Multiattribute utility theory in decision-making.
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Cost-Benefit Analysis↗
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[Optimizing subjective decisions: Use of multiattribute utility theory in medical therapeutic decisions].
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Decision Making↗
Evidence-based medicine, utilities, and quality of life.
Evidence-based medicine provides the highest quality of information for medical practitioners. At the top of the pyramid of evidence-based medicine are the prospective, randomized clinical trials and meta-analysis. Evidence-based medicine can be incorporated with quality-of-life parameters; the latter can be quantified using utility theory. With utility theory, utility values range from 0.0 (death state) to 1.0 (perfect health state). The higher the utility value, the better a person's quality of life. Interventional treatment can change the utility level experienced by a patient. A change in utility value induced by an interventional treatment can be amalgamated with the duration of the treatment effect to provide the number of quality-adjusted life-years (QALYs) gained by a specific treatment (QALYs = [gain in utility value] x [duration of treatment effect]). Thus, this formula takes into account both the improvement in quality of life and the improvement in length of life gained by a treatment. The number of QALYs gained by a treatment can then be incorporated with medical costs (discounted for the time value of money) to arrive at a final common denominator of $/QALY (cost per QALY). The parameter $/QALY can be used to compare the cost-effectiveness of interventional treatments across diverse specialties in medicine. In essence, this methodology allows a measure of the cost-effectiveness of a treatment that incorporates the highest quality of scientific information, clinical efficacy, patient quality-of-life preferences, and realistic costs.
Aged↗
Utilizing role theory to help employed parents cope with children's chronic illness.
Role theory is utilized to detail a six-step process for developing balanced coping through role negotiation. As applied in this paper, the role theory framework provides health educators with a useful tool for helping employed parents cope with a child's chronic illness. The emphasis is on partnering with parents or primary caregivers to identify, understand and manage the multiple role demands of working parents with chronically ill children. Role theory suggests ways health educators can support balanced coping by educating families about the demands of a child's illness, and helping to reduce those demands, helping to increase family resources, supporting parents and facilitating role negotiation. The ultimate goal is the development of balanced coping strategies that (1) meet the medical and emotional needs of the ill child, (2) allow parents to maintain their physical and mental health, and (3) enable parents to meet the demands of their other roles (e.g. paid employment).
Adaptation, Psychological↗
The nonexistence of interpersonal utility scales. A missing link in medical decision theory?
Utility scales, as elicited by the usual methods, are personal and cannot be averaged across individuals. Unfortunately, the Maximum Expected Utility principle calls for such averaging whenever medical decisions affect several patients--as they generally do because of budget constraints--and whenever a patient's scale is uncertain, such as for a comatose patient. Interpretation of therapeutic trials is particularly problematic when examined in this light, as are psychiatric decisions involving mental incompetence. To overcome this deficiency, a supplementary equal-right-to-treatment principle seems necessary, but the proposals examined here clash with the patient's right to choose his own utility scale for valuation of prospective treatment outcomes. Perhaps the basic assumption that personal suffering cannot be measured on an interpersonal scale is too radical, but the counterproposal involves too many assumptions to appear convincing. These issues have received remarkably little attention, if any, in the medical decision making literature.
Attitude of Health Personnel↗
Utilization review: theory, practice, and issues.
Utilization review is now carried out by most hospitals and many health care agencies, government-sponsored local agencies, third-party payers, and private companies, yet few practical explanations of the process are available. In this guide, the author differentiates between internal and external review and their likely outcomes, outlines the development of a utilization review system, and describes the stages and levels of review. Psychiatric utilization review is especially difficult to carry out; thus it rarely goes beyond evaluating need for hospitalization and length of stay. Utilization review in general still must deal with issues related to confidentiality, the clinical responsibility of the reviewer, and whether certification for admission can reward poor or inappropriate care.
Forecasting↗
LEAD: a methodology for learning efficient approaches to medical diagnosis.
Determining the most efficient use of diagnostic tests is one of the complex issues facing medical practitioners. With the soaring cost of healthcare, particularly in the US, there is a critical need for cutting costs of diagnostic tests, while achieving a higher level of diagnostic accuracy. This paper develops a learning based methodology that, based on patient information, recommends test(s) that optimize a suitable measure of diagnostic performance. A comprehensive performance measure is developed that accounts for the costs of testing, morbidity, and mortality associated with the tests, and time taken to reach diagnosis. The performance measure also accounts for the diagnostic ability of the tests. The methodology combines tools from the fields of data mining (rough set theory, in particular), utility theory, Markov decision processes (MDP), and reinforcement learning (RL). The rough set theory is used in extracting diagnostic information in the form of rules from the medical databases. Utility theory is used in bringing various nonhomogenous performance measures into one cost based measure. An MDP model together with an RL algorithm facilitates obtaining efficient testing strategies. The methodology is implemented on a sample problem of diagnosing solitary pulmonary nodule (SPN). The results obtained are compared with those from four alternative testing strategies. Our methodology holds significant promise to improve the process of medical diagnosis.
Algorithms↗
Multi-attribute preference functions. Health Utilities Index.
Multi-attribute utility theory, an extension of conventional utility theory, can be applied to model preference scores for health states defined by multi-attribute health status classification systems. The type of preference independence among the attributes determines the type of preference function required: additive, multiplicative or multilinear. In addition, the type of measurement instrument used determines the type of preference score obtained: value or utility. Multi-attribute utility theory has been applied to 2 recently developed multi-attribute health status classification systems, the Health Utilities Index (HUI) Mark II and Mark III systems. Results are presented for the Mark II system, and ongoing research is described for the Mark III system. The theory is also discussed in the context of other well known multi-attribute systems. The HUI system is an efficient method of determining a general public-based utility score for a specified health outcome or for the health status of an individual. In clinical populations, the scores can be used to provide a single summary measure of health-related quality of life. In cost-utility analyses, the scores can be used as quality weights for calculating quality-adjusted life years. In general populations, the measure can be used as quality weights for determining population health expectancy.
Health Services↗
Life-cycle preferences over consumption and health: when is cost-effectiveness analysis equivalent to cost-benefit analysis?
This paper studies life-cycle preferences over consumption and health status. We show that cost-effectiveness analysis is consistent with cost-benefit analysis if the lifetime utility function is additive over time, multiplicative in the utility of consumption and the utility of health status, and if the utility of consumption is constant over time. We derive the conditions under which the lifetime utility function takes this form, both under expected utility theory and under rank-dependent utility theory, which is currently the most important nonexpected utility theory. If cost-effectiveness analysis is consistent with cost-benefit analysis, it is possible to derive tractable expressions for the willingness to pay for quality-adjusted life-years (QALYs). The willingness to pay for QALYs depends on wealth, remaining life expectancy, health status, and the possibilities for intertemporal substitution of consumption.
Attitude to Health↗
Assigning values to intermediate health states for cost-utility analysis: theory and practice.
Cost-utility analysis (CUA) was developed to guide the allocation of health care resources under a budget constraint. As the generally stated goal of CUA is to maximize aggregate health benefits, the philosophical underpinning of this method is classic utilitarianism. Utilitarianism has been criticized as a basis for social choice because of its emphasis on the net sum of benefits without regard to the distribution of benefits. For example, it has been argued that absolute priority should be given to the worst off when making social choices affecting basic needs. Application of classic utilitarianism requires use of strength-of-preference utilities, assessed under conditions of certainty, to assign quality-adjustment factors to intermediate health states. The two methods commonly used to measure strength-of-preference utility, categorical scaling and time tradeoff, produce rankings that systematically give priority to those who are better off. Alternatively, von Neumann-Morgenstern utilities, assessed under conditions of uncertainty, could be used to assign values to intermediate health states. The theoretical basis for this would be Harsanyi's proposal that social choice be made under the hypothetical assumption that one had an equal chance of being anyone in society. If this proposal is accepted, as well as the expected-utility axioms applied to both individual choice and social choice, the preferred societal arrangement is that with the highest expected von Neumann-Morgenstern utility. In the presence of risk aversion, this will give some priority to the worst-off relative to classic utilitarianism. Another approach is to raise the values obtained by time-tradeoff assessments to a power a between 0 and 1. This would explicitly give priority to the worst off, with the degree of priority increasing as a decreases. Results could be presented over a range of a. The results of CUA would then provide useful information to those holding a range of philosophical points of view.
Cost-Benefit Analysis↗
Prospect relativity: how choice options influence decision under risk.
In many theories of decision under risk (e.g., expected utility theory, rank-dependent utility theory, and prospect theory), the utility of a prospect is independent of other options in the choice set. The experiments presented here show a large effect of the available options, suggesting instead that prospects are valued relative to one another. The judged certainty equivalent for a prospect is strongly influenced by the options available. Similarly, the selection of a preferred prospect is strongly influenced by the prospects available. Alternative theories of decision under risk (e.g., the stochastic difference model, multialternative decision field theory, and range frequency theory), where prospects are valued relative to one another, can provide an account of these context effects.
Adolescent↗
The evaluation of nursing theory: a method for our madness.
The profession of nursing has, in recent years, been trying to further develop, test and use proposed nursing theory. To utilize theory appropriately, in all domains of practice, education and research, it is important to know how to describe, analyze and evaluate theory. Evaluation of theory both within and among cultures should be a goal for the future of nursing to further advance the science of nursing. From a philosophical and historical standpoint, this paper attempts to define theory, including nursing theory, and then analyze criteria for the evaluation of theory. Finally, a more comprehensive set of criteria for the evaluation of theory is proposed, which may stimulate more informed decisions regarding the choice of nursing theory for use in practice, education and research, and from which may emerge new theories for and of nursing consistent with the 90s, and beyond.
Humans↗
Probabilistic Choice as a Consequence of Nonlinear (Sub) Optimization
Several researchers have convincingly argued that much probabilistic choice could be the result of (attempted) maximization of some utility function that is nonlinear in the choice probabilities. Others researchers have developed descriptive utility theories that are nonlinear in event probabilities. The present work combines these two viewpoints and motivates utility theories that can be nonlinear in either one or both of choice and event probabilities. The presented theories are based on the idea that most choice situations involve multiple incompatible goals which have to somehow be combined in reaching a decision. In particular, I assume that the decision maker is faced with a vector optimization problem which is converted to a scalar optimization problem, the latter being solved to yield a noninferior solution to the original vector optimization problem. I show that in certain special cases this approach yields the same utility representations as certain other recent nonlinear utility theories. Copyright 1997 Academic Press. Copyright 1997 Academic Press
Journal Article↗
Utilizing Rogers' Theory of Self-Concept in mental health nursing.
The work of mental health nurse is interactive in nature, the priority of which is the effective development and maintenance of a therapeutic relationship with clients. This field of nursing bases its practice on theories from many schools of thought in order to provide clients with the highest quality of care. One such theory is that of Carl Rogers whose practice as a psychotherapist was based on his Theory of Self-Concept. This paper examines the development of the Theory of Self-Concept from the works of Cooley, Mead, Allport and Rogers and relates to the therapeutic alliance between a primary nurse and a client who has been medically diagnosed as being 'depressed'. The implications for practice are considered and some of the difficulties of utilizing Rogers' theory on an in-patient unit are explored. The paper emphasizes the need for nurses to be aware of the use of such theories in order to enrich the care that clients receive. It also highlights the need for nurses to be aware of their own 'self' when working with clients, a state that can only be achieved if the nurses themselves have adequate clinical supervision and an environment which is supportive of such work.
Humans↗
Explaining distortions in utility elicitation through the rank-dependent model for risky choices.
The standard-gamble (SG) method has been accepted as the "gold standard" for the elicitation of utility when risk or uncertainty is involved in decisions, and thus for the measurement of utility in medical decisions. It is based on the assumptions of expected-utility theory. Unfortunately, there is now abundant evidence that expected utility is not empirically valid, and that the SG method overestimates risk aversion and the utilities of impaired health states. This paper shows how rank-dependent utility theory, a newly developed theory in decision science, can explain the main violations of expected utility. Thus it provides a means for correcting the SG method and for improving the assessments of quality-adjusted life years for medical decisions in which there is uncertainty about outcomes.
Bias↗
Utilizing learning theory to promote effectiveness of instruction in preclinical operative dentistry.
In comparing two methods of instruction, one must be cautious about forming conclusions because of certain variables which can influence results. Such variables are differences in populations, in instructor effectiveness, and in availability of instructional aids. The comparison does, however, demonstrate differences between the two groups. The fact that the entire class taught by the modified course passed the proficiency examination after nine trials, compared to 12 for those from the traditional course, is not in itself significant. The impressive fact is that in the early trials the rate of students who qualified for clinical practice was nearly doubled in the learning theory group. This might imply that the learning theory group demonstrated a greater degree of problem-solving ability because of opportunities for discovery learning within the course. Since both classes were given the proficiency examination approximately two-and-a-half months after they had completed the preclinical course, it would seem that the learning theory design resulted in retention of the objectives of the course by a significant number of students. Consequently, it is the authors' opinion that the learning theory design provided a more effective method of instruction. Clinical operative dentistry consists of highly intricate procedures which for their successful completion require complex psychomotor responses in the operator. Therefore a program of instruction in operative dentistry must be highly effective. When such a program is organized, utilization of learning theory principles, especially those of skill learning, may aid in achieving this goal.
Dental Cavity Preparation↗
A new and more robust test of QALYs.
Previous empirical tests of quality-adjusted life-years (QALYs), the most widely used outcome measure in economic evaluations of health care, generally yielded negative results. These tests were, however, for the most part based on expected utility, which is now widely acknowledged to be descriptively inaccurate. The observed violations might, therefore, have been caused by violations of expected utility. We performed a new test of QALYs, which is valid under expected utility and under the two most influential non-expected utility theories, rank-dependent utility and prospect theory, and found considerable support for the QALY model. Our findings suggest that QALYs may be valid if nonexpected utility formulas are used to compute health state utilities.
Choice Behavior↗
The utility and limitations of decision theory in the utilization of surgical staging and extended field radiotherapy in cervical cancer.
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Decision Theory↗