Who still prefers aggressive surgery for breast cancer? Implications for the clinical applications of clinical trials.

Conservative breast surgery and modified radical mastectomy may, according to recent reports, yield equivalent survival. Analysis of a 1985 Canada-wide study (N = 228) compared surgeons and oncologists still recommending modified radical mastectomy (30%) with those recommending less aggressive surgery (69%) for a hypothetical stage I patient. The groups did not differ significantly in most physician characteristics, estimated survival and cure probabilities, importance of most treatment goals, uncertainty about treatment choice, or most attitudinal responses. Although equally involved with and cognizant of the value of clinical trials, the modified radical group expressed more skepticism about the ability of trial results to be transferred to practice and to take sufficient account of patient uniqueness, indicating greater focus on variation than mean results. Trial results might be more readily adopted if they are reported in accessible data-bases, incorporating patient characteristics potentially relevant to treatment choice. This would allow clinicians to individualize treatment by analyzing patient subsets of their own choosing.

What role do patients wish to play in treatment decision making?

BACKGROUND: Although current ideology suggests patients should be active participants in decision making about their care, the literature suggests that patients wish to be informed but not involved. OBJECTIVE: To test the hypothesis that most patients want their physicians to take the responsibility for problem solving (PS, identifying the one right answer), but that many want to be involved in decision-making (DM, selecting the most desired bundle of outcomes) tasks. METHODS: Survey responses from 300 patients undergoing angiogram at a Toronto, Ontario, hospital were analyzed (response rate, 72%). Survey items included scales to measure desire for information and participation, including Autonomy Preference Index, the Krantz Health Opinion Survey, and the Deber-Kraetschmer Problem-Solving Decision-Making Scale measured on a scale from, 1 (doctor only) to 5 (patient only). RESULTS: Patients had a relatively high desire for information. On the Problem-Solving Decision-Making Scale, they overwhelmingly wished the PS tasks to be performed by or shared with the physician (98.4% of the 12 PS scores are between 1 and 3), but wanted to be involved in DM (78% of the 6 DM scores are between 3 and 5). Preference for handing over control to the physician was significantly greater for the vignette involving potential mortality (chest pain) than for the vignettes involving mainly morbidity (urinary problems) or quality of life (fertility). CONCLUSIONS: Although patients do not wish to be involved in PS tasks, few wish to hand over DM control to their physician. These findings suggest 2 major roles for clinicians--assisting patients in PS to structure choices and supporting them in making often difficult decisions.

Problem-solving and decision-making preferences: no difference between complementary and alternative medicine users and non-users.

The objective of this study was to determine if complementary and alternative medicine (CAM) Users are more autonomous than Non-Users with respect to their preferred role in decision-making (measured by the problem-solving decision-making or PSDM scale). A survey was mailed in spring 2001 to a random sample of 696 men (selected from the Ontario Cancer Registry), aged 18 years or older and diagnosed with prostate cancer in the preceding 2 years. Less than 5% of the 489 (72.1% response rate) men (mean age 68.6 years) who responded to the PSDM question in our survey were classified as having an autonomous role preference, while almost 1/3 of the respondents reported using CAM for their prostate cancer. The majority of respondents were classified as preferring a shared role and a substantial minority was classified as preferring a passive role. There was no statistically significant difference between CAM users and non-users with respect to their preferred role. The hypothesis that CAM Users are more autonomous problem solvers and decision makers is not supported by these findings; however, the generalizability of our results is limited by the fact that we surveyed a relatively older male population only.

Impact of a shared decision-making program on patients with benign prostatic hyperplasia.

OBJECTIVES: To determine patient views about the Shared Decision-Making Program (SDP), an interactive videodisk program designed to inform patients with benign prostatic hyperplasia (BPH) about their condition and treatment options and to determine its impact on perceived knowledge and treatment preference. METHODS: Six hundred seventy-eight patients with symptomatic BPH from eight Canadian centers viewed the SDP. Before and after viewing the video, patients answered questionnaires designed to assess treatment preference, knowledge gained, and satisfaction with this educational format. A 1-year follow-up survey was also conducted. RESULTS: Most patients showed a high desire for information and high satisfaction with the SDP; this satisfaction persisted at 1 year. Patients' self-reported knowledge increased significantly (P <0.0001). However, the SDP did not alter initial treatment preferences among those with already formed preferences, although it aided almost half of those initially undecided in forming a preference. Viewing the SDP also appeared to enhance the physician-patient relationship. CONCLUSIONS: Patients saw the SDP as an effective method for teaching patients about BPH and the risks and benefits of various treatments, clarifying particular areas about which many patients appear to have a desire for more information than is often provided. Patients were enthusiastic about the educational value of the program, and their active participation in the decision-making process may actually enhance the physician-patient relationship. Contrary to other studies, we found no significant alterations in treatment preferences. Problems relating to the cost and timely updating of the software need to be addressed for these kinds of programs to realize their full potential.

The Canadian health care system: an overview.

Although health care is a provincial responsibility in Canada, universal hospital insurance was fully adopted by 1961; universal medical insurance followed 10 years later. Each province enacted universal insurance after the federal government offered to pay 50% of provincial hospital and medical care costs. Hospital insurance had wide public and provider support but universal medical care insurance was opposed by organized medicine. The federal government soon realized that it had no control over total expenditures and no mechanisms for controlling costs. In 1977 it enacted Bill C-37 which limited total federal contributions and made those contributions independent of provincial health care expenditures so that increased costs had to be met by the provinces. Since private health care insurance for universal benefits is prohibited by the federal terms of reference for health insurance, the provinces must raise the money by taxes and (in some provinces) premiums. Although prohibited by the terms of reference of the universal program, some provinces have adopted hospital user fees and are allowing their physicians to bill patients in excess of provincial fee schedules. The 1980s have seen increased confrontations between the federal and provincial governments and between the provinces and their providers. The issues are cost containment and control of the system. The provinces have two broad options. The first is more private funding through private insurance and user fees. The proposed new Canada Health Act will probably prohibit such charges. A second option involves greater control and management of the system by the provinces; this has already occurred in Quebec. Greater control is vigorously opposed by physicians and hospitals. The Canadian solution to health insurance problems in the past has been moderation. Extreme moves in either direction would represent a break with tradition, but they may prove to be unavoidable.

Overconfidence among physicians and nurses: the 'micro-certainty, macro-uncertainty' phenomenon.

Overconfidence in clinicians was examined in two independently designed studies, each using a different research approach. The first study examined treatment choices of physicians in treating breast cancer, and the second rapid decision making among nurses working in Intensive Care Units. In both studies, individual respondents were highly confident they had made the right choice ('micro-certainty'), although there was no consensus across respondents as to what the optimal treatment would be ('macro-uncertainty'). The difference between micro-certainty of individuals and macro-uncertainty within the clinical community may cast some light on the persistence of practice variation. The implications of overconfidence in clinical treatment for patients, practitioners, and professional regulation are discussed.

Health care in Canada: current trends and issues.

Canada's universal health care system is perceived as threatened by rising costs, an aging population, and technological growth. This popular and successful program has largely kept costs under control while maintaining quality and ensuring equity. However, its success demonstrates the limits of medical care; remaining health problems are less amenable to improvement by merely improving access to traditional services. A widening view of health implies a larger health role in other policy arenas, and a larger group of legitimate participants; coordinating an evolving and expanding system becomes increasingly difficult. Policy options include some combination of laissez faire, business as usual, managed care, manpower regulation, and system change. Change implies controversy and conflict. Hard decisions are clearly ahead.

The determinants of treatment choice in end-stage renal disease: can we generalize about decision making from specific studies?

Practitioner judgments about treatments for hypothetical end-stage renal disease patients were examined by two mailed surveys. It was hypothesized that treatment choice was a function of four hierarchically arranged sets of factors: disease- and treatment-specific, patient-specific, environment- and institution-specific, and practitioner-specific. The first survey identified six vignettes for which the case-specific factors alone did not yield a generally accepted treatment decision. These six cases were used in the second survey, whose results are reported here. Practitioner-specific characteristics were found to be only weakly related to treatment choice. Guttman scale analysis showed no significant practitioner propensity to use any given treatment. Instead, the number of colleagues in a respondent's renal unit picking a given therapy for a given patient was the strongest predictor of an individual's choice. Contextual factors--clinical details of the case and decision rules within the institution--appeared to overwhelm provider-specific tendencies; characteristics of the decision generally outweighed characteristics of the decision maker. This framework of factors may be useful for analyzing inter-provider variation. Consequences for certain approaches to the study of decision making (especially single-site studies and regression-based models) are noted.

Using explicit decision rules to manage issues of justice, risk, and ethics in decision analysis: when is it not rational to maximize expected utility?

Concepts of justice, risk, and ethics can be merged with decision analysis by requiring the analyst to specify explicity a decision rule or sequence of rules. Decision rules are categorized by whether they consider: 1) aspects of outcome distributions beyond central tendencies; 2) probabilities as well as utilities of outcomes; and 3) means as well as ends. This formulation suggests that distribution-based decision rules could address both risk (for an individual) and justice (for the population). Rational choice under risk if choices are one-time only (vs. repeated events) or if one branch contains unlikely but disastrous outcomes might ignore probability information. Incorporating risk attitude into decision rules rather than utilities could facilitate use of multiattribute approaches to measuring outcomes. Certain ethical concerns could be addressed by prior specification of rules for allowing particular branches. Examples, including selection of polio vaccine strategies, are discussed, and theoretical and practical implications of a decision rule approach noted.

How physicians use the stress test for the management of angina.

The authors examined physicians' reasons for ordering an exercise tolerance test and the influence of the test results on management decisions. Subjects of this study included 265 family physicians in Pennsylvania who completed a questionnaire on the management of a patient with typical chronic stable angina. Eighty-one percent of the respondents reported they would order a noninvasive stress test as a first step in the management of the patient. Of these physicians, 40% would refer the patient to a cardiologist only if the exercise tolerance test were strongly positive, 8% would refer only if it were negative, and 53% would not change their referral decisions on the basis of test results. No more than 57% of the physicians rated as very important any given reason for ordering a noninvasive diagnostic test. The results suggest that a test may be ordered routinely but without a consensus as to why it is ordered and without an effect on clinical management decisions.

Contraception with the cervical cap: effectiveness, safety, continuity of use, and user satisfaction.

With the growing interest in barrier contraceptive methods, the cervical cap has come back into use in North America. We examined the cap's effectiveness, safety, continuity of use, and user satisfaction among 617 women who were fitted at a family planning clinic in Toronto, Canada, between May 1981 and November 1983. Follow-up information was available for 516 of these women. Using a life table analysis with Bayesian adjustment, the probability of becoming pregnant after 12 months of use was 0.166 with a standard error of 0.022. There is evidence that after 1 year of use the caps deteriorate and that this deterioration may increase the risk of pregnancy. Many of the women in this study were very satisfied with the cervical cap; however, such problems as dislodgement, discomfort to user and partner, difficulty with insertion and removal, and unpleasant odour affected acceptability and continuity of use. It is likely that these problems could be alleviated by improving the quality of or changing the materials, modifying the design to improve the fit, and providing a greater range of sizes.

Regulating biotechnology: a rational-political model of policy development.

While technology assessment is seen as a mechanism for achieving effective and efficient use of health care resources, it has not as yet made the impact on policy decisions that its potential would suggest. Considerable barriers have been encountered in translating assessment results into policy concerning the adoption and use of technologies, with 'political' factors often being decisive. This paper places technology assessment in the content of the policy process to clarify both (a) how conflicting interests and organizational features can often hinder the selection of optimal policies, and (b) the potential roles technology assessment could nonetheless play. The resulting framework is termed the 'rational-political' model of policy development. The paper uses the example of policy making about the regulation of biotechnology, drawing on information from a survey of decision-makers (n = 561) involved in issues concerning the development, approval, and payment for pharmaceutical products.

Assessment of Ontario's Geriatric Preventive Dentistry Program.

Ontario's Geriatric Preventive Dentistry Program (mandated under the Health Protection and Promotion Act) is assessed using the rational comprehensive approach. Policy options are examined, taking into account population characteristics, the nature of the health problem, current service delivery policy and resources, and barriers to access. Examining the 1974 Task Force recommendations, sets of draft guidelines issued in 1982, 1983, and 1984, and the revised 1985 guidelines as implemented, one can note changes in the benefits offered and in eligibility for coverage. The final program appears to be largely a symbolic policy response, which is unlikely to have major implications for either efficiency or community effectiveness. Implications of the current program, including the possibility it may be a precursor to more effective policies, are noted.

Public health in Canada: a comparative study of six provinces.

PURPOSE: To describe the public health systems and their projected futures in six provinces in the context of two developments: 1) the emerging discourse on population health and 2) the trend toward regionalization of the health care system. METHODS: Telephone interviews with key informants and key document review. RESULTS AND CONCLUSIONS: Communicable disease control and health protection are currently the "core businesses" of public health; the population health discourse has not resulted in mandated programming. The reality is a retrenchment of public health scope during a time that should be considered conducive to expansion. Only Ontario has not regionalized its health care system, although public health is already delivered regionally. Alberta, Saskatchewan and Manitoba have either evolved or are evolving toward an integrated health system. There were concerns about the potential impact on public health identity and funding of this "vertical integration". Regionalization of public health may result in units that are too small to support adequate local expertise and may jeopardize development and enforcement of province-wide programs.

From equal access to health care to equitable access to health: a review of Canadian provincial health commissions and reports.

Having achieved equality of access to health care, Canadian policymakers are setting new policy goals, within resource constraints, primarily to achieve equity of access to health. Across the country, provincial royal commissions have explored a number of policy options to achieve this goal. These options are reviewed and critically analyzed within the context of such challenges in health policy as insufficient access to high-technology care and the limits of medical care, and such external challenges as economic and demographic trends, federal-provincial disputes, and ideological beliefs. Particular attention is given to the implications of a broader definition of health and the concept of regional health authorities. Based on the provincial reviews, the authors conclude that Canada wants to achieve equitable access to health. With the shift of health policy away from the formerly protected arena of medical care, achieving equitable access to health will require both an alteration of priorities and values and considerable political will. Canada will be forced to meet these new challenges to maintain current achievements and to make its system even more successful.

Corporatization and deprivatization of health services in Canada.

Canada's system of health services has been shaped by the forces and values in the Canadian political, cultural, social, and economic environment; these forces continue to place constraints on future changes. We distinguish between "corporatization" and "privatization", and the implications of each for improved efficiency of the system. Although the organization of health services is, in certain provinces, undergoing significant structural changes, there is evidence that rather than privatizing, the system may actually be continuing to experience what we have termed deprivatization, as the scope of government involvement expands to include a more comprehensive definition of health care. Trends in Canada differ considerably from those in the United States; universal health insurance has curbed the ability and desire of institutions to exclude members of some socioeconomic groups from receiving care. U.S.-based models, if applied to Canada, could lead to both higher costs and lower quality of care. Considerable efficiencies can be realized within Canada's current system.

Canadian Medicare: can it work in the United States? Will it survive in Canada?

Any discussion of health care reform in the United States inevitably draws comparisons from the Canadian model. This Article frames the debate over the merits of the Canadian system by introducing its basic features, exploring its advantages, and discussing its limitations. In evaluating the prospects for a Canadian-type system in the United States, the author focuses on the need to rethink--as Canada has--the viability of market-based approaches to health care.

Regulatory intensity, hospital size and the formalization of medical staff organization in hospitals.

Using a theory of organizational response to regulation, this study examined the effects of regulatory intensity and hospital size on the formalization of medical staff organization in Canadian hospitals. The general hypothesis was that, in provinces with greater regulatory intensity, hospitals would exhibit greater formalization of medical staff, and greater involvement of physicians in hospital governance and management; larger hospitals would have greater formalization of medical staff than smaller hospitals. Data from 574 hospitals indicated that both hospital size and provincial regulatory intensity were important factors predictive of the overall formalization of medical staff organization. Depending upon the provincial location, hospitals have developed different patterns of formalizing their medical staff structures.

Critical elements in the process of decision making: a nursing perspective.

Decision making is a fundamental element of nursing work, one that is essential to understand as organizations explore cost effective ways to deliver quality health care. While the importance of decision making has been well articulated, previous descriptions of nursing work have had difficulty describing completely this cognitive component. This paper identifies critical elements within the process of nursing decision making that have not been addressed adequately within current decision making frameworks. In this exploratory research, nursing personnel described their work; qualitative content analysis was used to categorize components of nursing decision making within these descriptions. Revealed are complex nursing decisions that occur after the selection of nursing intervention, and prior to the implementation of that intervention. These decisions address the complex network of interactions involved with enactment of the nursing role, the repertoire of leadership skills such as collaboration, negotiation, and delegation required to elicit the involvement of other individuals; discretionary decisions made in the allocation of resources; priority setting; and strategizing. These findings have implications for nursing competency and quality of care, cost-effective delivery of health care, and nursing education.

Healthcare restructuring: the impact of job change.

Restructuring, particularly redeployment and job change, had a dramatic impact on the working conditions and practices of nursing personnel. This study was conducted to determine whether nurses (RNs and RPNs) who experienced job change perceived their work-lives differently than those who did not undergo job change and, whether nurses who experienced different types of job change (new role, new unit, or new hospital) varied in their perceptions. A questionnaire exploring themes relevant to redeployment was administered to all nurses (N = 3,408) in two large teaching hospitals that had undergone restructuring. The response rate was 50.7% (n = 1,728). Of the responses, 1,662 were used in the analysis. T-tests and ANOVAs were used to compare groups of nurses. Nurses who changed their jobs perceived their commitment to the organization, their work environment and quality of care differently than those who did not change jobs. Nurses with different types of job change differed in their organizational commitment, perceptions of work-related injuries, attitudes towards job change, need for orientation and new knowledge, and feelings about the health care team. Results will assist managers to address the specific needs of nurses with different experiences of job change in the restructured workplace.