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Does order matter when distributing resources? (Jun-03)

Should people with more severe health problems receive state funding for treatment before people with less severe health problems? See how your opinion compares with the opinions of others.

Imagine that you are a government official responsible for deciding how state money is spent on different medical treatments. Your budget is limited so you cannot afford to offer treatment to everyone who might benefit. Right now, you must choose to spend money on one of two treatments.

  • Treatment A treats a life threatening illness. It saves patients' lives and returns them to perfect health after treatment
  • Treatment B treats a different life threatening illness. It saves patients' lives but is not entirely effective and leaves them with paraplegia after treatment. These patients are entirely normal before their illness but after treatment will have paraplegia.

Suppose the state has enough money to offer Treatment A to 100 patients. How many patients would have to offered Treatment B so that you would have difficulty choosing which treatment to offer?

How do your answers compare?

The average person said that it would become difficult to decide which treatment to offer when 1000 people were offered Treatment B.

What if you had made another comparison before the one you just made?

In the study, some people were asked to make a comparison between saving the lives of otherwise-healthy people and saving the lives of people who already had paraplegia. After they made that comparison, they made the comparison you just completed. The average person in that group said it would take 126 people offered Treatment B to make the decision difficult. The differences are shown in the graph below

Why is this important?

The comparison you made is an example of a person tradeoff (PTO). The PTO is one method used to find out the utilities of different health conditions. These utilities are basically measures of the severities of the conditions. More severe conditions have a lower utility, and less severe conditions have a higher utility, on a scale of 0 to 1. Insurance companies, the government, and other organizations use these utilities as a way to decide which group to funnel money into for treatments.

On the surface, it seems like basing the money division on the severity of a condition is a good and fair method, since theoretically the people who are in the greatest need will be treated first. However, the PTO raises issues of fairness and equity that aren't accounted for in other utility elicitation methods like the time tradeoff (TTO) and rating scale (RS).

For example, when asked to decide how many people with paraplegia would have to be saved to equal saving 100 healthy people, many people say 100; that is, they think it is equally important to save the life of someone with paraplegia and a healthy person. Going by values obtained using the TTO or RS, an insurance company may conclude that 160 people with paraplegia (using a utility of .6) would have to be saved to make it equal to saving 100 healthy people. This would mean that less benefit would be gotten by saving someone with paraplegia, and thus they might not cover expenses for lifesaving treatments for people with paraplegia as much as they would for a healthy person. The PTO shows that many people would not agree with doing this, even though their own responses to other utility questions generated the policy in the first place.

For more information see:

Ubel PA, Richardson J, Baron J. Exploring the role of order effects in person trade-off elicitations. Health Policy, 61(2):189-199, 2002.

Is Bill Gates' time worth more than yours? (Jul-03)

Informal caregiving for relatives (parents, grandparents, spouses) can be time consuming. Can we attach dollar value to that time? Is everyone's time worth the same amount?

Imagine that your mother is suffering from moderate dementia and needs assistance with daily activities such as bathing and dressing. You are the only person available to care for her, as you are an only child and your father has passed away. On average, your mother will need about 2 to 3 hours of help per day, or 17 hours per week total.

Assuming that you provide 17 hours of care per week, that means you will provide about 900 hours of care each year. How much money would you say the time you devote to caregiving is worth each year?
 
Now imagine that Bill Gates, the world's richest person, is in the same situation as you. He has to provide 17 hours of care per week to his mother. How do you think the value of the time he spends giving care compares to the value of the time you spend giving care?
 
  • His is worth more
  • His is worth the same amount
  • His is worth less

How do your answers compare?

According to a study done to determine the costs of informal caregiving, the average value of the time spent giving care to someone with moderate dementia was about $7400. This was calculated using an average time of about 900 hours per year, at the mean wage for a home health aide in 1998 of $8.20 per hour.

What if the person you're caring for has less or more severe dementia?

As you might imagine, the cost of informal care differs depending on the severity of dementia. People with mild dementia don't need as much care (8.5 hours per week), and those with severe dementia need much more (41.5 hours per week). The amount of care needed directly impacts the estimated cost of care:

Dementia severity Hours of care per week Estimated cost of informal care
Mild 8.5 $3630
Moderate 17.4 $7420
Severe 41.5 $17,700
Why is this important?

As the Baby Boomer generation ages, the number of people needing informal care is going to increase dramatically. In order to make informed policy decisions regarding care for older people, the government will need an estimate of the value of informal care. A major obstacle to this is that there is no set way for making the estimates.

Earlier, you said that Bill Gate's caregiving time would be worth the same amount as yours. That implies that basing national estimates of caregiving costs on average wages would be the proper way to go about the calculations, since it means everyone's time is equally valuable.

However, some people think that not everyone's time is of equal value. In that case, using average wages to estimate the total cost of caregiving may not lead to an accurate representation. If one group of people is more likely to provide care than another group, then the average value of all caregivers' time may not be the same as the average of all peoples' time. This would possibly lead to an over- or underestimation of caregiving costs, depending on the value of the time of common groups of caregivers. Even without an agreed-upon estimation method, some valuable data can be generated.

The estimation method used in this study likely led to conservative figures, so the true costs of informal caregiving are probably higher than reported here. Even using this conservative method, the costs to society are staggering. The researchers estimated that the cost of informal caregiving for dementia alone in 1998 was $18.6 billion, which is almost two-thirds as much money as that actually spent on paid home care services for all conditions, not just dementia! That figure will grow considerably in the not-so-distant future when the Baby Boomers begin to need caregiving, whether formal or informal, and will likely have a large impact not just on health care systems, but on society as a whole as more and more people are called on to provide informal care.

For more information see:

Langa KM, et al. National estimates of the quantity and cost of informal caregiving for the elderly with dementia. Journal of General Internal Medicine. 16:770-778, 2001.

Bioethics Grand Rounds: Musical Event "When Death Comes Callin"

Wed, October 26, 2016, 12:00pm
Location: 
UH Ford Amphitheater & Lobby

When Death Comes Callin': Songs and Reflections About Death

Charlotte DeVries, Jeanne Mackey, Merilynne Rush, and friends offer a program of songs and brief readings reflecting various perspectives on death - humorous, sad, thoughtful, and quirky.

Lunch is provided on a first-come, first-served basis.

Mon, June 23, 2014

Brian Zikmund-Fisher was interviewed by Reuters Health for the article "Shared decision making still lacking for cancer screening." He discusses his research and trade-offs in cancer screenings. "What this study does is it shows that despite all of the initiatives and the discussion of shared decision making that has been going on, we don't seem to be moving the needle very much," he states. 

His interview also received press in the Chicago Tribune and New York Daily News.

Funded by VA Health Services Research and Development Career Development Award

Funding Years: 2015-2019

Heart attack and stroke, which together are called cardiovascular disease, cause over 1/3 of all deaths in VA patients. The current guidelines for the prevention of these conditions focus on lowering patients'blood pressure and cholesterol levels. A new treatment strategy, which I call benefit-based tailored treatment, that instead guides treatment decisions based on the likelihood that a medication would prevent a heart attack or stroke could prevent more cardiovascular disease, with lower medication use, and be more patient centered. The purpose of this Career Development Award is to develop and assess tools and approaches that could enable the implementation of benefit-based tailored treatment of cardiovascular disease, in particular a decision support tool and educational program for clinicians and a performance profiling system. The decision support tool will enable better care by showing clinicians patient-specific estimates of the likelihood that their medication decisions will prevent a cardiovascular disease event. The performance profiling system will encourage better care by assessing the quality of care provided at VA sites and in PACT teams based on how well the medical care provided follows this treatment strategy. The project will have three aims:
Aim 1 : In the first aim, I will seek to understand clinicians'and patients'perceptions of and receptivity to the use of benefit-based tailored treatment for cardiovascular disease. Information gained from qualitative research with clinicians will help assess and improve the usability and effectiveness of the decision support tool and educational program for clinicians, along with the acceptability of the treatment strategies in general. Information gained from focus groups with patients will help learn their priorities in cardiovascular disease prevention, to help identify ways to make the interventions and their assessments more patient-centered.
Aim 2 : In the second aim, the decision support tool and educational program will be assessed in a real-world randomized pilot study involving thirty clinicians. Half of the clinicians will be provided the decision support tool and education intervention for ten patients each, the other half will receive a traditional quality improvement program and treatment reminders. The study will have formative goals of ensuring that clinicians and patients believe the tool is valuable and does not disrupt care processes or workflow for anyone in the PACT team. This will be studied with qualitative and survey assessments. The primary summative outcome will be the influence of the intervention on clinicians'treatment decisions. Secondary outcomes will assess patients'satisfaction with their visits and their clinicians.
Aim 3 :
The third aim will develop and evaluate a novel performance measurement system based on benefit- based tailored treatment. First, the performance profiling system will be developed. Then the profiling system's ability to reliably differentiate high quality from low-quality care will be evaluated.

PI: Jeremy Sussman

2015 CBSSM Research Colloquium and Bishop Lecture (Lawrence O. Gostin, J.D., LL.D Hon.)

Tue, March 17, 2015, 8:30am to 4:00pm
Location: 
Alumni Center, 200 Fletcher St., Ann Arbor, MI

The Center for Bioethics and Social Sciences in Medicine (CBSSM) Research Colloquium was held Tuesday, March 17, 2015 at the Founders Room, Alumni Center, 200 Fletcher St., Ann Arbor, MI.

The CBSSM Research Colloquium featured the Bishop Lecture in Bioethics as the keynote address.  Lawrence O. Gostin, J.D., LL.D (Hon.) presented the Bishop Lecture with a talk entitled: "Law, Ethics, and Public Health in the Vaccination Debates: Politics of the Measles Outbreak."

Lawrence Gostin is University Professor, Georgetown University’s highest academic rank conferred by the University President. Prof. Gostin directs the O’Neill Institute for National and Global Health Law and is the Founding O’Neill Chair in Global Health Law. He is Professor of Medicine at Georgetown University, Professor of Public Health at the Johns Hopkins University, and Director of the Center for Law & the Public’s Health at Johns Hopkins and Georgetown Universities. Prof. Gostin is also the Director of the World Health Organization Collaborating Center on Public Health Law & Human Rights.

The 2015 Research Colloquium Presentation Schedule:

  • 8:30 AM -- Check in & refreshments
  • 9:00 AM -- Welcome
  • 9:15 AM -- Aaron Scherer, PhD, CBSSM Postdoctoral Fellow: "Elephants, Donkeys, and Medicine: Political Differences in Health Risk Perceptions and Adherence to Medical Recommendations"
  • 9:45 AM -- Natalie Bartnik, MPH, Research Associate, HBHE Genetics Research Group, UM School of Public Health: "Why, how and when oncologists disclose genome sequencing results in clinical practice"
  • 10:15 AM -- Michele Gornick, PhD, MICHR PTSP Postdoctoral Fellow, VA HSRD Fellow & CBSSM Research Investigator: "Information and deliberation make a difference: The public’s preferences for the return of secondary genomic findings"
  • 10:45 AM -- Break
  • 11:00 AM -- Lawrence O. Gostin, JD, LLD (Hon.), 2015 Bishop Lecture in Bioethics: "Law, Ethics, and Public Health in the Vaccination Debates: Politics of the Measles Outbreak"
  • 12:30 PM -- Lunch
  • 1:30 PM -- Stephanie Kukora, MD and Nathan Gollehon, MD, Fellows, Division of Neonatal-Perinatal Medicine, Department of Pediatrics, UM Mott Children’s Hospital: "Epidemiology of outpatient prenatal consultation: implications for decision-making and perinatal outcomes"
  • 2:00 PM -- Minnie Bluhm, PhD, MPH, Assistant Professor, School of Health Sciences, Eastern Michigan University: "Oncologists' decisions about administering late chemotherapy: What makes it so difficult?"
  • 2:30 PM -- Break
  • 2:45 PM -- Danielle Czarnecki, PhD Candidate, UM Department of Sociology: "Moral Women, Immoral Technologies: How Devout Women Negotiate Maternal Desires, Religion, and Assisted Reproductive Technologies"
  • 3:15 PM -- Uchenna Ezeibe, MD, Resident Physician, UMHS Department of Pediatrics & Communicable Diseases: "Pediatric Ethics Consultation Service at a Tertiary Hospital: A Retrospective Review"

Funded by National Institutes of Health

Funding Years: 2015-2020

This project represents a collaboration across the Health and Retirement Study (HRS) international partner studies with the aim of developing a harmonized diagnostic assessment protocol for dementia and cognitive impairment without dementia (CIND), to be used in the ongoing, nationally representative Longitudinal Aging Survey in India (LASI). We propose to develop this diagnostic assessment protocol by first linking doctor diagnosis in a sample of patients at four geriatric hospitals in India to two dementia test protocols ? the HRS Harmonized Cognitive Assessment Protocol (HCAP) and the 10/66 Community Screening Interview for Dementia (CSI-D) ? and cognition tests from the LASI core survey. We will then examine the data generated at this first stage to develop an adaptive test protocol to be used for the in-home assessment of dementia and CIND, contingent on subjects? performance on the LASI core cognitive tests. The proposed supplemental study to the ongoing representative, longitudinal LASI study will enable the investigation of dementia and CIND in a nationally representative sample of older Indians. The two-stage development of an adaptive test protocol will ensure both the clinical accuracy of diagnosis and community-level representation, not bound by accessibility to health care. Integrating the new data with the rich data from the main LASI study will enable the estimation of economic and care giving burden associated with cognitive decline among older adults in India.

PI: Kenneth Langa

Dr. Angela Fagerlin was elected to serve on the Senate Advisory Committee on University Affairs (SACUA). The committee is executive arm of the University Senate and of the Senate Assembly. SACUA meets weekly and consists of nine members of the Senate Assembly elected by the Assembly for three-year terms. Read more.

CBSSM Postdoctoral Research Fellow, Kayte Spector-Bagdady presented the keynote address  at the 2015 International Association of Clinical Research Nurses (IACRN) 7th Annual Conference. Her talk was entitled, “Why We've Always Needed Ethics: Grants, Research, and the Law."

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