Context. Time preference (how preference for an outcome changes depending on when the outcome occurs) affects clinical decisions, but little is known about determinants of time preferences in clinical settings. Objectives. To determine whether information about mean population time preferences for specific health states can be easily assessed, whether mean time preferences are constant across different diseases, and whether under certain circumstances substantial fractions of the patient population make choices that are consistent with a negative time preference. Design. Self-administered survey. Setting. Family physician waiting rooms in four states. Pa tients. A convenience sample of 169 adults. Intervention. Subjects were presented five clinical vignettes. For each vignette the subject chose between interventions maximizing a present and a future health outcome. The options for individual vignettes varied among the patients so that a distribution of responses was obtained across the population of patients. Main outcome measure. Logistic regression was used to estimate the mean preference for each vignette, which was translated into an implicit discount rate for this group of patients. Results. There were marked differences in time preferences for future health outcomes based on the five vignettes, ranging from a negative to a high positive (116%) discount rate. Conclusions. The study provides empirical evidence that time preferences for future health outcomes may vary substantially among disease conditions. This is likely because the vignettes evoked different rationales for time preferences. Time preference is a critical element in patient decision making and cost-effectiveness research, and more work is necessary to improve our understanding of patient preferences for future health outcomes. Key words: time factors ; models, psychological; attitude to health; outcome assessment (health care). (Med Decis Making 2000;20:263-270)
The understanding and correct application of cancer screening guidelines is an important aspect of early cancer detection. Prior reports have indicated deficiencies in physicians' knowledge of the subject, promoting various educational activities aimed at primary care physicians. By using an interactive computer program to assess knowledge of the American Cancer Society cancer screening guidelines in a group of 306 family physicians, we found that knowledge of this subject continues to leave room for improvement.
Journal Article Factors Associated with Paradoxical Survival at Higher Blood Pressures in the Very Old Get access Robert D. Langer, Robert D. Langer From the Department of Community and Family Medicine, University of California, San Diego, School of Medicine, La Jolla, CA Reprint requests to Dr. Robert D. Langer, Department of Community and Family Medicine, M-007, 9500 Gilman Drive, University of California, San Diego, La Jolla, CA 92093-0607. Search for other works by this author on: Oxford Academic PubMed Google Scholar Theodore G. Ganiats, Theodore G. Ganiats From the Department of Community and Family Medicine, University of California, San Diego, School of Medicine, La Jolla, CA Search for other works by this author on: Oxford Academic PubMed Google Scholar Elizabeth Barrett-Connor Elizabeth Barrett-Connor From the Department of Community and Family Medicine, University of California, San Diego, School of Medicine, La Jolla, CA Search for other works by this author on: Oxford Academic PubMed Google Scholar American Journal of Epidemiology, Volume 134, Issue 1, 1 July 1991, Pages 29–38, https://doi.org/10.1093/oxfordjournals.aje.a115990 Published: 01 July 1991 Article history Received: 22 August 1990 Accepted: 18 February 1991 Published: 01 July 1991
PURPOSE The purpose of this study was to describe clinical encounters in primary care research networks and compare them with those of the National Ambulatory Medical Care Survey (NAMCS). METHODS Twenty US primary care research networks collected data on clinicians and patient encounters using the Primary Care Network Survey (PRINS) Clinician Interview (PRINS-1) and Patient Record (PRINS-2), which were newly developed based on NAMCS tools. Clinicians completed a PRINS-1 about themselves and a PRINS-2 for each of 30 patient visits. Data included patient characteristics; reason for the visit, diagnoses, and services ordered or performed. We compared PRINS data with data obtained from primary care physicians during 5 cycles of NAMCS (1997–2001). Data were weighted; PRINS reflects participating networks and NAMCS provides national estimates. RESULTS By discipline, 89% of PRINS clinicians were physicians, 4% were physicians in residency training, 5% were advanced practice nurses/nurse-practitioners, and 2% were physician's assistants. The majority (53%) specialized in pediatrics (34% specialized in family medicine, 9% in internal medicine, and 4% in other specialties). All NAMCS clinicians were physicians, with 20% specializing in pediatrics. When NAMCS and PRINS visits were compared, larger proportions of PRINS visits involved preventive care and were made by children, members of minority racial groups, and individuals who did not have private health insurance. A diagnostic or other assessment service was performed for 99% of PRINS visits and 76% of NAMCS visits (95% confidence interval, 74.9%–78.0%). A preventive or counseling/education service was provided at 64% of PRINS visits and 37% of NAMCS visits (95% confidence interval, 35.1%–38.0%). CONCLUSIONS PRINS presents a view of diverse primary care visits and differs from NAMCS in its methods and findings. Further examinations of PRINS data are needed to assess their usefulness for describing encounters that occur in primary care research networks.
This guideline provides evidence-based recommendations to manage diffuse acute otitis externa (AOE), defined as generalized inflammation of the external ear canal, which may also involve the pinna or tympanic membrane. The primary purpose is to promote appropriate use of oral and topical antimicrobials and to highlight the need for adequate pain relief.In creating this guideline, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) selected a development group representing the fields of otolaryngology-head and neck surgery, pediatrics, family medicine, infectious disease, internal medicine, emergency medicine, and medical informatics. The guideline was created with the use of an explicit, a priori, evidence-based protocol.The group made a strong recommendation that management of AOE should include an assessment of pain, and the clinician should recommend analgesic treatment based on the severity of pain. The group made recommendations that clinicians should: 1) distinguish diffuse AOE from other causes of otalgia, otorrhea, and inflammation of the ear canal; 2) assess the patient with diffuse AOE for factors that modify management (nonintact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state, prior radiotherapy); and 3) use topical preparations for initial therapy of diffuse, uncomplicated AOE; systemic antimicrobial therapy should not be used unless there is extension outside of the ear canal or the presence of specific host factors that would indicate a need for systemic therapy. The group made additional recommendations that: 4) the choice of topical antimicrobial therapy of diffuse AOE should be based on efficacy, low incidence of adverse events, likelihood of adherence to therapy, and cost; 5) clinicians should inform patients how to administer topical drops, and when the ear canal is obstructed, delivery of topical preparations should be enhanced by aural toilet, placing a wick, or both; 6) when the patient has a tympanostomy tube or known perforation of the tympanic membrane, the clinician should prescribe a nonototoxic topical preparation; and 7) if the patient fails to respond to the initial therapeutic option within 48 to 72 hours, the clinician should reassess the patient to confirm the diagnosis of diffuse AOE and to exclude other causes of illness. And finally, the panel compiled a list of research needs based on limitations of the evidence reviewed.This clinical practice guideline is not intended as a sole source of guidance in evaluating patients with AOE. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all individuals with this condition and may not provide the only appropriate approach to the diagnosis and management of this problem.This is the first, explicit, evidence-based clinical practice guideline on acute otitis externa, and the first clinical practice guideline produced independently by the AAO-HNSF.
In 2016, the Second Panel on Cost-effectiveness in Health and Medicine updated the seminal work of the original panel from 2 decades earlier. The Second Panel had an opportunity to reflect on the evolution of cost-effectiveness analysis (CEA) and to provide guidance for the next generation of practitioners and consumers. In this article, we present key topics for future research and policy.During the course of its deliberations, the Second Panel discussed numerous topics for advancing methods and for improving the use of CEA in decision making. We identify and consider 7 areas for which the panel believes that future research would be particularly fruitful. In each of these areas, we highlight outstanding research needs. The list is not intended as an exhaustive inventory but rather a set of key items that surfaced repeatedly in the panel's discussions. In the online Appendix , we also list and expound briefly on 8 other important topics.We highlight 7 key areas: CEA and perspectives (determining, valuing, and summarizing elements for the analysis), modeling (comparative modeling and model transparency), health outcomes (valuing temporary health and path states, as well as health effects on caregivers), costing (a cost catalogue, valuing household production, and productivity effects), evidence synthesis (developing theory on learning across studies and combining data from clinical trials and observational studies), estimating and using cost-effectiveness thresholds (empirically representing 2 broad concepts: opportunity costs and public willingness to pay), and reporting and communicating CEAs (written protocols and a quality scoring system).Cost-effectiveness analysis remains a flourishing and evolving field with many opportunities for research. More work is needed on many fronts to understand how best to incorporate CEA into policy and practice.
