Treatment Effect Models with Strategic Interaction in Treatment Decisions

This study considers treatment effect models in which others' treatment decisions can affect one's own treatment and outcome. Focusing on the case of two-player interactions, we formulate treatment decision behavior as a complete information game with multiple equilibria. Using a latent index framework and assuming a stochastic equilibrium selection, we prove that the marginal treatment effect from one's own treatment and that from the partner can be identified separately. Based on our constructive identification results, we propose a two-step semiparametric procedure for estimating the marginal treatment effects using series approximation. We show that the proposed estimator is uniformly consistent and asymptotically normally distributed. As an empirical illustration, we investigate the impacts of risky behaviors on adolescents' academic performance

A Moment in Human Development: Legal Protection, Ethical Standards and Social Policy on the Selective Non-Treatment of Handicapped Neonates

Selective non-treatment decisions involving severely handicapped neonates have recently come under renewed judicial and legislative scrutiny. In this article, the author examines the legal, ethical and social considerations attendant to the non-treatment decision. In Part II he discusses the predominant ethical viewpoints relating to this issue and proposes a new moral standard based on personal interests. Part III presents a survey of the jurisprudence relating to selective non-treatment decisions. Parts IV and V of this article provide a critical examination of the recently enacted Child Abuse Amendments of 1984, a federal legislative initiative designed to regulate treatment decisions relating to handicapped infants. The author suggests that the ethical standards and treatment criteria proposed in this article may prove useful to courts seeking to balance the handicapped neonate\u27s constitutional right to privacy with the requirements of the new federal law

Socioeconomic status and physicians' treatment decisions

This paper aims at shedding light on the social gradient by studying the relationship between socioeconomic status (SES) and provision of health care. Using administrative data on services provided by General Practitioners (GPs) in Norway over a five year period (2008-12), we analyse the quantity, composition and value of services provided by the GPs according to patients' SES measured by education, income or ethnicity. Our data allow us to control for a wide set of patient and GP characteristics. To account for (unobserved) heterogeneity, we limit the sample to patients with a specific disease, diabetes type 2, and estimate a model with GP fixed effects. Our results show that patients with low SES visit the GPs more often, but the value of services provided per visit is lower. The composition of services varies with SES, where patients with low education and African or Asian ethnicity receive more medical tests but shorter consultations, whereas patients with low income receive both shorter consultations and fewer tests. Thus, our results show that GPs differentiate services according to SES, but give no clear evidence for a social gradient in health care provision.COMPETE, QREN, FEDER, FC

Glioblastoma in the elderly - how do we choose who to treat?

Objective: Glioblastoma (GBM) is the commonest primary malignant brain tumour amongst the adult population. Incidence peaks in the 7th and 8th decades of life and as our global population ages, rates are increasing. GBM is an almost universally fatal disease with life expectancy in the range of 3–5 months amongst the elderly. Materials and Methods: The assessment of elderly GBM patients prior to treatment decisions is poorly researched and unstandardised. In order to begin tackling this issue we performed a cross-sectional survey across all UK based consultant neuro-oncologists to review their current practice in assessing elderly GBM patients. Results: There were 56 respondents from a total of 93 recipients (60% response rate). All respondents confirmed that at least some patients aged 70 or over were referred to their clinics from the local multidisciplinary team meeting (MDT). Only 18% of consultants routinely performed a cognitive or frailty screening test at initial consultation. Of those who performed a screening test, the majority reported that the results of the test changed their treatment decision in approximately 50% of cases. Participants ranked performance status as the most important factor in determining treatment decisions. Conclusions: Considering the heterogeneity of this patient population, we argue that performance status is a crude measure of vulnerability within this cohort. Elderly GBM patients represent a unique clinical scenario because of the complexity of distinguishing neuro-oncology related symptoms from general frailty. There is a need for specific geriatric assessment models tailored to the elderly neuro-oncology population in order to facilitate treatment decisions

Socioeconomic Status and Physicians’ Treatment Decisions

This paper aims at shedding light on the social gradient by studying the relationship between socioeconomic status (SES) and provision of health care. Using administrative data on services provided by General Practitioners (GPs) in Norway over a five year period (2008- 12), we analyse the quantity, composition and value of services provided by the GPs according to patients' SES measured by education, income or ethnicity. Our data allow us to control for a wide set of patient and GP characteristics. To account for (unobserved) heterogeneity, we limit the sample to patients with a specific disease, diabetes type 2, and estimate a model with GP fixed effects. Our results show that patients with low SES visit the GPs more often, but the value of services provided per visit is lower. The composition of services varies with SES, where patients with low education and African or Asian ethnicity receive more medical tests but shorter consultations, whereas patients with low income receive both shorter consultations and fewer tests. Thus, our results show that GPs differentiate services according to SES, but give no clear evidence for a social gradient in health care provision

Factors Influencing Corn Fungicide Treatment Decisions

Fungal disease management in U.S. corn production has undergone a major shift in the last 2 decades. The decision to apply fungicide, a management practice that was once rarely considered, is now contemplated annually by many U.S. corn producers. We investigate potential factors underlying the fungicide treatment decision. We use economics, agronomy, and plant pathology literature to develop a conceptual model of the fungicide treatment decision and test the model using a survey of Midwest corn producers. We find the treatment decision is positively related to perceived economic gains, but heuristic factors also have a strong influence

Factors Affecting Dental Restorative Treatment Decisions

Dental caries is a dynamic process rather than a diagnosis. It is therefore inappropriate to cite an exact 'threshold' at which interventive operative dental care becomes the 'correct' treatment option. This thesis explored this problem by applying decision theory to one diagnostic test for caries - namely the bitewing radiograph. Fifteen 'mock' dentitions were assembled, using materials of similar radiodensity to oral structures. A number of cariously involved teeth were included in these dentitions. Radiographs were taken using a standardised technique to ensure that the quality and density of the simulated radiographs were as similar as possible to those taken 'in vivo'. Twenty dental practitioners each made 360 treatment decisions based on these bitewing radiographs. Subsequently the teeth were serially sectioned, examined histologically, and the extent of any caries in each tooth was recorded and correlated with the visual appearance of the tooth surfaces. The dentists' decisions were then subjected to Receiver Operator Characteristic (ROC) and Kappa analysis. The work described also explored the value placed on various tooth-states by the population. By using the available literature and the results of the two studies described above, a decision tree was constructed which permitted examination of the expected values of treatment decisions. This decision analysis allowed recommendations to be made concerning the setting of treatment thresholds. The first part of the study showed that the microscopic, radiographic and visual appearances of a tooth were not always directly related to one another. The analysis of the dentists' decisions indicated that individual practitioners have differing views about the importance of sensitivity and specificity, and therefore have different thresholds at which they institute treatment. These values and attitudes influenced the treatment decisions made to a greater extent than the dentists' views about the depth of lesion needing restoration. The decision analysis indicated that, for the sample populations of dentists and patients investigated, the detectability of caries on bitewing radiographs was not great enough to warrant their routine use as diagnostic tools. The treatment thresholds held by the group of dentists in the study were inappropriate in relation to the utilities for dental health held by the population examined. This study has highlighted the importance of three methods of evaluating diagnostic tests. It has shown that the values dentists place on the outcomes of their decisions affect their treatment thresholds more profoundly than lesion depth. Therefore restorative treatment thresholds should be reviewed and appropriate training given so that dental diagnostic skills are improved and clinical decisions made according to the values that patients hold

The road to precision oncology

The ultimate goal of precision medicine is to use population-based molecular, clinical and other data to make individually tailored clinical decisions for patients, although the path to achieving this goal is not entirely clear. A new study shows how knowledge banks of patient data can be used to make individual treatment decisions in acute myeloid leukemia

Factors that Influence Providers’ Pain Treatment Decisions

poster abstractMedical and non-medical factors influence providers’ pain treatment decisions. Among these, patient demographic characteristics and substance use have received particular attention. However, few empirical studies have examined the specific factors providers rely on for their pain treatment decisions. This study employed lens model methodology to examine the factors that providers reportedly used, actually used, and would have used (if available) to make pain treatment decisions. We hypothesized that: (1) providers would rate patients’ pain history and description of pain as the most influential factors provided in the clinical vignettes, and (2) providers would rate patients’ substance use history as the most important factor not provided in the vignettes. 100 providers viewed 16 computer-simulated patients; each included a picture with accompanying text describing the patient’s medical condition. After making multi-modal treatment ratings for each patient, providers indicated the factors they used to make treatment decisions and the factors they would have used (if available) to make decisions. Results indicated that most providers reported being influenced by patients’ pain histories (98%) and descriptions (96%), whereas fewer reported using patients' movement (75%) or demographic characteristics (62%). Providers reported that they wanted additional information on patients’ treatment histories (98%), current/average pain (96%), and drug use (94%) to guide their decisions. Exploratory analyses indicated that, compared to providers who were not statistically influenced by patient demographics, a slightly greater proportion of providers who were statistically influenced by patient demographics wanted additional information about patients’ alcohol use to inform their decisions, χ2 (1) = 3.09, p = .08. These results suggest that providers prioritize both objective and subjective information about patients’ pain conditions, as well as patients’ substance use behaviors, when making treatment decisions. These findings have important implications for pain management and may lead to improved patient safety and care

Cost-effectiveness of noninvasive liver fibrosis tests for treatment decisions in patients with chronic hepatitis C

The cost-effectiveness of noninvasive tests (NITs) as alternatives to liver biopsy is unknown. We compared the cost-effectiveness of using NITs to inform treatment decisions in adult patients with chronic hepatitis C (CHC). We conducted a systematic review and meta-analysis to calculate the diagnostic accuracy of various NITs using a bivariate random-effects model. We constructed a probabilistic decision analytical model to estimate health care costs and outcomes (quality-adjusted life-years; QALYs) using data from the meta-analysis, literature, and national UK data. We compared the cost-effectiveness of four treatment strategies: testing with NITs and treating patients with fibrosis stage ≥F2; testing with liver biopsy and treating patients with ≥F2; treat none; and treat all irrespective of fibrosis. We compared all NITs and tested the cost-effectiveness using current triple therapy with boceprevir or telaprevir, but also modeled new, more-potent antivirals. Treating all patients without any previous NIT was the most effective strategy and had an incremental cost-effectiveness ratio (ICER) of £9,204 per additional QALY gained. The exploratory analysis of currently licensed sofosbuvir treatment regimens found that treat all was cost-effective, compared to using an NIT to decide on treatment, with an ICER of £16,028 per QALY gained. The exploratory analysis to assess the possible effect on results of new treatments, found that if SVR rates increased to >90% for genotypes 1-4, the incremental treatment cost threshold for the "treat all" strategy to remain the most cost-effective strategy would be £37,500. Above this threshold, the most cost-effective option would be noninvasive testing with magnetic resonance elastography (ICER=£9,189). Conclusions: Treating all adult patients with CHC, irrespective of fibrosis stage, is the most cost-effective strategy with currently available drugs in developed countries. © 2014 The Authors