Male involvement in contraceptive decision making

We report a participant-observation study of seven family planning agencies in a large Northeastern city that were investigated to discover the extend to which young men are encouraged by birth control counselors to be involved in decision making about contraception. Our results indicated that male involvement is only mildly encouraged; the implications for sexual decision making and for social service agencies are discussed.     

The involvement of a consumer council in organizational decision making in a public psychiatric hospital

This article describes a consumer group within a public psychiatric hospital that serves primarily a forensic population. Some barriers to participation included the severity of some clients' mental illness, an organizational culture that does not fully support participation, the lack of clients' awareness of problems or alternative actions, and inherent power imbalances between clients and staff. Despite these barriers, the consumer group has made improvements for facility clients. Some factors associated with this success included strong administrative support, the allocation of a highly qualified staff liaison to work with the group, and the integration of the group into the facility's formal decision-making structure. Lessons are offered for the development of similar groups within public psychiatric hospitals and community-based mental health agencies.     

Discounting and decision making in the economic evaluation of health-care technologies

Discounting costs and health benefits in cost-effectiveness analysis has been the subject of recent debate - some authors suggesting a common rate for both and others suggesting a lower rate for health. We show how these views turn on key judgments of fact and value: on whether the social objective is to maximise discounted health outcomes or the present consumption value of health; on whether the budget for health care is fixed; on the expected growth in the cost-effectiveness threshold; and on the expected growth in the consumption value of health. We demonstrate that if the budget for health care is fixed and decisions are based on incremental cost effectiveness ratios (ICERs), discounting costs and health gains at the same rate is correct only if the threshold remains constant. Expecting growth in the consumption value of health does not itself justify differential rates but implies a lower rate for both. However, whether one believes that the objective should be the maximisation of the present value of health or the present consumption value of health, adopting the social time preference rate for consumption as the discount rate for costs and health gains is valid only under strong and implausible assumptions about values and facts.     

Public involvement in science and decision making

Members of the public are becoming increasingly interested in understanding risks associated with their exposure to radionuclides and chemicals in the environment. They also want to be more involved in decision making about future exposures to risks. This paper reviews one community's involvement in decisions about technical methods to calculate soil cleanup criteria for the Rocky Flats Environmental Technology Site near Denver, Colorado. The public anticipated that much of the site would be available for their use following cleanup. Final decisions regarding the future use of the site have yet to be made; however, the soil action levels were developed for this eventuality. When the public expressed considerable concern about cleanup standards for the site in 1996, a community group met to focus efforts on reviewing the cleanup standards. Later, the U.S. Department of Energy officially established the community panel to oversee an independent calculation of radionuclide soil action levels that would be used as the basis for cleanup at Rocky Flats. The primary radionuclide of concern was 239+240Pu. The Radionuclide Soil Action Level Oversight Panel (Panel) was substantively involved in all aspects of the work, from selecting the contractor, approving the computer code that formed the basis of the calculation, and assisting in developing the exposure scenarios, to selecting the values for the numerous input parameters. Communicating the uncertainties to the public, which was a major component of the analysis of soil action levels, presented a unique challenge. Over the course of the 18-mo project, the Panel and interested members of the public gained an understanding of the technical elements of the calculation and the sensitivities of the different parameters. This project serves as an excellent model of the effectiveness of public involvement in science and decision making for the future. It also illustrates the public expectations, difficulties, and time commitments encountered when making scientific decisions in a public forum. Although the process was time consuming for the scientists responsible for the calculations, a more technically defensible as well as publicly acceptable soil action level emerged. The technical approach developed during the project has been recommended for use as a decision-making tool for cleanup of the site.     

Evidence-based decision making in public health.

A stronger focus on evidence-based decision making in day-to-day public health practice is needed. This article describes the rationale for this need, including (1) the inter-relationships between evidence-based medicine and evidence-based public health (EBPH); (2) commonly used analytic tools and processes; (3) keys to when public health action is warranted; (4) a strategic, six-step approach to more analytic decision making; and (5) summary barriers and opportunities for widespread implementation of EBPH. The approach outlined is being tested through a series of courses for mid-level managers in the Missouri Department of Health--initial results from a pilot test are encouraging. It is hoped that the greater use of an evidence-based framework in public health will lead to more effective programs.     

Prescription medicines: decision‐making preferences of patients who receive different levels of public subsidy

Objective To compare the relative importance of medicine attributes and decision‐making preferences of patients with higher or lower levels of insurance coverage in a publicly funded health care system. Design and setting Cross‐sectional telephone survey of randomly selected regular medicine users aged ≥18 years in the Hunter Valley, NSW, Australia. Main variables studied Questions about 27 medicine attributes and active involvement in decisions to start a new medicine. Results After adjustment, there were few differences between the 408 concession card holders (high insurance) and 410 general beneficiaries (low insurance) in their assessment of the importance of medicine attributes. For both groups, the explanation of treatment options, establishing the need for the medicine, and medicine efficacy and safety were the most important considerations. Medicine costs, the treatment burden and medicine familiarity were less important; the views of family and friends ranked lowest. There was a statistically significantly greater influence of the regular doctor for the concession card holders than general beneficiaries (93.6 vs. 84%, adjusted OR 2.80, 95% CI 1.31, 5.99). Concession card holders were more likely to favour doctors having more say in the decision‐making process (crude OR 1.69, 95% CI 1.28, 2.24), and more likely to report the most recent treatment decision being made by the doctor alone, compared with general beneficiaries (61.2 vs. 40.3%). Conclusion Medicine need, efficacy and safety are viewed as paramount for most patients, irrespective of insurance status. While patients report the importance of participation in treatment decisions, delegation of decision making to the doctor was common in practice.     

Patients' preferences for involvement in treatment decision making in Japan

Background  

A number of previous studies have suggested that the Japanese have few opportunities to participate in medical decision-making, as a result both of entrenched physician paternalism and national characteristics of dependency and passivity. The hypothesis that Japanese patients would wish to participate in treatment decision-making if adequate information were provided, and the decision to be made was clearly identified, was tested by interview survey.     

The contingency of patient preferences for involvement in health decision making

BACKGROUND: Studies indicate that better patient compliance and higher patient satisfaction result when agreement exists between the physician and the patient regarding the medical problem and its treatment. PURPOSES: This study will extend previous work by investigating (1) under what conditions patients prefer to be actively involved in their treatment decisions, (2) the underlying theoretical reasons that may account for patient decision-making preferences, and (3) what medical decision-making model can guide physicians and medical policy makers when adapting their medical decision-making styles. METHODOLOGY/APPROACH: A total of 2,765 individuals were surveyed by the National Opinion Research Center as part of the 2002 General Social Survey (GSS). This survey included a one-time topical module on "Doctors and Patients," which incorporated questions on patient preferences concerning the physician-patient relationship. Demographic information (e.g., age, education, and sex) was analyzed against patient preferences for medical decision making. FINDINGS: Results support patient preferences for participatory medical decision making, and this is especially true for younger, more educated, and female patients. PRACTICE IMPLICATIONS: Common prudence would suggest that the best way to determine a patient's preference for participating in medical decision making is to simply ask them. However, the very asking of this straightforward question is based on the assumption that patients do wish to be actively involved. Results of this study support such an assumption. In the absence of all other knowledge, the results of this national survey support the health care practitioner's belief that U.S. patients, in general, have a preference for being actively involved in medical decision making and that this preference is truer for younger, female, and more educated patients.     

Quality of life assessments and levels of decision making: differentiating objectives

The purpose of this paper is to examine uses of quality of life (QOL) measurements at different levels of decision making within the health care system, ranging from the micro (clinical) level, through the meso (agency, institutional or regional) level to the macro and meta (governmental) levels. We use individualized, group and population-based QOL and preference assessments as illustrative examples of ways in which QOL information and decision making level interact. We conclude that the meso and macro levels pose particularly challenging problems, and suggest that, if the primary emphasis is placed on applications of QOL assessments at the micro (clinical) level of decision making, a research agenda that is much too limited may be adopted.Supported by a grant from the National Cancer Institute of Canada with funds from the Canadian Cancer Society.     

Understanding the role of contextual influences on local health-care decision making: case study results from Ontario, Canada

Approaches to involving the public in local health care decision making processes (and analyses of these approaches) have tended to treat participation and publics uniformly in search of the ideal method of involving the public or providing the same opportunities for public participation regardless of differing socio-economic, cultural, insitutional or political contexts within which decisions are made. Less attention has been given to the potential for various contextual factors to influence both the methods employed and the outcomes of such community decision-making processes. The paper explores the role that context (three sets of contextual influences more specifically) plays in shaping community decision-making processes. Results from case studies of public participation in local health-care decision making in four geographic communities in Ontario are presented. During the study period, two of these communities were actively involved in health services restructuring processes while one had recently completed its process and the fourth had not yet engaged in one. Several themes emerge from the case studies regarding the identification and role of contextual influences in differentially shaping participation in local health care decision-making. These include the propensity for communities with different social and structural attributes to engage in different "styles" of participation; the importance attached to "community values" in shaping both the qualitative and quantitative aspects of participation: the role of health councils, local government and inter-organizational collaboration as participation "enablers"; and the politicization of participation that occurs around contentious issues such as hospital closures.     

Patient involvement in clinical decision making: the effect of GP attitude on patient satisfaction

OBJECTIVE: This study investigates general practitioners' (GPs) and patients' attitudes to shared decision making, and how these attitudes affect patient satisfaction. BACKGROUND: Sharing of information and decisions in the consultation is largely accepted as the ideal in general practice. Studies show that most patients prefer to be involved in decision making and shared decision making is associated with patient satisfaction, although preferences vary. Still we know little about how the interaction of GP and patients' attitudes affects patient satisfaction. One such study was conducted in the USA, but comparative studies are lacking. DESIGN: Questionnaire survey distributed through GPs. SETTING AND PARTICIPANTS: The results are based on the combined questionnaires of 41 GPs and 829 of their patients in the urban municipality of Bergen in the western part of Norway. Main variables studied The data were collected using a nine-item survey instrument constructed to measure attitudes towards patient involvement in medical consultations. The patients were also asked to rate their satisfaction with their GP. RESULTS AND CONCLUSIONS: The patients had a strong preference for shared decision making. The GPs also generally preferred shared decision making, but to a lesser degree than the patients, which is the opposite of the findings of the US study. There was a positive effect of the GP's attitude towards shared decision making on patient satisfaction, but no significant effect of congruence of attitudes between patient and GP on patient satisfaction. The suggested explanation is that GPs that are positive to sharing decisions are more responsive to patients' needs and therefore satisfy patients even when the patient's attitude differs from the GPs' attitude. Hence, although some patients do prefer a passive role, it is important to promote positive attitudes towards patient involvement in medical consultations.