"Comprehensive Healthcare for America": Using the Insights of Behavioral Economics to Transform the U. S. Healthcare System.

"Comprehensive Healthcare for America" is a largely single-payer reform proposal that, by applying the insights of behavioral economics, may be able to rally patients and clinicians sufficiently to overcome the opposition of politicians and vested interests to providing all Americans with less complicated and less costly access to needed healthcare.

Proactive penicillin allergy testing in primary care patients labeled as allergic: outcomes and barriers.

OBJECTIVES: To promote penicillin allergy testing in an outpatient setting in patients labeled as penicillin allergic, to determine the number of those who are truly allergic, evaluate patient satisfaction with the testing, and educate both patients and clinicians about testing. METHODS: Patients with a history of penicillin allergy listed in their EHR were screened and recruited by their primary care office and referred for penicillin allergy testing. The results of allergy testing and patient satisfaction after testing were the main outcomes. We also surveyed the primary care physicians about perceived barriers to recruitment. RESULTS: A total of 82 patients were recruited, although only 37 actually underwent testing. None of these 37 had a positive skin test, and none of 36 had a positive oral challenge (1 refused it). Following testing, 2 patients (5%) had subjective reactions within 24 h. Thirty-one patients (84%) responded to a post-testing follow-up questionnaire; 3 (10%) were subsequently treated with a beta-lactam, and all reported that testing provided important information to their medical history. Providers identified time constraints, either their or their patients lack of time, as the major barrier to recruitment. CONCLUSIONS: Penicillin allergy testing safely evaluates patients labeled as penicillin allergic. It is well tolerated, and embraced by the patients who undergo testing. In our study, none of the patients tested had an allergic reaction, but we identified multiple barriers to developing a protocol for testing patients from the primary care setting.

The ethics of postoperative pain management: Mapping nurses' views.

AIM: We explored the positions of nurses working in hospitals regarding the acceptability of refusing to give a repeat dose of painkiller to a postoperative patient who requested it. These positions were compared with that of lay people, physicians, and other health professionals. DESIGN AND METHODS: Factorial design was used to assess the impact of 6 situational factors: the patient's age, the current level of pain as assessed by the nurse, the number of requests, the level of risk associated with the administration of a repeat dose, the outcome of surgery, and the giving of alternative mild analgesics. We implemented a combination of scenario technique and of cluster analysis. Data were collected from April 2013 to December 2015. PARTICIPANTS: 138 registered nurses, 32 nurse's aides, 33 physicians, 23 psychologists, and 169 lay people participated in the study. RESULTS: We found 4 qualitatively different meaningful positions. A plurality of participants (57% of nurses) considered that refusing was not acceptable, irrespective of circumstances. A substantial minority of participants (but 52% of physicians) considered that refusing was acceptable only if the level of pain was low and the risk was high. Other participants (mostly lay people) considered that refusing was always acceptable each time a risk of side effects, either serious or simply mild, was present.

Functional measurement in the field of Ethics in Politics / Medición funcional en el campo de la Ética en Política

We present, in a synthetic way, some of the main findings from ten studies that were conducted in the field of ethics in politics, using the Functional Measurement framework. These studies were about (a) Angolan and Mozambican people's views about the legitimacy of military-humanitarian interventions, (b) French people's perspectives regarding the government's responsibility for the health of consumers of illicit substances, (c) Togolese people's views about the acceptability of political amnesties in a time of political transition, (d) the perspective of victims of the genocide of the Tutsis in Rwanda regarding the attribution of guilt by association to offspring of perpetrators, (e) slave descendants' views about the acceptability of national policies on reparations for slavery, (f) Colombian people's willingness to forgive perpetrators of violence who harmed family members during the civil war, (g) the attitudes of French and Colombian people about national drug control policies, (h) Indian students' views about the appropriateness of the death penalty for murder or rape, (i) Colombian people's perspectives regarding corruption, and finally (j) Venezuelan people's conceptualization of human rights. The main findings are discussed in reference to six of the foundations of Moral Foundations Theory.

Este texto presenta, de forma resumida, algunos de los principales resultados de diez estudios que se realizaron en el campo de la ética y la política, en el marco de la Medición Funcional. Estos estudios trataron de: (a) los puntos de vista de la gente de Angola y Mozambique sobre la legitimidad de las intervenciones militares-humanitaria; (b) las perspectivas de los franceses con respecto a la responsabilidad del gobierno con la salud de los consumidores de sustancias ilícitas; (c) las perspectivas de las personas de Togo acerca de la aceptabilidad de amnistías políticas en un momento de transición política; (d) las perspectivas de las víctimas del genocidio de los Tutsis en Ruanda en cuanto a la atribución de culpabilidad a los descendientes de los perpetradores de violencia; (e) los puntos de vista de los descendientes de esclavos acerca de la aceptabilidad de las políticas nacionales de reparaciones por la esclavitud; (f) la disposición de los colombianos a perdonar autores de la violencia que causaron daño a miembros de la familia durante el conflicto armado interno; (g) las actitudes de los franceses y colombianos acerca de las políticas nacionales de control de drogas; (h) los puntos de vista de los estudiantes indios acerca de la idoneidad de la pena de muerte por asesinato o violación; (i) las perspectivas de los colombianos con respecto a la corrupción, y, finalmente, (j) la conceptualización de los derechos humanos en la población venezolana. Los principales resultados se discuten en relación con seis de los fundamentos de la Teoría de los Fundamentos Morales.

The acceptability of ending a patient's life: a France-Portugal-Spain comparison.

The views of French, Portuguese, and Spanish people on end-of-life decisions were compared. Two hundred seventy-seven adults from Barcelona, Oporto, and Toulouse judged the acceptability of life-ending procedures in 42 scenarios composed of all combinations of 3 factors: the patient's age (30 or 80 years), the patient's life expectancy (days, weeks, or months), and the type of procedure (suicide, suicide assisted by the physician, euthanasia by the physician at the request of a suffering patient, euthanasia of a comatose patient at the family's request, euthanasia of a comatose patient as stipulated in the patient's advance directives, euthanasia of a comatose patient without advance directions and without a request from the family, or euthanasia of a suffering patient without a request from the patient). In all 3 countries, the type of procedure had the major effect. The 4 procedures implemented by the patient or at the patient's request were, on average, considered acceptable. The 2 procedures not implemented at the patient's request were considered unacceptable. Euthanasia of a comatose patient at the request of the family was judged mildly acceptable. The attitudes of the people in Toulouse, Oporto, and Barcelona concerning the acceptability of ending a patient's life have now largely converged, although Spanish participants were statistically significantly more accepting than French and Portuguese participants.

Judging patients' pain from external cues.

Nurses, nurse's aides, and physicians were presented with vignettes describing elderly patients and were asked to assess their level of pain from four external cues (facial expression, verbalizations, avoidance of movements and positions, and interpersonal contact) in three conditions: when the illness was not known, when it was known to be arthritis, and when it was known to be cancer. For all health caregivers, the most important cue for judging pain was patients' facial expression. When the nature of the illness was not known, the impact of this cue was stronger than when the nature of the illness was known.

French lay people's views regarding the acceptability of involuntary hospitalization of patients suffering from psychiatric illness.

PURPOSE: To understand how lay people and health professionals in France judge the acceptability of hospitalizing a psychiatric patient against his will. METHODS: 123 lay people, 20 nurses, 5 psychologists, and 6 physicians judged the acceptability of involuntary hospitalization in each of 36 scenarios consisting of all combination of 4 factors: patient's adherence to treatment (agrees to take his medications or not); risk of suicide (none, immediate, multiple past attempts); risk of harming others (none, immediate, history of violence against others); attitude of patient's family (favorable to involuntary hospitalization or not). The judgment data were subjected to cluster analysis and subsequently to analysis of variance. RESULTS: 4 clusters were identified and labeled according to the factors that affected judgments: Never Favorable (7 participants, with mean acceptability judgment of 1.30 on a scale of 0-10); Threat to Others (35, with mean judgment of 8.68 when risk high, 2.94 when risk low), Threat to Others or Self and Adherence (88, with mean judgment of 6.89), and Always Favorable (24, with mean judgment of 8.41). CONCLUSIONS: 95% of participants agreed that involuntary hospitalization is acceptable under certain conditions, especially - in accordance with French law - when the patient presents a risk to others.

Young Kuwaitis' views of the acceptability of physician-assisted suicide.

AIM: To study the views of people in a largely Muslim country, Kuwait, of the acceptability of a life-ending action such as physician-assisted suicide (PAS). METHOD: 330 Kuwaiti university students judged the acceptability of PAS in 36 scenarios composed of all combinations of four factors: the patient's age (35, 60 or 85 years); the level of incurability of the illness (completely incurable vs extremely difficult to cure); the type of suffering (extreme physical pain or complete dependence) and the extent to which the patient requests a life-ending procedure, euthanasia or PAS (no request, some form of request, repeated requests). In all scenarios, the patients were women who were receiving the best possible care. The ratings were subjected to cluster analysis and analyses of variance. RESULTS: Five clusters were found. For 44%, PAS was always very unacceptable, no matter what the circumstances. For 23%, it was unacceptable, but less so if the patient was older or requested it repeatedly. For 16%, it was unacceptable if the patient was young but was acceptable if the patient was elderly. For 5%, it was unacceptable if the patient had extreme pain but was acceptable if completely dependent. For 11%, it was unacceptable if the patient did not request it but acceptable if she did. CONCLUSION: The majority of the Kuwaiti university students opposed PAS either categorically or with a slight variation according to circumstances. Nonetheless, a minority approved of PAS in some cases, particularly when the patient was elderly.

Multi-site heart disease risk assessment service provided by pharmacy students.

OBJECTIVE: To evaluate a pharmacy student service focused on patient coronary heart disease (CHD) risk assessment. DESIGN: Fourth-year pharmacy students offered a CHD risk assessment service at 5 physicians' offices as part of ambulatory care advanced pharmacy practice experience (APPE). Patient acceptance of the service was assessed using a satisfaction survey instrument. ASSESSMENT: Fifty-seven students educated 311 patients about CHD risk. Of the 258 patients who completed the satisfaction survey, 245 (95%) reported that the service was helpful in understanding CHD risk, and 79 (31%) learned of a personal CHD risk factor of which they were not previously aware. Student knowledge was assessed using a multiple-choice pretest and posttest focused on CHD knowledge recall. Students' test scores improved from pretest to posttest (mean 51.6 % +/- 1.1 vs. 64. 8% +/- 1.0. respectively; p = 0.01). CONCLUSIONS: A CHD risk assessment service provided by APPE students in ambulatory care settings was educational for both students and patients.

French general practitioners vary in their attitudes toward treating terminally ill patients.

The purpose of this study is to analyze French general practitioners' attitudes toward prescribing opiate painkillers for dying patients and compare them with their attitudes toward making frequent home visits. One hundred and fifteen general practitioners indicated the acceptability of prescribing opiates in 48 scenarios of terminal cancer patients with different levels of age, gender, stated pain, request for painkillers, and signs of depression; 103 of them also indicated the acceptability of making frequent home visits in the same 48 scenarios. The responses were analyzed using analysis of variance and cluster analysis. For prescribing opiates, four clusters of physicians were found: 13 prescribed primarily in response to stated pain; 43 to request for painkillers; 43 to the combination of pain, request, and depression; and 16 in virtually all cases. Using the same clusters to analyze visiting gave results that were very consistent with those for prescribing. We conclude that French general practitioners have differing and consistent styles in prescribing painkillers and making home visits to dying cancer patients.

The acceptability among lay persons and health professionals of actively ending the lives of damaged newborns.

BACKGROUND: Euthanasia is performed on occasion, even on newborns, but is highly controversial, and it is prohibited by law and condemned by medical ethics in most countries. AIM: To characterise and compare the judgments of lay persons, nurses, and physicians of the acceptability of actively ending the life of a damaged newborn. METHODS: Convenience samples of 237 lay persons, 214 nurses, and 76 physicians in the south of France rated the acceptability on a scale of 0-10 of giving a lethal injection in 54 scenarios composed of all combinations of 4 within-subject factors: gestational age of 6, 7, or 9 months; 3 levels of severity of either perinatal asphyxia or of genetic disease; attitude of the parents about prolonging care unknown, favourable, or unfavourable; and decision made individually by the physician or collectively by the medical team. Overall ratings were subjected to cluster analysis and each cluster to analysis of variance and graphic representation. RESULTS: Lay persons (mean acceptability rating 4.29) were significantly more favourable to euthanasia than nurses (2.84), p < .005, or physicians (2.12), p < .005. Five clusters were found with different judgment rules, i.e., how the information was integrated. More physicians (30 per cent) than nurses (14 per cent), p < .01, or lay persons (11 per cent), p < .01, rated euthanasia as never, under any condition, acceptable. Most, however, asserted that it was increasingly acceptable as the factors combined to favour it, especially when the parents desired to stop treatment. More physicians (45 per cent) and nurses (46 per cent) than lay persons (21 per cent), p < .01, used a complex conjunctive rule (level of parent's attitude x level of severity of damage x consultation with team or not) rather than a simple additive rule. CONCLUSIONS: Unlike law and medical ethics, most of the lay persons, nurses, and physicians judged the acceptability of euthanasia as a function of the circumstances. Most health professionals combined the factors in a conjunctive (multiplicative), rather than additive, fashion in accordance with legislation for adults in The Netherlands and elsewhere that requires a set of criteria to be fulfilled before it is legitimate to end a patient's life.

Do ethical judgments depend on the type of response scale? Comparing acceptability versus unacceptability judgments in the case of life-ending procedures

Using Functional Measurement (Anderson, 2008), Frileux, Lelièvre, Muñoz Sastre, Mullet, and Sorum (2003) examined the joint impact of several key factors on lay people’s judgments of the acceptability of physicians’ interventions to end patients’ lives. The level of acceptability was high, and the information integration rule that best described the participants’ judgments was Acceptability = Patient’s Request + Patient’s Age + Residual Suffering + Incurability. Critics suggested, however, that acceptability was high because the ethical problem was framed in terms of acceptability (Murphy, 2007). Presenting participants with acceptability scales may have caused the life-ending procedure to be represented in participants’ mind as basically “acceptable”. By contrast, presenting participants with unacceptability scales might cause the procedure to be represented as basically “unacceptable”. In the present study, therefore, we directly compared lay people’s judgments of the acceptability of life-ending procedures under two opposite conditions – an acceptability condition, and an unacceptability condition. The life-ending procedure did not appear as more acceptable to participants responding in terms of acceptability than to those responding in terms of unacceptability. In addition, the impacts of the factors describing the end-of-life situations were not affected by the type of judgment scale that was used. Functional Measurement seems to be resistant to goal-framing effects; the findings that have been observed using acceptability scales can be considered as robust(AU)

End-of-life preferences: a theory-driven inventory.

The study aimed at making a theory-driven inventory of end-of-life preferences. Participants were asked about a variety of preferences representing all eight motivational states described in Apter's Metamotivational Theory (AMT; Apter, 2001). Data from a convenience sample of 965 community participants and a convenience sample of 81 persons suffering from a terminal illness were examined using exploratory and confirmatory factor analysis. Ten factors were evidenced; they were easily interpretable in the AMT framework. In decreasing order of importance, people would, at the time of their death, like to have an understanding doctor, to be at peace with themselves, to remain autonomous, to keep a sense of humor, to remain able to oppose any decision taken without their consent, to remain an object of love, to remain a reference for others, to have resolved conflicts with others, to leave their businesses in good order, and to find themselves at peace with God.

Emergency physicians' pain judgments: cluster analyses on scenarios of acute abdominal pain.

Physicians have been found to give lower ratings of patients' pain than do the patients themselves. We hypothesized that the physicians' rating depends not only on the patient's pain rating but also on other cues. We also hypothesized that these cues influence physicians' pain treatment and urgency level. We gave to 52 emergency room physicians in Toulouse, France, 45 scenarios describing patients with acute abdominal pain, representing all combinations of 5 levels of patient's pain rating, 3 levels of behavioral manifestations of pain, and three signs of the severity of the abdominal pathology (namely, the likelihood of appendicitis). The participants rated the patient's pain, selected the intensity of pain treatment, and judged the degree of urgency of calling in a surgeon. In rating pain, physicians took into account the patient's rating, behavioral manifestations of pain, and the signs of abdominal pathology. Clusters analyses showed two sets of individual differences. When rating pain and choosing pain treatment, physicians gave either a low or high weight to behavioral pain cues. In urgency judgments, physicians could be separated into those who gave considerable weight to the different levels of severity and those who did not.

Consulting a complementary and alternative medical practitioner: a systematic inventory of motives among French patients.

OBJECTIVES: To classify people's motives for seeking care from complementary and alternative medicine practitioners. Participants were asked about a wide variety of motives representing all eight motivational states described in Reversal Theory (RT): telic, paratelic, conformist, negativist, mastery, sympathy, autic, and alloic. DESIGN: Data from a convenience sample of 256 participants was examined using factorial techniques. RESULTS: Six factors were evidenced that were easily interpretable in the RT framework. Participants perceived their motives largely in terms of goals and means, and within this domain they focused more on the goals (i.e., telic motives were more important than paratelic ones). Paratelic motives were, however, not unimportant: they ranked third. Participants also perceived their motives in terms of rules and constraints, and within this domain they focused more on rules (i.e., conformist motives were more important than negativist ones). Participants, finally, perceived their motives in terms of the combined domains of relationships and exchanges with others, namely, acting out of concern for others (alloic sympathy) as well as for themselves (autic mastery). CONCLUSIONS: If the six-factor structure is proved applicable, the six corresponding subscales could be used for systematically comparing motives among different types of patients, regarding different types of therapies, and among patients from different cultures.

Avoidance of anticipated regret: the ordering of prostate-specific antigen tests.

OBJECTIVE: When making decisions, people are known to try to minimize the regret that would be provoked by unwanted consequences of these decisions. The authors explored the strength and determinants of such anticipated regret in a study of physicians' decisions to order prostate-specific antigen (PSA) tests. METHODS: 32 US and 33 French primary care physicians indicated the likelihood they would order a PSA for 32 hypothetical men presenting for routine physical exams. They then indicated how much regret they would feel if they found advanced prostate cancer in 12 other patients for whom they had chosen not to order PSAs several years before. The latter patients differed according to age (55, 65, or 75 years), a prior request or not for PSA testing, and no or some irregularity of the prostate on the earlier rectal exam. RESULTS: ANOVA found that regret was higher when the patient had requested a PSA, the prostate was irregular, and the patient was younger. Shape had less effect when the patient had requested a PSA. US physicians had more regret than the French, patient request had a greater impact on the Americans, and increasing patient age reduced regret more among the French. In a 1-way correlation, the regret score was associated with the likelihood of ordering PSAs for both the French (r = 0.64, P < 0.005) and the Americans (r = 0.42, P< 0.02). In a regression analysis too, the regret score was the most important predictor of the likelihood of ordering a PSA (beta = 0.37, P < 0.0001). CONCLUSIONS: Regret over failing to diagnose aggressive prostate cancer is associated with a policy of ordering PSAs. This regret appears to be culturally sensitive.

High-dose versus standard-dose amoxicillin for acute otitis media.

BACKGROUND: Emergence of drug-resistant bacteria has led to a recommendation to use high-dose (HD) amoxicillin (80-90 mg/kg/d) rather than standard-dose (SD) amoxicillin (40-45 mg/kg/d) to treat children with acute otitis media (AOM). OBJECTIVE: To compare the efficacy and tolerability of HD versus SD amoxicillin among children with AOM who were considered at low risk for infection with antibiotic-resistant bacteria. METHODS: A double-blind, randomized, 3-year clinical trial was conducted using participants who met the following criteria: age >3 mo, weight