Evaluating risk: global fees and episodic care

In 1999, two articles in The Physician Executive -- "Part I: Global Theory and the Nature of Risk (July-August)." and "Part II: Towards a Choice-Based Model of Managed Care (October-November)" -- outlined the flaws of orthodox managed care theory and highlighted the unique advantages of moving to a genuinely market-based model, which included the concept of direct contracting for integrated episodes of care. This follow-up focuses on comparing an episode contracting system to a traditional capitated program and outlines the features that make this approach much more attractive to physicians, payers, and most importantly patients.     

The 2003 Heat Wave in France: Dangerous Climate Change Here and Now

In an analysis of the French episode of heat wave in 2003, this article highlights how heat wave dangers result from the intricate association of natural and social factors. Unusually high temperatures, as well as socioeconomic vulnerability, along with social attenuation of hazards, in a general context where the anthropogenic contribution to climate change is becoming more plausible, led to an excess of 14,947 deaths in France, between August 4 and 18, 2003. The greatest increase in mortality was due to causes directly attributable to heat: dehydration, hyperthermia, heat stroke. In addition to age and gender, combinatorial factors included preexisting disease, medication, urban residence, isolation, poverty, and, probably, air pollution. Although diversely impacted or reported, many parts of Europe suffered human and other losses, such as farming and forestry through drought and fires. Summer 2003 was the hottest in Europe since 1500, very likely due in part to anthropogenic climate change. The French experience confirms research establishing that heat waves are a major mortal risk, number one among so-called natural hazards in postindustrial societies. Yet France had no policy in place, as if dangerous climate were restricted to a distant or uncertain future of climate change, or to preindustrial countries. We analyze the heat wave's profile as a strongly attenuated risk in the French context, as well as the causes and the effects of its sudden shift into amplification. Research and preparedness needs are highlighted.     

Building blocks for graphical belief models

The graphical belief model is a versatile tool for modeling complex systems. The graphical structure and its implicit probabilistic and logical independence conditions define the relationships between many of the variables of the problem. The graphical model is composed of a collection of local models:models of both interactions between the variables sharing a common hyperedge and information about single variables. These local models can be constructed with either probability distributions or belief functions. This paper takes the latter approach and describes simple models for univariate and multivariate belief functions. The examples are taken from both reliability and knowledge representation problems.     

Graphical methods for comparing confounding in two or more designs

In many circumstances it is necessary to design an experiment with partial confounding of parameter estimates. In this situation, one would like to have tools to assess and compare candidate designs graphically. In this paper we discuss two graphical representations of design properties, and illustrate their application with two examples.     

Sexual minority youth in romantic relationships: Associations with youth well-being

This study investigated differences in depressive symptoms, loneliness, and self-esteem for monosexual (lesbian, gay) and plurisexual (bisexual, pansexual, queer) sexual minority youth (SMY) by relationship status (single, partnered) and relationship configuration (same-gender partner, different-gender partner). Participants included 338 SMY (M_age = 19.10 years) who reported on their relationship status, partner's gender identity, well-being, and ability to confide in partner about LGBTQ issues. Results indicated that for plurisexual youth, single status was associated with greater loneliness; plurisexual youth with same-gender partners reported fewer depressive symptoms and marginally greater ability to confide in their partner about LGBTQ issues than those with different-gender partners. Findings reveal similarities across SMY while also highlighting some unique challenges among plurisexual youth with different-gender partners.     

A value of information framework for assessing the trade-offs associated with uncertainty,duration, and cost of chemical toxicity testing

A number of investigators have explored the use of value of information (VOI) analysis to evaluate alternative information collection procedures in diverse decision-making contexts. This paper presents an analytic framework for determining the value of toxicity information used in risk-based decision making. The framework is specifically designed to explore the trade-offs between cost, timeliness, and uncertainty reduction associated with different toxicity-testing methodologies. The use of the proposed framework is demonstrated by two illustrative applications which, although based on simplified assumptions, show the insights that can be obtained through the use of VOI analysis. Specifically, these results suggest that timeliness of information collection has a significant impact on estimates of the VOI of chemical toxicity tests, even in the presence of smaller reductions in uncertainty. The framework introduces the concept of the expected value of delayed sample information, as an extension to the usual expected value of sample information, to accommodate the reductions in value resulting from delayed decision making. Our analysis also suggests that lower cost and higher throughput testing also may be beneficial in terms of public health benefits by increasing the number of substances that can be evaluated within a given budget. When the relative value is expressed in terms of return-on-investment per testing strategy, the differences can be substantial.     

A formulation of the concept of probability based on the use of experimental devices

This paper sets out to identify the abilities that a person needs to be able to successfully use an experimental device, such as a probability wheel or balls in an urn, for the elicitation of subjective probabilities. It is assumed that the successful use of the device requires that the person elicits unique probability values that obey the standard probability laws. This leads to a definition of probability based on the idea of the similarity between the likeliness of events and this concept is naturally extended to the idea that probabilities have strengths, which relates to information about the likeliness of an event that lies beyond a simple probability value. The latter notion is applied to the problem of explaining the Ellsberg paradox. To avoid the definition of probability being circular, probabilities are defined such that they depend on the choice of a reference set of events R which, in simple cases, corresponds to the raw outcomes produced by using an experimental device. However, it is shown that even when the events in R are considered as having an “equal chance” of occurring, the values and/or strengths of probabilities can still be affected by the choice of the set R.     

Review

Representing reality: issues and concepts in documentary by Bill Nichols. Bloomington and Indianapolis: University of Indiana Press, 1991. $39.95 cloth. ISBN: 0–253–34060–8. $17.50 paper. ISBN: 0–253–20681–2.     

The Interpretation of Line of Regard by Prelingually Deaf Children

The ability of 5- to 12-year-old deaf children to utilise and interpret another person's visual line of regard (where the eyes are looking) was studied in four experiments using cartoon faces. The children had little difficulty in determining whether or not a face was looking directly at them. They had more difficulty, however, with more complex tasks requiring them to infer mental states of desire and intention from line of regard and to ignore line of regard when it was inappropriate to attend to this cue. Deaf children raised in a hearing environment appear to have more difficulty with these more complex tasks than hearing children. The results are discussed in terms of the special difficulties facing some deaf children in the development of skills involving utilisation of line of regard and the implications for the development of joint attentional behaviour, theory of mind and dyadic social interaction in deaf and hearing children.