Informed decision making: the new paradigm

Health care cannot survive in its present form. It is becoming unaffordable for a large share of the country's population. Its quality and effectiveness inexplicably vary between communities and across time. With all these problems, the process of health care can be understood. All that are needed are good, basic data; its access, management, and analysis; and then presentation of facts and observations. Together, these functions describe the translation of data into information--the field of medical informatics. Information about such management concerns as clinical efficiency (which largely is related to appropriateness and cost-effectiveness) and about the realities of day-to-day medical practice can be used to improve the value of health care. Informed decision making is based solely on confidence that, given the right information and understanding, we can all make the right decisions. The right decisions mean better patient acceptance and satisfaction, a sense of value enhancement by payers, and support of the Hippocratic tradition.     

Physician executives' persuasive styles of communication in upward influence situations

This article examines the communicator style choices of physician executives when attempting to persuade a superior whose own style of communication is attractive and unattractive. In the November-December 1990 issue of Physician Executive, the author reported on persuasive strategies physician executives use to influence such targets of influence. Whereas the earlier study focused on what physician executives communicate to be persuasive, the present investigation treated the way physician executives communicate to persuade attractive and unattractive superiors. The results suggest that the way physician executives communicate in upward influence situations is affected by the way their superiors communicate with them.     

Immigration reform,American style

This article reviews the background of the proposed Immigration and Reform Act (also known as the Simpson-Mazzoli bill), which seeks to overhaul US immigration law for the first time since 1952. This bill is consistent with President Reagan's hard line on border enforcement and mandates stiff penalties for those who transport illegal aliens for commercial advantage or private profit. It further offers Mexico preferential treatment in immigration (40,000 additional visas/year). It includes an amnesty program to offer legal status to qualified illegal residents. The bill directs the President to develop a secure national worker identification system and would create a large-scale temporary foreign agricultural program for perishable commodities. Agricultural workers' families would not be eligible to accompany them unless they also obtain temporary visas. Foreign temporary workers, employable only in cases where local domestic workers are not available, must be provided with wages and working conditions equal to those prevailing among domestic workers. Stiff penalties are stipulated for employers who fail to abide with the terms of the program. In the author's opinion, this bill fails to appreciate the global character of international migration and its complexity. It relects a fundamental ambivalence about a strictly controlled main gate versus a back door approach to immigration as well as the conflicting images of the US as a nation of immigrants versus the historical reality of American nativism and xenophobia. Needed are comprehensive initiatives whose mutually reinforcing components can address the multiple dimensions of the immigration problem within a framework that does not ignore workers who have contributed to the economic well-being of the US, regardless of their legal status.     

Proxies for birth control. Comment on Kelly and Cutright,Sociological Focus,April 1983

Kelly and Cutright (1983), using regression techniques, conclude that birth control is among the more important determinants of Swedish illegitimacy. To derive this conclusion, they use changes in the marital fertility of wives aged 35-39 as a proxy for birth control. They maintain that annual change in the marital fertility rate of wives aged 35-39 is not likely to be greatly influenced by annual change in factors other than birth control. The "argument" appears to derive from the "desired family size" model of childbearing--a basic assumption of social demography. In it simplest form it states that most couples do not practice birth control until they reach a preconceived goal, or desired family size. It thus implies that a change in family size preferences will most affect the birth control practices of the oldest reproductive age groups. The simple form of the model has been questioned by the failure of Western couples to reproductively compensate for a major proportion of their child deaths, by the proportions of Western couples who say they would have preferred larger families than they actually had, by the predictive inadequacy of family size preferences, and by suggestions that age may be the more important determinant of reproduction. As a result some demographers now concede its inadequacy. Others are trying to relax its assumptions, with as yet problematic success. Essentially every Western fertility decline to date has been characterized by an increasing concentration of childbearing in the youngest age groups. In discussing this pattern social demographers have maintained that it could only have come about by a decline in family size preferences. This then is the standard argument supporting Kelly and Cutright's proxy for birth control. The authorities who offer it generally ignore the difficulties with the desired family size model and simply assert without justification that couples do in fact conform to it. Data on the age patterns of chronic disease and on the reproductive effects of environmental stressors suggest that the modern age pattern of fertility could also be produced by a deteriorating environment. Kelly and Cutright are incorrect in asserting that factors other than voluntary birth control could not be responsible for changes in fertility at ages 35-39. At best they may argue that their proxy is uniquely definitive provided that the desired family size model can be saved and provided the health of Western populations has not been compromised by technological change. At issue is a debate between what Dunlap calls the human exemptionalist and the ecological world views.     

Illegal immigrants in Canada: recent developments

Immigration policies and their management in a country like Canada have long been an interesting and instructive study for other countries. 1) With borders naturally protected by great distance from almost all migrant routes; 2) with a long, undefended border with the US and a further 3000 kilometers to its border on the south; 3) with a parliamentary system capable of comparatively rapid legislative and administrative responses to problems; and 4) with a relatively small legal, and even smaller illegal, population Canada had historically "experimented" with novel, often quite creative, immigration policies and programs to both encourage and control the increases in its population. This paper summarizes what Canada did and is doing in response to am important item of public policy--the entry and presence of illegal migrants. Canada has experimented with 1) discretionary amnesty for long-term illegals with a capacity to be successfully integrated into Canadian life, 2) tighter border controls with the extended use of the visitor's visa, and 3) employer sanctions. To address the problem more substantively, however, requires detailed study and significant change, including legislative change.     

Non-collegial simple games and the nowhere denseness of the set of preference profiles having a core

In recent papers, somewhat conflicting results on the generic emptiness of the core have been proven. Rubinstein (1979) has shown that the core is generically empty in the Kannai topology even without a restriction on the dimensionality of the alternative space. Schofield (1980) finds the core generically empty in the Whitney-C topology, but requires a dimensionality condition. This note explores the apparent conflict by proving a generalization of Rubinstein's result for the Whitney-C ⁰ topology, and showing that the result does not extend to the Whitney-C ¹ topology without a dimensionality condition.I would like to thank Kim Border and Richard McKelvey for their helpful discussion and comments. This research was supported in part by the National Science Foundation under Grant no. SES 78-2478781     

An analysis of cyclically dense data using EBLOC

Everett (1982a) has proposed a graph theoretic technique for analysing social networks. It is not usually possible to apply this method to data which contain a large number of interlocking cycles. We demonstrate a technique which overcomes this problem by referring to the data analysed by MacRae (1960).     

Setting health priorities: a review of concepts and approaches

The setting of health priorities is primarily concerned with the equitable distribution of resources and is now more than ever an important part of strategic planning within the National Health Service (NHS). The basic information which can be used to assist in such decision-making and the process by which different agencies become involved are important aspects of priority-setting; this article is based on a major review of the research literature on these aspects and provides a discussion and an analysis of experience within health and other fields. From this material a number of possible approaches to priority-setting are identified and discussed. The article concludes that, before it can be decided how priorities should be set in the future, outstanding questions about how far rational approaches are feasible, about who is to be involved and what role they should play, and about how far such decisions are to be taken nationally or locally will need further consideration.