Why Changing the Way People Make Decisions. Rafael Alfonso-Cristancho, MD, MSc,

Transcription

1 Why Changing the Way People Make Decisions Rafael Alfonso-Cristancho, MD, MSc,

2 How people make decisions? Rationally Emotionally

3 How people make decisions? Rationally Emotionally

4 How people make decisions? Rationally

5 Basic Principles Making decision requires trading off one goal against another (opportunity cost) A rational decision-maker takes an action if and only if the benefit of the action exceeds the cost Since individuals make decisions by comparing costs or benefits, their behavior may change when the costs or benefits change All of the above should work if we have perfect information (no uncertainty) 5

6 The Health Technology Value Plane + Costs Existing treatment dominates New treatment more effective but more costly - Effective C + Effective New treatment less costly but less effective New treatment dominates - Costs

7 HTA Appraisal Process in Health Plans New Technology Product Is it more effective? Yes Is it safer? Yes Does it offer improved value? Yes Are there other therapeutically comparable products? Yes No No No No Nonpreferred Preferred Prefer most cost-effective

8 Pervasiveness of Uncertainty Medical Technologies are licensed and marketed under conditions of uncertainty Uncertainty about efficacy (heterogeneity of treatment benefit) Uncertainty about effectiveness in real world Uncertainty about risks/harms Uncertainty about the outcomes of models, including links between surrogate markers and long-term outcomes Uncertainty about cost-effectiveness Uncertainty about budgetary impact

9 How people make decisions? Emotionally

10 Principles Behavioral economics does not assume that people are rational Framing of information can bias choice in systematic and predicted ways (Loss aversion) Choice architecture and Heuristics (choice overload, compromise effect, feedback) Pro-social behavior (status, self-image) Goal setting/time inconsistency Incentives (reprocity, competition, certainty effect) 10

11 The Xerox Machine % allowed cutting the line 100% 80% 60% 40% 20% 0% 60% Excuse me, I have five pages. May I use the Xerox machine?" 94% 93% "Excuse me, I have five Excuse me, I have five pages. May I use the pages. May I use the Xerox machine because Xerox machine because I I'm in a rush?" have to make some copies?" Benzion Chanowitz and Arthur Blank

12 Teachers and Incentives $4,000 up front, but told they'd have to return the money if their students didn't show academic improvement $8, twice as much -- but only after student's grades came in

13 Basic familiarity with probability Imagine that we flip a fair coin 1,000 times. What is your best guess about how many times the coin would come up heads in 1,000 flips? times out of 1, % answered incorrectly. Schwartz L et al, Annals of Internal Medicine, 1997, 127:

14 Convert percentage to proportion In the BIG BUCKS LOTTERY, the chance of winning a $10 prize is 1%. What is your best guess about how many people would win a $10 prize if 1000 people each buy a single ticket to BIG BUCKS? person(s) out of 1, % answered incorrectly.

15 Convert proportion to percentage In ACME PUBLISHING SWEEPSTAKES, the chance of winning a car is 1 in 1,000. What percent of tickets to ACME PUBLISHING SWEEPSTAKES win a car? % 80% answered incorrectly.

16 How people make decisions? Rationally Emotionally

17 Bariatric Surgery per 100,000 Medicare Enrollees (Year: ; Region Level: HRR) 17

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19 Interventions

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23 NOW IN CLINICAL PRACTICE

24 How do people make decisions? Understand the probabilities of various outcomes Be clear about what you value Be capable of making a choice

25 Adjuncts to counseling Inform Clarify preferences Prepare Patient decision aids Patients who use decision aids Have higher knowledge Are more involved in decision making Experience less decisional conflict Stacey D, et al, Cochrane Library 2011

26 Measurement How would you evaluate whether patients are making good decisions?

27 Measurement approaches Process Patient report of the interaction Provider report of the interaction Direct observation

28 Personal states Measurement approaches Outcomes Decisional Conflict Scale (O Connor) Satisfaction with Decisions (Holmes-Rovner) Decisional Regret (Brehaut) Knowledge Actions Adherence Treatment choice

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30 Control Preferences Scale

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32 Thank you Comments or