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Biomedical subjects

Monica Ortendahl

Publications and source records attributed to Monica Ortendahl.

10 recordsLinked to original sources
PubMed2006

A low tension between individual and societal time aspects in health improved outcomes.

OBJECTIVES: To review intertemporal choices, involving decisions with a trade-off between something now and something later. These choices are common in health both at an individual and societal level. METHODS: The present value of an outcome, for example, the amount of money or the health outcomes in various aspects, is equivalent to the value of a future outcome discounted with the delay of time. The concept of diminishing value over time is positive discounting. Economic forecasts generally use discount rates in which the value of a future dollar is less than the value of a present dollar, and where the discount rates are similar for the individual investor and society. The value of future health is commonly thought of as similar to the value of future money. Yet, the individual may rationally choose a discount rate that is exceedingly low or even negative. This paradox is particularly relevant when considering primary and secondary prevention, where initial and continuing costs may precede beneficent outcomes by decades, making discount rate selections the dominant factor in determining decisions. CONCLUSION: We suggest that the societal perspective should also recognize that discount rates for health outcomes are largely irrelevant and that even negative discount rates have crucial relevance.

Decision Making↗
PubMed2006

Discounting and risk characteristics in clinical decision-making.

Time-related aspects have attracted an increasing interest in medical decisions. Health promotion often works toward remote goals, and many clinical judgments and decisions include an exchange of costs today for benefits in the future. The concept of diminishing value over time is positive discounting when the benefits occur so far in the future that they seem of little value relative to the immediate cost. If there is a preference to live for the present rather than save for the future, such a preference might not contribute to good health according to a lower discount rate. As discounting is related to risk an analysis of uncertainty is required being an unavoidable condition in health work. Shared decision-making between doctor and patient has increasingly been emphasized, where risk characteristics and time-related aspects should be taken into account to reach a decision based upon mutual agreement. The framework of time and risk for analysis can perform a useful role in clinical judgments and decisions, where framing of different features of risk might diminish discounting and increase compliance to treatment. A summary of valuation factors in medical decision making is presented: (a) long-term decisions are sensitive to discount rates; (b) discount rates vary by domain, by outcome, by individuals and by level of certainty; (c) probability discounting is used if the risk is perceived as controllable; (d) the doctor uses expected value, the patient is risk aversive; (e) asymmetric discounting for patients and doctors gives poor compliance; (f) discount rates are influenced by framing.

Attitude of Health Personnel↗
PubMed2006

Smoking as a decision among pregnant and non-pregnant women.

OBJECTIVES: The purpose was to examine values and beliefs related to smoking, and to test the validity of a decision model based on the product of the value of smoking-related events and states, and the belief that these will occur, (in decision research labeled Expected Utility, or EU). METHODS: Over a two-week period eighty women, divided into subgroups consisting of pregnant vs. non-pregnant women, and those intending vs. those not intending to quit smoking, performed evaluations of values and beliefs for the two conditions of quitting and not quitting smoking. RESULTS: For both pregnant and non-pregnant women expected utility of smoking was negative. Of all the four groups pregnant women not intending to quit smoking estimated the expected utility of smoking as least negative. CONCLUSIONS: A decision analytic approach is applicable to describe the addictive behavior of smoking. Values as well as beliefs about smoking should be stressed in smoking cessation programs, especially among pregnant women.

Adult↗
PubMed2005

Framing health messages based on anomalies in time preference.

Time discounting processes and their effects are increasingly taken into account in health-related decisions. Because these effects have a potentially large impact the characteristics of discounting should also be taken into consideration when framing health messages. Research on the relationship between time and health is discussed with a special focus on discounting biases. The criteria for selection of articles were potential practical application when formulating health messages. Time discounting processes vary with individuals and contexts. Therefore, no single model is expected to describe discounting processes completely. Discounting biases appear more prevalent in health decisions than in economic decisions, even when health and monetary outcomes are matched for utility. Research on decision-making under conditions of uncertainty has documented numerous anomalies of expected utility. Analysis on the anomalies related to intertemporal choice and discounted utility (DU) include the magnitude effect, dynamic inconsistency effect, instant endowment, status quo bias, and sequence effect. Discounting biases in the formulation of preventive health messages are important. The desire for behavioral change in these programs would benefit from considering the psychological factor of discounting. Framing health messages in terms of large, important outcomes or long delays should induce lower implicit discount rates. Framing health messages as losses rather than gains, or as involving a series of outcomes rather than individual outcomes, might similarly lower the implicit discount rate used.

Costs and Cost Analysis↗
PubMed2004

Pregnant and nonpregnant smokers attitude toward smoking.

OBJECTIVES: The purpose was to study changes in attitude toward smoking over a relatively short span of 14 days after an initiation period during which period 40 women had decided to quit smoking and maintaining abstinence during their participation in the study. In the study were also included 40 women still smoking. METHODS: Eighty women participated in the study, with twenty in each group formed by the variables pregnancy/nonpregnancy and wishing to quit smoking/not wishing to quit smoking. The women were for each day (i.e., Days 1-7 and 14) asked to respond to the question 'How do you like smoking?' reflecting the participants' general attitude toward smoking. RESULTS: The main effects were decreased liking of smoking across time and across all groups, with an overall less liking in those who quit. This less liking did not differ across pregnancy status. There was only small effect for time giving a more negative attitude toward smoking, not actual outcomes, which were already different at baseline and stayed that way throughout. CONCLUSIONS: Motivational and psychological aspects have a larger impact on behavior change compared to physical variables like being pregnant or not.

Adult↗
PubMed2002

Time-related issues with application to health gains and losses.

Time-related aspects of health have attracted increasing interest, and it has become evident that many medical situations concern the exchange of present-day costs for future benefits. Traditional decision analytic paradigms weigh the probability of outcomes and the value of outcomes. Such analyses are incomplete if they do not consider the time of the outcome as well. The concept of diminishing value over time is positive discounting. Time discounting processes and effects have a potentially large impact on clinical decision making. Therefore, characteristics of discounting should be taken into consideration. Discounting processes are variable with individuals and also within different contexts such as gains and losses. No single model can be expected to describe time-related decisions within health. A more diversified use and critical appraisal of these concepts in medicine become more important as we attempt to refine decision models. A summary of valuation factors in medical decision making is presented: (a) long-term decisions are very sensitive to discount rates; (b) discount rates are greater for gains than for losses; (c) discount rates vary by domain, by outcome, by individuals over time, and by level of certainty; (d) individual preferences may reverse themselves over time; (e) the doctor uses expected value; the patient is risk aversive; (f) over a lifetime perspective, a flat or even negative discount rate will result in choices that minimize lifetime disability.

Attitude to Health↗
PubMed2002

The methotrexate therapeutic response in rheumatoid arthritis.

OBJECTIVE: Methotrexate (MTX) is used frequently as a disease modifying antirheumatic drug (DMARD) for rheumatoid arthritis (RA), and patients tend to continue taking this drug for longer periods than alternative single agents. The shape of the therapeutic response beyond one or 2 years, however, has not been fully studied. We examined the properties of the pure MTX "therapeutic segment," that period that begins with start of MTX and terminates when MTX is discontinued or another DMARD is added, by observational study. METHODS: We studied new MTX starts for the period 1988 through 1996 for 437 patients from a parent cohort of 4253 patients. Patients were drawn from 8 Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) data centers: 2 community based populations; 2 private rheumatological practices; 2 university referral practices; and 2 university clinics for underserved minority urban populations. Health Assessment Questionnaire (HAQ) Disability Index scores (0-3) were obtained prospectively each 6 months. RESULTS: At MTX start, patients had relatively long average disease duration of 16.7 years, and had moderately severe disability, with an initial HAQ mean disability score of 1.48. Over the 10 year period examined in the parent cohort of 4253 patients (and thus irrespective of therapy), the prevalence of MTX use rose from 19% to 45%, while mean HAQ disability declined from 1.34 to 1.11. This correspondence is consistent with an accrual of benefits from more frequent use of MTX and other DMARD over this period. The MTX therapeutic segment revealed a distinct shape. HAQ-Disability Index values began at 1.48 at baseline and declined to a maximal improvement of 1.23 at 30 months. This long period to maximum benefit may have been partly driven by a slow titration upward to an optimal dosage. After 42 months, disability for this population began to re-progress and reached 1.39 at 84 months, still below the pretreatment baseline. Re-progression to baseline was about 8 or more years. Cumulative disability averted with MTX treatment for this population was roughly 1.30 disability-unit-years. CONCLUSION: MTX treatment of RA in practice differs substantially from common perception and appears suboptimal by being too little, too late, and too long to treatment change. A modification of the "sawtooth strategy" in which the disease is "ratcheted down" by change of MTX therapy at 3 years or when re-progression has proceeded halfway to baseline, rather than waiting for return to baseline, is suggested by these data. Also suggested is the need for more rapid upward dosage titration and longer maintenance of an optimal or highest tolerated dosage. "Therapeutic segment" data provide insights into strategic approaches to management of RA since they allow estimation of population aggregate properties such as time to maximum benefit and the time to return to baseline.

Antirheumatic Agents↗