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Finocchiaro Castro M, Lisi D, Romeo D. Experimental evidence on the role of shared protocols as coordination device on clinical best practices. Sci Rep 2024; 14:9363. [PMID: 38654112 DOI: 10.1038/s41598-024-60186-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 04/19/2024] [Indexed: 04/25/2024] Open
Abstract
Our experiment assesses the level of coordination on clinical best practice among physicians and investigates whether the release of guidelines helps in supporting coordination. Based on three clinical vignettes using current national guidelines, physicians evaluate the appropriateness of each of the proposed courses of action. Afterwards, physicians are allowed to ask which action corresponds to national guidelines and change their ratings, if desired. On average, slightly more than half of the sample coordinated on appropriateness evaluations. Empirical analysis indicates that several organizational and individual variables influence the level of coordination. Additionally, the release of national guidelines improved both the level of conformity and coordination. Our findings suggest changes in implementation practices to increase the impact of these shared protocols in the health field.
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Affiliation(s)
- Massimo Finocchiaro Castro
- Department of Law, Economics and Social Science, Mediterranean University of Reggio Calabria, Reggio Calabria, Italy
- Health Econometrics and Data Group, University of York, York, UK
- Institute for Corruption Studies, Illinois State University, Normal, USA
| | - Domenico Lisi
- Health Econometrics and Data Group, University of York, York, UK.
- Department of Economics and Business, University of Catania, Catania, Italy.
| | - Domenica Romeo
- Health Econometrics and Data Group, University of York, York, UK
- Department of Economics and Business, University of Catania, Catania, Italy
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2
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Levkovich I, Elyoseph Z. Identifying depression and its determinants upon initiating treatment: ChatGPT versus primary care physicians. Fam Med Community Health 2023; 11:e002391. [PMID: 37844967 PMCID: PMC10582915 DOI: 10.1136/fmch-2023-002391] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Abstract
OBJECTIVE To compare evaluations of depressive episodes and suggested treatment protocols generated by Chat Generative Pretrained Transformer (ChatGPT)-3 and ChatGPT-4 with the recommendations of primary care physicians. METHODS Vignettes were input to the ChatGPT interface. These vignettes focused primarily on hypothetical patients with symptoms of depression during initial consultations. The creators of these vignettes meticulously designed eight distinct versions in which they systematically varied patient attributes (sex, socioeconomic status (blue collar worker or white collar worker) and depression severity (mild or severe)). Each variant was subsequently introduced into ChatGPT-3.5 and ChatGPT-4. Each vignette was repeated 10 times to ensure consistency and reliability of the ChatGPT responses. RESULTS For mild depression, ChatGPT-3.5 and ChatGPT-4 recommended psychotherapy in 95.0% and 97.5% of cases, respectively. Primary care physicians, however, recommended psychotherapy in only 4.3% of cases. For severe cases, ChatGPT favoured an approach that combined psychotherapy, while primary care physicians recommended a combined approach. The pharmacological recommendations of ChatGPT-3.5 and ChatGPT-4 showed a preference for exclusive use of antidepressants (74% and 68%, respectively), in contrast with primary care physicians, who typically recommended a mix of antidepressants and anxiolytics/hypnotics (67.4%). Unlike primary care physicians, ChatGPT showed no gender or socioeconomic biases in its recommendations. CONCLUSION ChatGPT-3.5 and ChatGPT-4 aligned well with accepted guidelines for managing mild and severe depression, without showing the gender or socioeconomic biases observed among primary care physicians. Despite the suggested potential benefit of using atificial intelligence (AI) chatbots like ChatGPT to enhance clinical decision making, further research is needed to refine AI recommendations for severe cases and to consider potential risks and ethical issues.
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Affiliation(s)
| | - Zohar Elyoseph
- Department of Psychology and Educational Counseling, Max Stern Academic College Of Emek Yezreel, Emek Yezreel, Israel
- Department of Brain Sciences, Imperial College London, London, UK
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3
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Ajuwon BI, Richardson A, Roper K, Lidbury BA. Clinical Validity of a Machine Learning Decision Support System for Early Detection of Hepatitis B Virus: A Binational External Validation Study. Viruses 2023; 15:1735. [PMID: 37632077 PMCID: PMC10458613 DOI: 10.3390/v15081735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
HepB LiveTest is a machine learning decision support system developed for the early detection of hepatitis B virus (HBV). However, there is a lack of evidence on its generalisability. In this study, we aimed to externally assess the clinical validity and portability of HepB LiveTest in predicting HBV infection among independent patient cohorts from Nigeria and Australia. The performance of HepB LiveTest was evaluated by constructing receiver operating characteristic curves and estimating the area under the curve. Delong's method was used to estimate the 95% confidence interval (CI) of the area under the receiver-operating characteristic curve (AUROC). Compared to the Australian cohort, patients in the derivation cohort of HepB LiveTest and the hospital-based Nigerian cohort were younger (mean age, 45.5 years vs. 38.8 years vs. 40.8 years, respectively; p < 0.001) and had a higher incidence of HBV infection (1.9% vs. 69.4% vs. 57.3%). In the hospital-based Nigerian cohort, HepB LiveTest performed optimally with an AUROC of 0.94 (95% CI, 0.91-0.97). The model provided tailored predictions that ensured most cases of HBV infection did not go undetected. However, its discriminatory measure dropped to 0.60 (95% CI, 0.56-0.64) in the Australian cohort. These findings indicate that HepB LiveTest exhibits adequate cross-site transportability and clinical validity in the hospital-based Nigerian patient cohort but shows limited performance in the Australian cohort. Whilst HepB LiveTest holds promise for reducing HBV prevalence in underserved populations, caution is warranted when implementing the model in older populations, particularly in regions with low incidence of HBV infection.
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Affiliation(s)
- Busayo I. Ajuwon
- National Centre for Epidemiology and Population Health, ANU College of Health and Medicine, The Australian National University, Acton, Canberra, ACT 2601, Australia; (K.R.); (B.A.L.)
- Department of Biosciences and Biotechnology, Faculty of Pure and Applied Sciences, Kwara State University, Malete 241103, Nigeria
| | - Alice Richardson
- Statistical Support Network, The Australian National University, Acton, Canberra, ACT 2601, Australia;
| | - Katrina Roper
- National Centre for Epidemiology and Population Health, ANU College of Health and Medicine, The Australian National University, Acton, Canberra, ACT 2601, Australia; (K.R.); (B.A.L.)
| | - Brett A. Lidbury
- National Centre for Epidemiology and Population Health, ANU College of Health and Medicine, The Australian National University, Acton, Canberra, ACT 2601, Australia; (K.R.); (B.A.L.)
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4
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Abstract
BACKGROUND Clinical prediction models should be validated before implementation in clinical practice. But is favorable performance at internal validation or one external validation sufficient to claim that a prediction model works well in the intended clinical context? MAIN BODY We argue to the contrary because (1) patient populations vary, (2) measurement procedures vary, and (3) populations and measurements change over time. Hence, we have to expect heterogeneity in model performance between locations and settings, and across time. It follows that prediction models are never truly validated. This does not imply that validation is not important. Rather, the current focus on developing new models should shift to a focus on more extensive, well-conducted, and well-reported validation studies of promising models. CONCLUSION Principled validation strategies are needed to understand and quantify heterogeneity, monitor performance over time, and update prediction models when appropriate. Such strategies will help to ensure that prediction models stay up-to-date and safe to support clinical decision-making.
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Attema AE, Galizzi MM, Groß M, Hennig-Schmidt H, Karay Y, L'Haridon O, Wiesen D. The formation of physician altruism. JOURNAL OF HEALTH ECONOMICS 2023; 87:102716. [PMID: 36603361 DOI: 10.1016/j.jhealeco.2022.102716] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/21/2022] [Accepted: 11/29/2022] [Indexed: 06/17/2023]
Abstract
We study how patient-regarding altruism is formed by medical education. We elicit and structurally estimate altruistic preferences using experimental data from a large sample of medical students (N = 733) in Germany at different progress stages in their studies. The estimates reveal substantial heterogeneity in altruistic preferences of medical students. Patient-regarding altruism is highest for freshmen, significantly declines for students in the course of medical studies, and tends to increase again for last year students, who assist in clinical practice. Also, patient-regarding altruism is higher for females and positively associated to general altruism. Altruistic medical students have gained prior practical experience in healthcare, have lower income expectations, and are more likely to choose surgery and pediatrics as their preferred specialty.
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Affiliation(s)
- Arthur E Attema
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, The Netherlands.
| | - Matteo M Galizzi
- Department of Psychological and Behavioural Science, London School of Economics and Political Science, UK.
| | - Mona Groß
- Department of Business Administration and Healthcare Management, University of Cologne, Germany.
| | - Heike Hennig-Schmidt
- Laboratory for Experimental Economics, Department of Economics, University of Bonn, Germany.
| | | | - Olivier L'Haridon
- Center for Research in Economics and Management (CREM), University of Rennes 1, France; Institut Universitaire de France, France.
| | - Daniel Wiesen
- Department of Business Administration and Healthcare Management, University of Cologne, Germany.
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Andersen M, Pant A. Effects of utilization management on health outcomes: evidence from urinary tract infections and community-acquired pneumonia. Expert Rev Pharmacoecon Outcomes Res 2022; 22:981-992. [PMID: 35427203 PMCID: PMC9463087 DOI: 10.1080/14737167.2022.2067529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 04/14/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Utilization management policies are pervasive in the Medicare Part D program. We assess the effect of utilization management restrictions in the Medicare Part D program on the quality of care in two clinical areas - community-acquired pneumonia (CAP) and urinary tract infections (UTI). METHODS In this study, we identified new cases of CAP and UTI from Medicare claims data from 2010 to 2016. We assessed the relationship between exposure to utilization management for antibiotic medications suitable for treating these conditions and adverse health outcomes, based on the Agency for Healthcare Research and Quality prevention quality indicators. RESULTS We identified 147,526 cases of CAP and 632,407 UTI cases in our data. In these samples, the adverse event rate varied from 3.6 to 5.7%. The probability of an adverse event increased by 0.75 (p = 0.061) percentage points for each ten percentage point increase in exposure to quantity limits (one form of utilization management) among people with CAP. There was no relationship between utilization management and adverse events in the UTI cohort. CONCLUSIONS In some circumstances, exposure to utilization management policies-particularly quantity limits-may adversely affect health.
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Affiliation(s)
- Martin Andersen
- Department of Economics, University of North Carolina at Greensboro, Greensboro, NC, USA
| | - Anurag Pant
- Department of Economics, University of North Carolina at Greensboro, Greensboro, NC, USA
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7
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Birkner B, Blankart KE. The Effect of Biosimilar Prescription Targets for Erythropoiesis-Stimulating Agents on the Prescribing Behavior of Physicians in Germany. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1528-1538. [PMID: 35525830 DOI: 10.1016/j.jval.2022.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 02/23/2022] [Accepted: 03/03/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES This study aimed to aid decision makers by analyzing the impact of introducing biosimilar prescription targets on physician prescribing behavior in the prescription of biologic erythropoiesis-stimulating agents in Germany. METHODS We combined secondary data of regional level biosimilar prescription targets and secondary data of routinely collected claims data of dispensed prescriptions by physicians operating within the statutory health insurance system in ambulatory care across 7 German regions from 2009 to 2015. Two-way fixed-effects regression analysis was used to identify the average treatment effect of introducing biosimilar prescription targets at the physician level. The main outcome of interest was the share of biosimilar prescriptions on all prescriptions within the substance group. We compared 6 regions that introduced biosimilar prescription targets with 1 region without any prescription target policy. RESULTS Introducing biosimilar prescription targets increased the average share of biosimilars between 6 percentage points (P < .05) in Hamburg and up to 20 percentage points (P < .001) in Saxony-Anhalt. Stratification of specialists by prescription volume and adoption status indicated heterogeneous effects. We identified similar but higher effects for high-volume prescribers. Disentangling of effects with regard to the composition of biosimilar share suggested that the increase in biosimilar share was driven by increased biosimilar use accompanied by a nonsignificant decrease in original biologics prescriptions. CONCLUSIONS Prescription targets to alter physician prescribing behavior meet their intended goals by increasing biosimilar share. Physicians partly responded to the policy by decreasing overall prescriptions of the target substance. Prescription targets might be a useful tool, but decision makers need to consider all aspects of potential responses.
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Affiliation(s)
- Benjamin Birkner
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany.
| | - Katharina E Blankart
- Faculty of Business Administration and Economics/CINCH Health Economics Research Center, Universität Duisburg-Essen, Duisburg, Germany
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Dubois P, Tunçel T. Identifying the effects of scientific information and recommendations on physicians' prescribing behavior. JOURNAL OF HEALTH ECONOMICS 2021; 78:102461. [PMID: 33991803 PMCID: PMC8384687 DOI: 10.1016/j.jhealeco.2021.102461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 06/12/2023]
Abstract
We investigate how the prescribing behavior of physicians reacts to scientific information and recommendations released by public authorities. Taking the example of antidepressant drugs, we use French panel data on exhaustive prescriptions made by a representative sample of general practitioners to more than 110,000 depressed patients between 2000 and 2008. New results revealing an increase in suicidal thinking among children taking selective serotonin reuptake inhibitors (SSRIs) were reported in 2004 and prompted the release of new guidelines by public health authorities. We identify the effect of this unexpected warning on physicians' drug choices while addressing the possibility that patients heterogeneity may be correlated with unobserved physician characteristics. While the warning decreased the average probability of prescribing SSRIs, we find that physicians' responses to the warning were very heterogeneous and larger if the physician had a higher preference for prescribing SSRIs before the warning.
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Affiliation(s)
- Pierre Dubois
- Toulouse School of Economics, Université de Toulouse Capitole, Toulouse, France.
| | - Tuba Tunçel
- Department of Applied Economics, HEC Montreal, Canada.
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9
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Gender differences in physician decisions to adopt new prescription drugs. Soc Sci Med 2021; 277:113886. [PMID: 33882439 DOI: 10.1016/j.socscimed.2021.113886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/19/2021] [Accepted: 03/26/2021] [Indexed: 11/20/2022]
Abstract
Physician adoption of new technologies is a key issue for population health and the sustainability of the healthcare system. This paper explores gender differences in general practitioners' (GPs) adoption of new oral anticoagulants. We combine detailed individual data on physician and practice style characteristics from the Medicine in Australia: Balancing Employment and Life (MABEL) panel survey of Australian physicians with administrative prescribing data from the Australian Pharmaceutical Benefits Scheme (PBS) and the Medicare Benefits Schedule (MBS) for the period January 1, 2012 and December 31, 2015. After adjusting for various factors proposed in the literature as drivers of this gender gap, in addition to risk preferences and personality traits, we find a large statistical gender difference in the speed of adoption with men being faster than women in uptake. However, conditional on having prescribed for the first time, female and male GPs differ only slightly in the intensity of use of these new drugs. We show that the gender gap depends on the measure of uptake and discuss possible channels that could be driving the relatively large gender difference that remains in the speed of adoption.
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10
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Qin X, Huckfeldt P, Abraham J, Yee D, Virnig BA. Generic entry of aromatase inhibitors and pharmaceutical access: Initiation of hormonal therapy, timeliness of initiation, and drug choice. Res Social Adm Pharm 2020; 17:1588-1595. [PMID: 33358400 DOI: 10.1016/j.sapharm.2020.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/27/2020] [Accepted: 12/13/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The trade-offs between innovation and pharmaceutical access are central to the policy debate on drug pricing. High prices may limit access, result in medication underuse, and negatively affect outcomes. Generic drugs make treatments more affordable. Prior research measured access as utilization without a defined population that should receive certain drugs, it is unknown whether generic entry reduces underuse and thus improves access. OBJECTIVES To measure changes in access (use, timeliness) with the introduction of three generic aromatase inhibitors (AIs, oral breast cancer drugs) between June 2010 and June 2011. METHODS This population-based study included 93,650 older (65+) women diagnosed with hormone receptor-positive breast cancer between 2007 and 2013 in the Surveillance, Epidemiology and End Results-Medicare linked database. We examined changes in access with generic entry for initiation of any adjuvant hormonal therapy drug (AIs or tamoxifen) within one year of diagnosis, time from diagnosis to initiation, and choice of initial therapy. RESULTS Among 93,650 newly diagnosed breast cancer cases, 67,372 initiated one of the four drugs. With generic entry, initiation rates increased from 69.5% to 74.3%, but non-initiation remained high (up to 25.7%). After controlling for demographics, clinical factors, and insurance coverage, the probability of initiation increased by 4.6 percentage points (P < 0.001, 95%CI: [4.1,5.2]) after generic entry. With generic entry, estimated time to initiation decreased by 0.3 months (P < 0.001, 95%CI: [0.2,0.3]) from 4.1 months, and the probability of choosing AIs over tamoxifen increased by 5.9 percentage points (P < 0.001, 95%CI: [5.3,6.5]). Patterns did not substantially differ by level of cost-sharing. CONCLUSIONS Generic entry of AIs was associated with increased probability of receiving recommended treatments, timeliness of treatment, and the probability of receiving clinically preferred treatments. Price changes with generic entry only partially explained these improvements. High non-initiation rates after generic entry suggest prices are not the sole determinant of access.
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Affiliation(s)
- Xuanzi Qin
- Division of Health Policy & Management, School of Public Health, University of Minnesota, 420 Delaware St. S.E, Minneapolis, MN, 55455, USA.
| | - Peter Huckfeldt
- Division of Health Policy & Management, School of Public Health, University of Minnesota, 420 Delaware St. S.E, Minneapolis, MN, 55455, USA
| | - Jean Abraham
- Division of Health Policy & Management, School of Public Health, University of Minnesota, 420 Delaware St. S.E, Minneapolis, MN, 55455, USA
| | - Douglas Yee
- Masonic Cancer Center, University of Minnesota, 425 E. River Pkwy, Minneapolis, MN, 55455, USA
| | - Beth A Virnig
- Division of Health Policy & Management, School of Public Health, University of Minnesota, 420 Delaware St. S.E, Minneapolis, MN, 55455, USA
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Blankart KE, Stargardt T. The impact of drug quality ratings from health technology assessments on the adoption of new drugs by physicians in Germany. HEALTH ECONOMICS 2020; 29 Suppl 1:63-82. [PMID: 32542875 DOI: 10.1002/hec.4108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/03/2020] [Accepted: 03/10/2020] [Indexed: 06/11/2023]
Abstract
Payers are increasingly calling for the value of new drugs to be measured explicitly. We analyze how the availability of drug quality ratings by health technology assessment (HTA) agencies affects the adoption of new drugs by physicians in Germany. We combine data from drug quality ratings, promotional spending, and a physician panel. In a latent utility model, time to adoption is specified as a function of quality rating, promotional spending by manufacturers, and physician-specific variables. As expected, drugs with a positive rating were adopted faster (p < 0.001) than those without. However, our results suggest that it was the publication of the quality rating itself that affected adoption. Indeed, before a quality rating was published, drugs that went on to receive a positive quality rating were not adopted significantly faster than drugs that went on to receive a negative quality rating. In contrast, after the publication of the HTA quality rating, drugs with a positive rating were adopted significantly faster than those without (p < 0.05). The per physician value of a positive quality rating was EUR 393.50. Our results suggest that there are returns from HTAs beyond their use in price negotiations.
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Affiliation(s)
- Katharina Elisabeth Blankart
- Hamburg Center for Health Economics, University of Hamburg, Hamburg, Germany
- CINCH Health Economics Research Center and Faculty of Business Administration and Economics, University of Duisburg-Essen, Essen, Germany
| | - Tom Stargardt
- Hamburg Center for Health Economics, University of Hamburg, Hamburg, Germany
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Cuddy E, Currie J. Treatment of mental illness in American adolescents varies widely within and across areas. Proc Natl Acad Sci U S A 2020; 117:24039-24046. [PMID: 32958646 PMCID: PMC7533674 DOI: 10.1073/pnas.2007484117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Many mental health disorders first manifest in adolescence, and early treatment may affect the course of the disease. Using a large national database of insurance claims, this study focuses on variations in the type of care that adolescent patients receive when they are treated for an initial episode of mental illness. We found large variations in the probability that children receive follow-up care and in the type of follow-up care received across zip codes. We also found large variations in the probability that children receive drug treatments that raise a red flag when viewed through the lens of treatment guidelines: Overall, in the first 3 mo after their initial claim for mental illness, 44.85% of children who receive drug treatment receive benzodiazepines, tricyclic antidepressants, or a drug that is not Food and Drug Administration-approved for their age. On average, these children are 12 y old. While the supply of mental health professionals impacts treatment choices, little of the overall variation is explained by supply-side variables, and at least half of the variation in treatment outcomes occurs within zip codes. These results suggest that other factors, such as physician practice style, may play an important role in the types of treatment that children receive.
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Affiliation(s)
- Emily Cuddy
- Department of Economics, Princeton University, Princeton, NJ 08540
| | - Janet Currie
- Center for Health and Wellbeing, Princeton University, Princeton, NJ 08540
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Nunes A, Trappenberg T, Alda M. The definition and measurement of heterogeneity. Transl Psychiatry 2020; 10:299. [PMID: 32839448 PMCID: PMC7445182 DOI: 10.1038/s41398-020-00986-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 07/21/2020] [Accepted: 08/10/2020] [Indexed: 12/31/2022] Open
Abstract
Heterogeneity is an important concept in psychiatric research and science more broadly. It negatively impacts effect size estimates under case-control paradigms, and it exposes important flaws in our existing categorical nosology. Yet, our field has no precise definition of heterogeneity proper. We tend to quantify heterogeneity by measuring associated correlates such as entropy or variance: practices which are akin to accepting the radius of a sphere as a measure of its volume. Under a definition of heterogeneity as the degree to which a system deviates from perfect conformity, this paper argues that its proper measure roughly corresponds to the size of a system's event/sample space, and has units known as numbers equivalent. We arrive at this conclusion through focused review of more than 100 years of (re)discoveries of indices by ecologists, economists, statistical physicists, and others. In parallel, we review psychiatric approaches for quantifying heterogeneity, including but not limited to studies of symptom heterogeneity, microbiome biodiversity, cluster-counting, and time-series analyses. We argue that using numbers equivalent heterogeneity measures could improve the interpretability and synthesis of psychiatric research on heterogeneity. However, significant limitations must be overcome for these measures-largely developed for economic and ecological research-to be useful in modern translational psychiatric science.
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Affiliation(s)
- Abraham Nunes
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
- Faculty of Computer Science, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Thomas Trappenberg
- Faculty of Computer Science, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Martin Alda
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada.
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Blankart KE, Arndt F. Physician-Level Cost Control Measures and Regional Variation of Biosimilar Utilization in Germany. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17114113. [PMID: 32526943 PMCID: PMC7313006 DOI: 10.3390/ijerph17114113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 11/16/2022]
Abstract
Biologic drugs represent a large and growing portion of health expenditures. Increasing the use of biosimilars is a promising option for controlling spending growth in pharmaceutical care. Amid the considerable uncertainty concerning physicians’ decision to prescribe biosimilars, explicit cost control measures may help increase biosimilar use. We analyze the role of regional cost control measures for biosimilars and their association with physician prescriptions in ambulatory care in Germany. We collect data on cost control measures implemented by German physician associations and national claims data on statutory health insurance covering 2009 to 2015. We perform panel regressions that include time and physician fixed effects to identify the average associations between cost control measures and biosimilar share/use while controlling for unobserved physician heterogeneity, patient structure, and socioeconomic factors. We identify 44 measures (priority prescribing, biosimilar quota) for erythropoiesis-stimulating substances, filgrastim, and somatropin. Estimates of cost control measures and their consequences for biosimilar share and use are heterogeneous by drug, measure type, and physician group. Across specialists, biosimilar quotas accounted for 5.13% to 9.75% of the total average biosimilar share of erythropoiesis-stimulating substances. Explicit quota regulations are more effective than priority prescribing. Regional variation in biosimilar use can be partly attributed to the presence of cost control measures.
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Affiliation(s)
- Katharina E. Blankart
- CINCH—Health Economics Research Center, Faculty of Economics and Business Administration, University of Duisburg-Essen, 45127 Essen, Germany;
- Leibniz Science Campus Ruhr, 45030 Essen, Germany
- Correspondence: ; Tel.: +49-201-183-4403
| | - Friederike Arndt
- CINCH—Health Economics Research Center, Faculty of Economics and Business Administration, University of Duisburg-Essen, 45127 Essen, Germany;
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Currie JM, Macleod WB. UNDERSTANDING DOCTOR DECISION MAKING: THE CASE OF DEPRESSION TREATMENT. ECONOMETRICA : JOURNAL OF THE ECONOMETRIC SOCIETY 2020; 88:847-878. [PMID: 32981946 PMCID: PMC7514077 DOI: 10.3982/ecta16591] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Treatment for depression is complex, requiring decisions that may involve trade-offs between exploiting treatments with the highest expected value and experimenting with treatments with higher possible payoffs. Using patient claims data, we show that among skilled doctors, using a broader portfolio of drugs predicts better patient outcomes, except in cases where doctors' decisions violate loose professional guidelines. We introduce a behavioral model of decision making guided by our empirical observations. The model's novel feature is that the trade-off between exploitation and experimentation depends on the doctor's diagnostic skill. The model predicts that higher diagnostic skill leads to greater diversity in drug choice and better matching of drugs to patients even among doctors with the same initial beliefs regarding drug effectiveness. Consistent with the finding that guideline violations predict poorer patient outcomes, simulations of the model suggest that increasing the number of possible drug choices can lower performance.
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Nunes A, Trappenberg T, Alda M. We need an operational framework for heterogeneity in psychiatric research. J Psychiatry Neurosci 2020; 45:3-6. [PMID: 31845771 PMCID: PMC6919921 DOI: 10.1503/jpn.190198] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Abraham Nunes
- From the Department of Psychiatry (Nunes, Alda) and the Faculty of Computer Science (Trappenberg, Nunes), Dalhousie University, Halifax, NS, Canada
| | - Thomas Trappenberg
- From the Department of Psychiatry (Nunes, Alda) and the Faculty of Computer Science (Trappenberg, Nunes), Dalhousie University, Halifax, NS, Canada
| | - Martin Alda
- From the Department of Psychiatry (Nunes, Alda) and the Faculty of Computer Science (Trappenberg, Nunes), Dalhousie University, Halifax, NS, Canada
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17
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Henderson TA, van Lierop MJ, McLean M, Uszler JM, Thornton JF, Siow YH, Pavel DG, Cardaci J, Cohen P. Functional Neuroimaging in Psychiatry-Aiding in Diagnosis and Guiding Treatment. What the American Psychiatric Association Does Not Know. Front Psychiatry 2020; 11:276. [PMID: 32351416 PMCID: PMC7176045 DOI: 10.3389/fpsyt.2020.00276] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/23/2020] [Indexed: 12/12/2022] Open
Abstract
While early efforts in psychiatry were focused on uncovering the neurobiological basis of psychiatric symptoms, they made little progress due to limited ability to observe the living brain. Today, we know a great deal about the workings of the brain; yet, none of this neurobiological awareness has translated into the practice of psychiatry. The categorical system which dominates psychiatric diagnosis and thinking fails to match up to the real world of genetics, sophisticated psychological testing, and neuroimaging. Nevertheless, the American Psychiatric Association (APA) recently published a position paper stating that neuroimaging provided no benefit to the diagnosis and treatment of psychiatric disorders. Using the diagnosis of depression as a model, we illustrate how setting aside the unrealistic expectation of a pathognomonic "fingerprint" for categorical diagnoses, we can avoid missing the biological and, therefore, treatable contributors to psychopathology which can and are visualized using functional neuroimaging. Infection, toxicity, inflammation, gut-brain dysregulation, and traumatic brain injury can all induce psychiatric manifestations which masquerade as depression and other psychiatric disorders. We review these and provide illustrative clinical examples. We further describe situations for which single photon emission computed tomography (SPECT) and positron emission tomography (PET) functional neuroimaging already meet or exceed the criteria set forth by the APA to define a neuroimaging biomarker, including the differential diagnosis of Alzheimer's disease and other dementias, the differential diagnosis of ADHD, and the evaluation of traumatic brain injury. The limitations, both real and perceived, of SPECT and PET functional neuroimaging in the field of psychiatry are also elaborated. An important overarching concept for diagnostic imaging in all its forms, including functional neuroimaging, is that imaging allows a clinician to eliminate possibilities, narrow the differential diagnosis, and tailor the treatment plan. This progression is central to any medical diagnostic process.
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Affiliation(s)
- Theodore A Henderson
- The Synaptic Space, Inc., Denver, CO, United States.,Neuro-Luminance, Inc., Denver, CO, United States.,Dr. Theodore Henderson, Inc., Denver, CO, United States.,International Society of Applied Neuroimaging, Denver, CO, United States
| | - Muriel J van Lierop
- International Society of Applied Neuroimaging, Denver, CO, United States.,Private Practice, Toronto, ON, Canada
| | - Mary McLean
- International Society of Applied Neuroimaging, Denver, CO, United States.,Private Practice, Toronto, ON, Canada
| | - John Michael Uszler
- International Society of Applied Neuroimaging, Denver, CO, United States.,Nuclear Medicine, Providence St. John's Health Center, Santa Monica, CA, United States.,Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, United States
| | - John F Thornton
- International Society of Applied Neuroimaging, Denver, CO, United States.,Rossiter-Thornton Associates, Toronto, ON, Canada
| | - Yin-Hui Siow
- International Society of Applied Neuroimaging, Denver, CO, United States.,Nuclear Medicine, Southlake Regional Health Centre, Newmarket, ON, Canada
| | - Dan G Pavel
- International Society of Applied Neuroimaging, Denver, CO, United States.,PathFinder Brain SPECT, Deerfield, IL, United States
| | - Joe Cardaci
- International Society of Applied Neuroimaging, Denver, CO, United States.,Fremantle-School of Medicine, University of Notre Dame, Fremantle, WA, Australia.,Diagnostic Nuclear Medicine, Hollywood Private Hospital, Nedlands, WA, Australia.,Consultant Physician, Perth, WA, Australia
| | - Phil Cohen
- International Society of Applied Neuroimaging, Denver, CO, United States.,Nuclear Medicine, Lions Gate Hospital, Vancouver, BC, Canada.,Radiology, University of British Columbia, Vancouver, BC, Canada
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18
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Cutler D, Skinner JS, Stern AD, Wennberg D. Physician Beliefs and Patient Preferences: A New Look at Regional Variation in Health Care Spendingf. AMERICAN ECONOMIC JOURNAL. ECONOMIC POLICY 2019; 11:192-221. [PMID: 32843911 PMCID: PMC7444804 DOI: 10.1257/pol.20150421] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
There is considerable controversy about the causes of regional variations in health care expenditures. Using vignettes from patient and physician surveys linked to fee-for-service Medicare expenditures, this study asks whether patient demand-side factors or physician supply-side factors explain these variations. The results indicate that patient demand is relatively unimportant in explaining variations. Physician organizational factors matter, but the most important factor is physician beliefs about treatment. In Medicare, we estimate that 35 percent of spending for end-of-life care and 12 percent of spending for heart attack patients (and for all enrollees) is associated with physician beliefs unsupported by clinical evidence. (JEL D83, H75, I11, I18).
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Affiliation(s)
- David Cutler
- Cutler: Department of Economics, Harvard University, 230 Littauer Center, 1805 Cambridge Street, Cambridge, MA 02138, and National Bureau of Economic Research; Skinner: Department of Economics, Dartmouth College, Hinman Box 6106, Hanover, NH 03755, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, and National Bureau of Economic Research; Stern: Technology and Operations Management Unit, Harvard Business School, Morgan Hall 433, Boston, MA 02136, and Ariadne Labs at Brigham and Women’s Hospital and the Harvard T. H. Chan School of Public Health; Wennberg: Quartet Health, 114 West 41st Street, New York, NY 10036
| | - Jonathan S. Skinner
- Cutler: Department of Economics, Harvard University, 230 Littauer Center, 1805 Cambridge Street, Cambridge, MA 02138, and National Bureau of Economic Research; Skinner: Department of Economics, Dartmouth College, Hinman Box 6106, Hanover, NH 03755, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, and National Bureau of Economic Research; Stern: Technology and Operations Management Unit, Harvard Business School, Morgan Hall 433, Boston, MA 02136, and Ariadne Labs at Brigham and Women’s Hospital and the Harvard T. H. Chan School of Public Health; Wennberg: Quartet Health, 114 West 41st Street, New York, NY 10036
| | - Ariel Dora Stern
- Cutler: Department of Economics, Harvard University, 230 Littauer Center, 1805 Cambridge Street, Cambridge, MA 02138, and National Bureau of Economic Research; Skinner: Department of Economics, Dartmouth College, Hinman Box 6106, Hanover, NH 03755, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, and National Bureau of Economic Research; Stern: Technology and Operations Management Unit, Harvard Business School, Morgan Hall 433, Boston, MA 02136, and Ariadne Labs at Brigham and Women’s Hospital and the Harvard T. H. Chan School of Public Health; Wennberg: Quartet Health, 114 West 41st Street, New York, NY 10036
| | - David Wennberg
- Cutler: Department of Economics, Harvard University, 230 Littauer Center, 1805 Cambridge Street, Cambridge, MA 02138, and National Bureau of Economic Research; Skinner: Department of Economics, Dartmouth College, Hinman Box 6106, Hanover, NH 03755, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, and National Bureau of Economic Research; Stern: Technology and Operations Management Unit, Harvard Business School, Morgan Hall 433, Boston, MA 02136, and Ariadne Labs at Brigham and Women’s Hospital and the Harvard T. H. Chan School of Public Health; Wennberg: Quartet Health, 114 West 41st Street, New York, NY 10036
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19
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Pinho M, Pinto Borges A, Cookson R. Do Healthcare Professionals have Different Views about Healthcare Rationing than College Students? A Mixed Methods Study in Portugal. Public Health Ethics 2017. [DOI: 10.1093/phe/phx005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Micaela Pinho
- University Portucalense, Research on Economics, Management and Information Technologies - REMIT, Portucalense Institute for Legal Research - IJP and University of Aveiro, Research Unit in Governance, Competitiveness and Public Policies - GOVCOPP
| | - Ana Pinto Borges
- Núcleo de Investigação do ISAG – European Business School, Lusíada University of North
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