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Biomedical subjects

D A Asch

Publications and source records attributed to D A Asch.

At least 73 records · Page 4Linked to original sources
PubMed1995

Why some health policies don't make sense at the bedside.

Cost-effectiveness analysis and other forms of decision analysis are becoming more common in the medical literature and are increasingly influential in the development of health policy. Nevertheless, many clinicians find it difficult to apply policies developed from these analyses to individual encounters with patients. We examine the assumptions behind these analyses and argue that the perspective they embody can make clinical strategies appear to be less risky in theory than they are at the bedside. We believe that this problem underlies the intuitive concern many physicians have about policy analyses and calls into question the value of these analyses in shaping clinical practice. These analyses aggregate the benefits and burdens of alternative interventions across different individual persons. Thus, overall population risk appears blunted, as it would in a diversified portfolio of stocks that react differently to financial forces or in a herd of cattle that react differently to veterinary interventions. The assumptions behind these analyses make sense if aggregate outcome is what matters, but not if one cares about each individual investment or animal. Because such aggregation tends to understate individual risk, when applied to human health policy, it may misrepresent the interests of patients and cannot be assumed to provide useful guidelines for decision making at the bedside.

Cost-Benefit Analysis↗
PubMed1995

Medical specialists prefer to withdraw familiar technologies when discontinuing life support.

OBJECTIVE: To assess how members of different specialties vary in their decisions about which form of life support to withdraw. The hypothesis was that each specialty would be more comfortable withdrawing its "own" form of life support relative to other forms and other specialties. DESIGN: Mail survey. SETTING: 24 medical centers. PARTICIPANTS: 225 specialists in six specialties and 225 comparison physicians randomly matched according to percentage of time devoted to clinical practice. MEASUREMENTS: The six specialties were linked with six life-sustaining technologies related to their special expertise: 1) pulmonologists with mechanical ventilation, 2) nephrologists with hemodialysis, 3) gastroenterologists with tube feedings, 4) hematologists with blood products, 5) cardiologists with intravenous vasopressors, and 6) infectious disease specialists with antibiotics. The subjects ranked different forms of life support in the order in which they would prefer to withdraw them. They also expressed their preferences in response to hypothetical clinical vignettes. RESULTS: In five of the six specialties, the specialists had a relative preference for withdrawing their "own" form of life support, compared with the preferences of the comparison physicians. Overall, the physicians tended to prefer withdrawing a form of life support closely linked with their own specialty. CONCLUSIONS: Just as some specialist physicians tend to reach for different technologies first in treating patients, they also tend to reach for different technologies first when ceasing treatment. Specialists' preferences for different ways to withdraw life support not only may reflect a special understanding of the limits of certain technologies, but also may reveal how ingrained are physicians' patterns of practice.

Anti-Bacterial Agents↗
PubMed1995

Timing payments to subjects of mail surveys: cost-effectiveness and bias.

Although mailed surveys are an important component of epidemiological research, results from mailed surveys are often suspect because of poor response rates and the potential for nonresponse bias. Previous work has demonstrated that paying subjects to complete questionnaires increases response rates, but this work has not well addressed the impact of the timing of incentives on total cost, cost effectiveness, and response bias. We surveyed 400 university employees about health benefits. By random allocation, half received a check for $5 along with the mailed survey, and the other half received the promise of $5 on return of a completed survey. The response rates for both groups were about the same (64 and 59%, respectively), but prepayment was less expensive in aggregate and less expensive per response. In addition, we found that subjects with lower salaries were more likely to respond when paid in advance. We conclude that prepayment may actually be less expensive and more cost effective than payment on completion, but that the timing of payment may influence the profile of respondents.

Adult↗
PubMed1995

Decisions to limit or continue life-sustaining treatment by critical care physicians in the United States: conflicts between physicians' practices and patients' wishes.

We surveyed a national sample of 879 physicians practicing in adult intensive care units in the United States, in order to determine their practices with regard to limiting life-sustaining medical treatment, and particularly their decisions to continue or forgo life support without the consent or against the wishes of patients or surrogates. Virtually all of the respondents (96%) have withheld and withdrawn life-sustaining medical treatment on the expectation of a patient's death, and most do so frequently in the course of a year. Many physicians continue life-sustaining treatment despite patient or surrogate wishes that it be discontinued (34%), and many unilaterally withhold (83%) or withdraw (82%) life-sustaining treatment that they judge to be futile. Some of these decisions are made without the knowledge or consent of patients or their surrogates, and some are made over their objections. We conclude that physicians do not reflexively accept requests by patients or surrogates to limit or continue life-sustaining treatment, but place these requests alongside a collection of other factors, including assessments of prognosis and perceptions of other ethical, legal, and policy guidelines. While debate continues about the ethical and legal foundations of medical futility, our results suggest that most critical care physicians are incorporating some concept of medical futility into decision making at the bedside.

Adult↗
PubMed1995

Physician characteristics associated with decisions to withdraw life support.

OBJECTIVE: This study was undertaken to identify attributes of physicians associated with physicians' decisions to withdraw life support. METHODS: Of the 862 Pennsylvania internists surveyed and asked to make decisions in response to hypothetical vignettes and to report their actual experience with the withdrawal of life support, 485 (56%) responded. The data were analyzed with regression models. RESULTS: With other factors controlled, physicians were more willing to withdraw life support if they were young, practiced in a tertiary care setting, or spent more time in clinical practice; they were less willing if they were Catholic or Jewish. Physicians reported a higher frequency of actually withdrawing life support if they were young, had more contact with ICU patients, spent more time in clinical practice, or were specialists. Physicians with a greater willingness to withdraw were more likely to report having done so. CONCLUSIONS: Physicians' personal characteristics are associated with both their preferences and their practice in the withdrawal of life support, and a greater willingness to withdraw is associated with a higher frequency of withdrawal. The influence of physician characteristics demonstrates that patient preferences and clinical circumstances do not exclusively govern such ethical decisions.

Adult↗
PubMed1994

Conflicts over post-exposure testing for human immunodeficiency virus: can negotiated settlements help?

Health care workers with needlestick exposures to patients' blood often request a test of the patient for evidence of infection with human immunodeficiency virus. If the patient refuses the test, a conflict develops between the interests of the health care worker and those of the patient. Traditional approaches to this dilemma attempt to balance the rights or utilities of abstract patients and health care workers. While these approaches have the advantage of offering clear guidelines in advance of conflict, the interests of the actual participants may differ from those used to create the guidelines. In nonmedical settings, conflicts are often resolved efficiently through negotiation and monetary exchanges. Although negotiated monetary settlements between health care workers and patients may be an impractical way to resolve medical conflicts, models developed from these perspectives provide insights into the individual interests of physicians and patients. Changing existing rules about medical record documentation, or increasing the penalties for the misuse of medical information, may satisfy the interests on both sides of the conflict and so represent integrative bargaining solutions. Even so, as the relationship between health care workers and their patients evolves, more explicit strategies for negotiation may become a reasonable solution to the problem of conflict.

AIDS Serodiagnosis↗
PubMed1994

Different response rates in a trial of two envelop styles in mail survey research.

To determine whether academic physicians' response rates to a mail survey depend on the envelope used to mail the survey, we randomized 901 internists affiliated with a university department of medicine to receive a survey in either a university envelope or a Veterans Affairs envelope. The response rate among those receiving the Veterans Affairs envelope (41%) was 20% higher than the response rate among those receiving the university envelope (34%). We conclude that the packaging of a mail survey can influence the response rate.

Data Collection↗
PubMed1993

Biases in how physicians choose to withdraw life support.

We have investigated biases in physicians' decisions regarding the form of life support to withdraw from critically ill patients in whom the decision to withdraw has already been made. Using a specially designed instrument that solicited both self-reported preferences and also responses to experimentally varied clinical vignettes, we surveyed 862 American internists, of whom 481 (56%) responded. Physicians do have preferences about the form of life support withdrawn. From most likely to least likely the order is: blood products, haemodialysis, intravenous vasopressors, total parenteral nutrition, antibiotics, mechanical ventilation, tube feedings, and intravenous fluids. Four biases in decision making were also identified. Physicians prefer to withdraw forms of therapy supporting organs that failed for natural rather than iatrogenic reasons, to withdraw recently instituted rather than longstanding interventions, to withdraw forms of therapy resulting in immediate death rather than delayed death, and to withdraw forms of therapy resulting in delayed death when confronted with diagnostic uncertainty. Because these biases may have clinical, social, and ethical consequences counter to patient goals, and because they may affect the underlying decision whether to withdraw life support at all, they may represent impediments to rational and compassionate decision making in critical care.

Attitude of Health Personnel↗
PubMed1993

Reporting the results of cystic fibrosis carrier screening.

The recent discovery of the cystic fibrosis gene has offered the possibility of population-based cystic fibrosis carrier screening. Although > 100 distinct mutations have been identified, five of these in aggregate represent about 85% of the alleles in Britain and the United States. Screening programs that test for these five mutations can be designed to offer several alternative ways to communicate the risk to a pregnancy and several alternative ways to manage a pregnancy. At this time we favor a strategy of screening partners in a couple in sequence, screening the second partner only if the first is positive; nevertheless, different strategies will appeal to different couples.

Cystic Fibrosis↗
PubMed1992

The downsizing of internal medicine residency programs.

A variety of forces are converging to reduce the number of internal medicine residency positions offered in this country. This reduction, referred to as downsizing, has been proposed as the solution to several of the problems facing internal medicine. We examine the forces that underlie the current enthusiasm for downsizing; we consider the alternative strategies by which downsizing might be implemented; and we consider the implications of these alternatives on different groups of stakeholders. Although downsizing may represent a legitimate approach to real problems, any mechanism to reduce the number of training positions in internal medicine will have broad implications for medical education and patient care well into the next century. Special efforts must be taken to ensure that downsizing will not exacerbate the existing problem of overspecialization and limited access to care.

Internal Medicine↗
PubMedDate not supplied

Further explorations of medical decisions for individuals and for groups.

BACKGROUND: Important discrepancies between clinical practice and health policy may be related to the ways in which physicians and others make decisions about individuals and groups. Previous research has found that physicians and laypersons asked to consider an individual patient generally make different decisions than those asked to consider a group of comparable patients, but this discrepancy has not been observed in more recent studies. This study was designed to explore possible reasons for these findings. METHODS: Prospective jurors (N = 1,013) each made a recommendation regarding a risky treatment for an incurable blood condition. Perspective (individual vs group) was crossed with uncertainty frame (probability vs frequency) and response wording (original vs revised) in a 2 x 2 x 2 between-participants design. RESULTS: When the strength of participants' recommendations was considered, the effects of perspective, uncertainty frame, and response wording were not statistically significant. When recommendations were dichotomized, participants in the revised-response-wording conditions were more likely to recommend treatment to the group than to the individual. CONCLUSIONS: These results conflict with previous findings for this scenario and suggest that reported differences between decisions for individuals and decisions for groups are not robust.

Adolescent↗
PubMedDate not supplied

Preference for equity as a framing effect.

BACKGROUND: In previous studies, the authors found that most people, given a fixed budget, would rather offer a less effective screening test to 100% of a Medicaid population than a more effective test to 50% of the population. In a subsequent study, the authors found that the number of people preferring the less effective screening test was dramatically reduced when the percentage of Medicaid enrollees receiving it was less than 100. In this article, 2 new studies are reported that explore whether people's preferences for equity versus efficiency are susceptible to a framing effect. METHODS: In 2 studies, the authors presented subjects with multiple scenarios involving screening tests that vary in the proportion of people who could receive the tests within a budget constraint and the number of people whose lives each test would save. Across scenarios, the proportion of Medicaid enrollees who could receive each test was varied, as was the question of whether scenarios involved Medicaid enrollees from the same or a different state. In addition, the authors varied the order in which subjects received the scenarios. RESULTS: In the 1st study, people's preferences for equity over efficiency varied significantly depending on the way situations were framed. Preference for equity was stronger when the more widely distributed choice covered the entire population than when it covered only half the population (P < 0.001). In addition, people's preferences were susceptible to order effects, with preference for equity being significantly stronger when the 1st scenario received by subjects involved 1 screening test that could be offered to the entire population (P < 0.001). In the 2nd study, preferences for equity over efficiency diminished even when the different framings were descriptions of identical circumstances--preference for equity was significantly reduced when the population to be screened was framed broadly, in terms of the percentage of patients across 2 states who could receive testing rather than narrowly, in terms of the percentages of patients in 1 state who could receive testing (P = 0.04). CONCLUSION: Policy planners should be careful about accepting public preferences for equity over efficiency at face value, because such preferences can be dramatically influenced by framing effects and order effects.

Adolescent↗
PubMedDate not supplied

Do nonpatients underestimate the quality of life associated with chronic health conditions because of a focusing illusion?

BACKGROUND: A number of studies show that the general public often estimates that the quality of life (QOL) associated with various health conditions is worse than patients say it is. These studies raise the possibility that people overestimate the impact that unfamiliar health conditions will have on their quality of life. One possible reason people overestimate this is because they are susceptible to a focusing illusion--when asked to imagine themselves in unfamiliar circumstances, people overestimate the emotional impact of those features of their life that would change. METHODS: The authors surveyed members of the general public to test the hypothesis that their QOL ratings of hypothetical health conditions would be higher (indicating a better quality of life) after thinking about how the health condition would affect a broad range of life domains. Across 3 experiments, the authors varied the health conditions people were asked to consider (either paraplegia, below-the-knee amputation, or partial blindness), the life domains they were asked to consider, the response mode with which they evaluated how each health condition would affect each life domain, whether subjects rated the health condition before and after considering life domains or only after, and whether subjects rated their own current quality of life first. RESULTS: Across 3 experiments, using 10 different questionnaire versions, only 1 instance was found in which subjects' ratings were significantly higher after thinking about the effect of the health condition on life domains than before, and the magnitude of this increase was small. CONCLUSION: It could not be established that a focusing illusion contributes significantly to the discrepancy in QOL ratings of patients and nonpatients. Further research should explore other factors that could contribute to the discrepancy or other ways of testing for the influence of a focusing illusion.

Adult↗