the conduct of the evaluation.     

From public health and demographic research to decision making: An intervention study in Giza Governorate-Egypt

The purpose of the current study was to develop an empirical model that shows how various contextual data are analyzed, interpreted and presented as evidence-based information for decision making and action taking. A Pre-test-Posttest intervention study was conducted at the National Population Council (NPC)-Giza governorate (GG) where all data were collected from all governmental organizations on an annual basis at the district level (19 districts), which include 28 indicators. Composite indices and indicators (n = 9) had been ranked and presented as a matrix that assigned districts into three situations: Best (green zone), prospective (yellow zone) and critical (red zone). Intervention: Presentation of the “Districts’ Enactment Matrix” (DEM) for the year 2014 in GG –Regional Council for Population (RCP) quarterly meetings, headed by the governor and attended by representatives of all ministries. The feedback and recommendation for action taking by participants were reported by the researchers. Evaluation of the intervention was done by comparing DEM 2014 and DEM 2016. Results: At the governorate level, short-term strategies were used to improve the situation. All the districts in red zone 2014 and two districts in the yellow zone had demonstrated positive changes in their 28 indicators. Conclusion: The DEM model is a simple tool that facilitates communication between researchers and decision-makers that could be applied in different public health and population programs.     

The Manipulation: Socio-economic decision making

We analyze one-shot Prisoner’s Dilemma decisions made by participants of the high-stakes TV game show The Manipulation, and document the influence of social life factors on economic decisions, alongside the participants’ rational considerations. In particular, we employ a social psychology approach to provide a new perspective on the determinants of financial assistance. Our insights from the TV game are corroborated by a controlled laboratory experiment. We find that helping and sharing behavior in strategic situations is explained by Attribution Theory (AT) and beliefs about expected cooperativeness. Specifically, participants’ decisions are influenced by perceived controllability of opponents’ conditions (an attributional characteristic influencing perception of responsibility and related emotions) and social-relations-based beliefs regarding the opponents’ expected cooperativeness.     

Adolescent women's contraceptive decision making.

A modified rational decision model incorporating salient events and social influences (particularly from sexual partners) is used to analyze adolescent women's consistent use of oral contraceptives (OCs) over a six-month period. Data are taken from a panel study of 308 clients of an inner-city family planning clinic. Expected OC use was computed for each subject on the basis of subjective expected utility (SEU) theory, and is found in multivariate analyses to be a significant predictor of actual OC use. In addition, variables representing baseline and follow-up partner influences, the salience of pregnancy for the subject, and positive side effects of OCs during the first months of use are found to predict OC use. Partner's support of OC use during follow-up and positive side effects of OCs are found to predict OC use among subjects for whom OC use was not the expected decision according to baseline SEU. Implications of the findings for models of adolescents' contraceptive behavior and for clinicians are discussed.     

Neighborhood associations and urban decision making in Albuquerque

Neighborhood associations have the potential to be important players in the urban decision‐making process. There are numerous examples of situations in which they have exercised their unique capabilities to influence decisions that have a direct impact on their members. But their role in the larger arena of the city they inhabit is less clear. This study explores the degree to which neighborhood associations, through their newsletters, acknowledge and support citywide goals. A content analysis of 173 newsletters from forty‐four neighborhood associations in Albuquerque, New Mexico, revealed that they do provide some support for several citywide goals but not for the majority of them.     

The assessment of values in medical decision making

Individuals, families, and health care providers consider medical treatment decisions in light of their respective values about life iin varying states of health. The clarification of health care values is important not only in the context of everyday clinical decision making, but also for advance care planning and the resolution of ethical dilemmas. This article argues that objective assessment tools may facilitate the process of clarifying and communicating health care values in these contexts. The article reviews arguments for the importance of values assessment in health care planning, methods used to date for health care values assessment, conceptual and methodological challenges for the measurement of health care values, and lessons learned through the process of developing and piloting a Health Care Values Survey. Objective values assessment tools appear useful for eliciting health care values, although multiple challenges for reliable, valid, and clinically useful measurement of values are identified.     

Ethics of resource allocation: instruments for rational decision making in support of a sustainable health care

Objective: In all western countries health care budgets are under considerable constraint and therefore a reflection process has started on how to gain the most health benefit for the population within limited resource boundaries. The field of “ethics of resource allocation” has evolved only recently in order to bring some objectivity and rationality in the discussion. In this article it is argued that priority setting is the prerequisite of ethical resource allocation and that for purposes of operationalization, instruments such as “need assessment” and “health technology assessment (HTA)” are essential worktools for making more rational decisions. Thresholds (deduced from the need assessment and HTA) are—within this context—guiding but not binding principles. Method: Discussion of theoretical concepts of not only priority setting, need assessment and HTA complemented by practical examples for showing the challenges and the need, but also the chances of a more explicit and transparent policy of resource allocation in health care. Results: Priority setting in health care is based on the values of equity, justice and solidarity. Health packages decisions are determined from medical need (the severity of the condition) and/or the appropriateness of medical interventions (their cost-effectiveness). With growing awareness that originally effective and cost-effective services and programmes are eventually provided inappropriately, the focus is shifting towards the organisational aspects of provision and application. Therefore, need assessment is based on the distinction of health care needs from demand, supply, or actual care. Additionally HTA provides the evidence on health care interventions in a way that it becomes obvious who benefits from an intervention and who definitely does not benefit, but eventually is harmed. Conclusions: Health services research on effective and cost-effective interventions and research/monitoring of performance that the effective and cost-effective services are provided appropriately are of increasing importance for guiding the decision-making process on priority setting and need assessment. Effective healthcare for all is sustainable, if we start to put expenditures in perspective and focus health policies and research strategies on managing expectations through patient information and a more realistic notion of medical advancements and, on the other hand, on encouraging need-based and cost-effective innovations.

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Zusammenfassung Ziel: In allen Ländern des Westens ist die Haushaltslage im Gesundheitswesen heute äußerst angespannt, weshalb nun ein Reflexionsprozess begonnen hat, wie mit begrenzten Haushaltsmitteln der größtmögliche gesundheitliche Nutzen für die Bevölkerung erzielt werden kann. Erst in jüngster Zeit ist die “Ethik der Mittelzuweisung” als Arbeitsgebiet entwickelt worden, mit dem Ziel, eine gewisse Objektivität und Rationalität in die Diskussion zu bringen. In diesem Artikel argumentieren wir, dass eine ethische Mittelzuweisung Prioritätssetzungen erfordert und dass Instrumente wie Bedarfeinschätzung (Need Assessment) und Bewertung medizinischer Verfahren [Health Technology Assessment (HTA)] wesentliche Arbeitswerkzeuge zur Erzielung rationaler Entscheidungen sind. Schwellenwerte (abgeleitet aus Need Assessment und HTA) dienen in diesem Zusammenhang als leitende, jedoch nicht bindende Prinzipien. Methode: Diskussion theoretischer Begriffe der Prioritätssetzung, Bedarfeinschätzung und HTA, ergänzt durch praktische Beispiele zur Darstellung der Herausforderungen des Bedarfs nach, aber auch der Chancen für eine explizitere und transparentere Politik der Mittelzuweisung im Gesundheitswesen. Ergebnisse: Prioritätssetzung im Gesundheitswesen basiert auf den Werten Gleichheit, Gerechtigkeit und Solidarität. Entscheidungen über Versorgungspakete richten sich nach der medizinischen Bedarfslage (Schwere der Erkrankung) und/oder der Angemessenheit medizinischer Eingriffe (Kosteneffektivität). Mit der wachsenden Erkenntnis, dass ursprünglich effektive und kosteneffektive Leistungen und Programme am Ende unangemessen bereitgestellt werden, richtet sich die Aufmerksamkeit mehr auf Organisationsaspekte der Bereitstellung und Anwendung. Need Assessment basiert daher auf der Unterscheidung zwischen Bedarf im Gesundheitswesen und Nachfrage, Angebot oder tatsächlicher Versorgung. HTA fasst dann die Evidenz zu Eingriffen seitens des Gesundheitswesens zusammen, sodass offenbar wird, wem ein Eingriff nützt und wem er mit Sicherheit nicht nützt, sondern am Ende schadet. Schlussfolgerungen: Forschungen der Gesundheitsdienste zu effektiven und kosteneffektiven Eingriffen sowie die Erforschung/Erfolgskontrolle einer angemessenen Bereitstellung effektiver und kosteneffektiver Dienste sind von wachsender Bedeutung für die Information des Entscheidungsprozesses zur Prioritätssetzung und Bedarfseinschätzung. Eine effektive Gesundheitsversorgung für alle bleibt tragbar, sofern wir beginnen, Ausgaben in Perspektive zu setzen und gesundheitspolitische Entscheidungen und Forschungsstrategien darauf ausrichten, Erwartungen zu lenken, indem wir die Patienten informieren und eine realistischere Einschätzung medizinischer Fortschritte fördern, und uns zugleich auf bedarfsorientierte und kosteneffektive Innovationen konzentrieren.

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Résumé Objectif : Dans tous les pays occidentaux, les budgets de santé publique sont soumis à de fortes contraintes, ce pourquoi un processus de réflexion a commencé sur la question de savoir comment obtenir avec des moyens limités la plus grande utilité possible pour la population en termes de santé. Ce n’est que récemment que « l’éthique de l’allocation des ressources » a été développée pour apporter une certaine part d’objectivité et de rationalisme dans la discussion. Le présent article soutient que l’attribution de priorités est la condition préalable indispensable à l’allocation des ressources et que des instruments tels que l’évaluation des besoins (need assessment) et l’évaluation des technologies de la santé (ETS/HTA) sont des outils essentiels pour parvenir à des décisions plus rationnelles. Les valeurs seuils (déduites de l’évaluation des besoins et de l’ETS) servent dans ce contexte de principes directeurs, mais non contraignants. Méthode : Discussion sur les notions théoriques d’attribution de priorités, d’évaluation des besoins et d’ETS, complétée par des exemples pratiques mettant en évidence les défis et les besoins, mais aussi les chances d’une politique d’allocation des ressources de santé plus explicite et transparente. Résultats : L’attribution des priorités dans le domaine de la santé se base sur les valeurs d’équité, de justice et de solidarité. Les décisions relatives à des ensembles thérapeutiques sont déterminées par le besoin médical (gravité de la maladie) et/ou le caractère opportun des interventions médicales (efficacité des coûts). Avec la prise de conscience que des services et des programmes initialement opérationnels et efficaces en termes de coûts sont appliqués de manière inappropriée, l’attention se porte sur les aspects organisationnels de l’attribution et de l’application. L’évaluation des besoins se base par conséquent sur la distinction entre les besoins de santé provenant de la demande, de l’offre et de l’approvisionnement effectivement fourni. L’évaluation des technologies de la santé procède à une synthèse des preuves faisant apparaître qu’une intervention de santé est utile à un patient, lui est en toute certitude inutile, voire préjudiciable. Conclusions : Les recherches des services de santé sur les interventions efficaces en termes de thérapie et de coûts, de même que la recherche/le suivi des performances sur une fourniture appropriée de services efficaces en termes de thérapie et de coûts revêtent une importance croissante pour guider le processus décisionnel sur l’attribution des priorités et l’évaluation des besoins. Une couverture de santé efficace pour tous n’est viable que si nous commençons à mettre les dépenses en perspective et à concentrer les politiques de la santé et les stratégies de recherche sur la gestion des attentes, en informant les patients et en promouvant une estimation plus réaliste des progrès médicaux, et d’autre part en encourageant les innovations fondées sur les besoins et sur le rendement des coûts.

     

Intertemporal decision making with present biased preferences

I study the behavior of individuals with present biased preferences who are involved in costly, long-run projects. By using generic cost and reward functions, I characterize the behaviors of the sophisticated, partial naive and naive types. It is shown that there may arise cases where naives needlessly put effort on projects they never complete. Moreover, in endogenous total cost projects, the naive types always end up completing projects of lesser quality than originally intended. By introducing a bonus motive, it is shown that agents with higher self-control problems should be given a higher bonus to prevent inefficient procrastination. I, then, characterize the behavior of partially naives who potentially learn self-preferences. It is found that without learning self-preferences, partial naives behave either like sophisticates or naives depending on the level of naivete; with learning, if the learning pace is fast enough, procrastination until the deadline does not occur.     

Organizational ethics, decision making, undecidability

In this paper we develop a conceptualisation of organizational decision‐making as a practice that is, necessarily, ethical. The paper starts with a discussion of the notion of decision‐making as it relates to organizational rationality and the relationship between management and control. Drawing on Derrida's discussions of undecidability and responsibility, we suggest that as well as being able to consider organizational decision‐making as an instance of (albeit bounded) rationality or calculability, it can also be regarded as a process of choice amongst heterogenous possibilities. On that basis, we follow Derrida in arguing that for a decision to be considered an instance of responsible action it must be made with neither recourse to knowledge of its outcome nor to the application of pre‐ordained rules. Illustrating our argument with a discussion of Eichmann's ‘I was just following orders’ defence, we suggest that rules for ethical decision making, rather than ensuring ethical outcomes, can work to insulate organizations from moral responsibility. We conclude with a discussion of ethics and democracy in relation to responsible decision making in organizations.     

Inefficiency of democratic decision making in an unstable society

The political power is said to be efficient if good results in decision making are achieved by moderate means. For example, if a large parliament makes the same decisions as a given president, the power efficiency of the president is better than that of the parliament. We study the efficiency of three forms of political power, president, cabinet of ministers, and the parliament, using the model from the author's earlier publications on the mathematical theory of democracy. We define an indicator of power quality, referring to the weight of the coalition whose preference is satisfied by each decision. We prove that a presidential power can be absolutely efficient when the society is divided by preferences into (almost) equal coalitions, which is interpreted as social instability, because a small change in preferences breaks the equilibrium. When the society is stable, i.e. there are predominant coalitions, the cabinet and the parliament provide a better power quality. For a model with a large number of independent individuals we derive approximation formulas of the indicator of the power quality which imply a geometric interpretation of optimal president, cabinet, and parliament as providing the greatest projections of their characteristic vectors on the characteristic vector of the society. We draw an analogy to the geometric interpretation of forces in physics. From our standpoint, democratic (collective) forms of power are efficient in a stable society. In an unstable society, a parliament and a cabinet are less efficient than personal power. Linking social stability to economic development, we conclude that a democratic political system is not the cause but rather a result of economic development which makes the society stable. We comment on the political development in the ex-Soviet Union. In particular, we justify the separation of the Soviet Union into independent states as a measure to make the power more powerful when its potential has been exhausted. However, we doubt that democratic transformations can contribute to solving economic problems and that real democratic systems will be established in the ex-Soviet republics before at least major economic difficulties have been overcome. We also outline some applications of our results to Gallup polls of public opinion and to multicriteria decision making.First version of the article is published as Discussion paper No. 185 at the Universität Hagen, Germany