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Finocchiaro Castro M, Lisi D, Romeo D. Experimental evidence on the role of shared protocols as coordination device on clinical best practices. Sci Rep 2024; 14:9363. [PMID: 38654112 DOI: 10.1038/s41598-024-60186-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 04/19/2024] [Indexed: 04/25/2024] Open
Abstract
Our experiment assesses the level of coordination on clinical best practice among physicians and investigates whether the release of guidelines helps in supporting coordination. Based on three clinical vignettes using current national guidelines, physicians evaluate the appropriateness of each of the proposed courses of action. Afterwards, physicians are allowed to ask which action corresponds to national guidelines and change their ratings, if desired. On average, slightly more than half of the sample coordinated on appropriateness evaluations. Empirical analysis indicates that several organizational and individual variables influence the level of coordination. Additionally, the release of national guidelines improved both the level of conformity and coordination. Our findings suggest changes in implementation practices to increase the impact of these shared protocols in the health field.
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Affiliation(s)
- Massimo Finocchiaro Castro
- Department of Law, Economics and Social Science, Mediterranean University of Reggio Calabria, Reggio Calabria, Italy
- Health Econometrics and Data Group, University of York, York, UK
- Institute for Corruption Studies, Illinois State University, Normal, USA
| | - Domenico Lisi
- Health Econometrics and Data Group, University of York, York, UK.
- Department of Economics and Business, University of Catania, Catania, Italy.
| | - Domenica Romeo
- Health Econometrics and Data Group, University of York, York, UK
- Department of Economics and Business, University of Catania, Catania, Italy
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2
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Avdic D, von Hinke S, Lagerqvist B, Propper C, Vikström J. Do responses to news matter? Evidence from interventional cardiology. JOURNAL OF HEALTH ECONOMICS 2024; 94:102846. [PMID: 38183949 DOI: 10.1016/j.jhealeco.2023.102846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 01/08/2024]
Abstract
We examine physician responses to a global information shock and how these impact their patients. We exploit international news over the safety of an innovation in healthcare, the drug-eluting stent. We use data on interventional cardiologists' use of stents to define and measure cardiologists' responsiveness to the initial positive news and link this to their patients' outcomes. We find substantial heterogeneity in responsiveness to news. Patients treated by cardiologists who respond slowly to the initial positive news have fewer adverse outcomes. This is not due to patient-physician sorting. Instead, our results suggest that the differences are partially driven by slow responders being better at deciding when (not) to use the new technology, which in turn affects their patient outcomes.
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Affiliation(s)
- Daniel Avdic
- Department of Economics, Deakin University, 70 Elgar Road, Burwood VIC 3125, Australia.
| | - Stephanie von Hinke
- School of Economics, University of Bristol, United Kingdom; IFS, United Kingdom
| | | | - Carol Propper
- IFS, United Kingdom; Imperial College Business School, Imperial College London, United Kingdom; Monash University, Australia; CEPR, United Kingdom
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McKibbin R. The effect of RCTs on drug demand: Evidence from off-label cancer drugs. JOURNAL OF HEALTH ECONOMICS 2023; 90:102779. [PMID: 37352724 DOI: 10.1016/j.jhealeco.2023.102779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 05/10/2023] [Accepted: 05/31/2023] [Indexed: 06/25/2023]
Abstract
This paper investigates the effect of scientific information from randomized controlled clinical trials (RCTs) on the demand for off-label uses of cancer drugs. This is a unique setting where demand for a drug for a specific use is observable both before and after the first RCT results are released. Using variation in the timing of RCTs across off-label uses of drugs, I find that demand responds asymmetrically to the trial results based on the statistical significance of the clinically relevant endpoint. When this endpoint is statistically significant, there is a large and immediate increase in demand. When this end point is not statistically significant, physicians are relatively slow to abandon use of the drug.
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Avdic D, Ivets M, Lagerqvist B, Sriubaite I. Providers, peers and patients. How do physicians' practice environments affect patient outcomes? JOURNAL OF HEALTH ECONOMICS 2023; 89:102741. [PMID: 36878022 DOI: 10.1016/j.jhealeco.2023.102741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 02/10/2023] [Accepted: 02/20/2023] [Indexed: 06/18/2023]
Abstract
We study how physicians' practice environments affect their treatment decisions and quality of care. Using clinical registry data from Sweden, we compare stent choices of cardiologists moving across hospitals over time. To disentangle changes in practice styles attributable to hospital- and peer group-specific factors, we exploit quasi-random variation on cardiologists working together on the same days. We find that migrating cardiologists' stent choices rapidly adapt to their new practice environment after relocation and are equally driven by the hospital and peer environments. In contrast, while decision errors increase, treatment costs and adverse clinical events remain largely unchanged despite the altered practice styles.
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Affiliation(s)
- Daniel Avdic
- Department of Economics, Deakin university, 70 Elgar Road, Burwood, VIC 3125, Australia.
| | - Maryna Ivets
- Ruhr Graduate School in Economics, Germany; CINCH-Health Economics Research Center, Germany
| | - Bo Lagerqvist
- UCR and Department of Medical Sciences, Uppsala University, Sweden
| | - Ieva Sriubaite
- Centre for Health Economics, Monash University, Australia
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5
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Si Y, Bateman H, Chen S, Hanewald K, Li B, Su M, Zhou Z. Quantifying the financial impact of overuse in primary care in China: A standardised patient study. Soc Sci Med 2023; 320:115670. [PMID: 36669284 DOI: 10.1016/j.socscimed.2023.115670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 01/13/2023]
Abstract
Overuse of health care is a potential factor in explaining the rapid increase in health care expenditure in many countries; however, it is difficult to measure overuse. This study employed the novel method of using unannounced standardised patients (SPs) to identify overuse, document its patterns and quantify its financial impact on patients in primary care in China. We trained 18 SPs to present consistent cases of two common chronic diseases and recorded 492 physician-patient interactions in 63 public and private primary hospitals in a capital city in western China in 2017 and 2018. Overuse, defined as the provision of unnecessary medical tests and drugs, was identified by a panel of medical experts based on national clinical guidelines. We estimated linear regression models to investigate how hospital, physician and patient characteristics were associated with overuse and to quantify the financial impact of overuse after controlling for a series of fixed effects. We found overuse in 72.15% of the SP visits. The high prevalence of overuse was similar among public and private hospitals, low-competence and high-competence physicians, male and female physicians, junior and senior physicians and male and female patients, but it varied between patients presenting different diseases. Compared to the non-overuse group, overuse significantly increased the total cost by 117.8%, the test cost by 58.8% and the drug cost by 100.3%. The financial impact of overuse was consistent across the aforementioned hospital, physician and patient characteristics. We suggest that the overuse observed in this study is unlikely to be attributable to physician incompetence but rather to the financing framework for primary care in China. These findings illuminate the cost escalation of primary care in China, which is a form of medical inefficiency that should be urgently addressed.
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Affiliation(s)
- Yafei Si
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia.
| | - Hazel Bateman
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia
| | - Shu Chen
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia
| | - Katja Hanewald
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia
| | - Bingqin Li
- Social Policy Research Centre, University of New South Wales, Sydney, Australia
| | - Min Su
- School of Public Administration, Inner Mongolia University, Hohhot, China
| | - Zhongliang Zhou
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China.
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Attema AE, Galizzi MM, Groß M, Hennig-Schmidt H, Karay Y, L'Haridon O, Wiesen D. The formation of physician altruism. JOURNAL OF HEALTH ECONOMICS 2023; 87:102716. [PMID: 36603361 DOI: 10.1016/j.jhealeco.2022.102716] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/21/2022] [Accepted: 11/29/2022] [Indexed: 06/17/2023]
Abstract
We study how patient-regarding altruism is formed by medical education. We elicit and structurally estimate altruistic preferences using experimental data from a large sample of medical students (N = 733) in Germany at different progress stages in their studies. The estimates reveal substantial heterogeneity in altruistic preferences of medical students. Patient-regarding altruism is highest for freshmen, significantly declines for students in the course of medical studies, and tends to increase again for last year students, who assist in clinical practice. Also, patient-regarding altruism is higher for females and positively associated to general altruism. Altruistic medical students have gained prior practical experience in healthcare, have lower income expectations, and are more likely to choose surgery and pediatrics as their preferred specialty.
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Affiliation(s)
- Arthur E Attema
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, The Netherlands.
| | - Matteo M Galizzi
- Department of Psychological and Behavioural Science, London School of Economics and Political Science, UK.
| | - Mona Groß
- Department of Business Administration and Healthcare Management, University of Cologne, Germany.
| | - Heike Hennig-Schmidt
- Laboratory for Experimental Economics, Department of Economics, University of Bonn, Germany.
| | | | - Olivier L'Haridon
- Center for Research in Economics and Management (CREM), University of Rennes 1, France; Institut Universitaire de France, France.
| | - Daniel Wiesen
- Department of Business Administration and Healthcare Management, University of Cologne, Germany.
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Shurtz I. Heuristic thinking in the workplace: Evidence from primary care. HEALTH ECONOMICS 2022; 31:1713-1729. [PMID: 35607261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 09/12/2021] [Accepted: 05/02/2022] [Indexed: 06/15/2023]
Abstract
We study whether primary care physicians (PCPs) exercise left digit bias with respect to patients' age. Relying on a comprehensive administrative visit level data from a large Israeli HMO, we measure the intensity of patients' medical examination in visits that take place around a decadal birthday-a birthday that ends with zero-within a regression discontinuity framework. We find that in standard settings with clear patient information there is no evidence that PCPs exhibit left digit bias. However, when PCPs meet unfamiliar patients seeking immediate care, they are more likely to use basic diagnostic tests just above the decadal birthday threshold, indicating that under these circumstances, PCPs do use left digit bias.
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Affiliation(s)
- Ity Shurtz
- Department of Economics, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Wu B, David G. Information, relative skill, and technology abandonment. JOURNAL OF HEALTH ECONOMICS 2022; 83:102596. [PMID: 35303551 DOI: 10.1016/j.jhealeco.2022.102596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/16/2022] [Accepted: 01/27/2022] [Indexed: 06/14/2023]
Abstract
We study the role of relative task-specific skill in explaining the heterogeneity in physicians' technology abandonment decisions in response to negative information shocks. We show that after an unexpected FDA safety warning on the use of minimally invasive hysterectomies, physicians alter their procedural mix towards open procedures and away from the minimally invasive procedures. This effect is less pronounced for physicians more skilled in performing minimally invasive procedures relative to open procedures, highlighting relative skill as an explanation for differential technology abandonment. Since physicians with higher relative skill are more likely to use minimally invasive procedures before the FDA safety communication, we find that the FDA intervention led to a substantial increase in practice variation across physicians with different relative skill levels. These findings are consistent with a theoretical model that predicts physicians' response to new information regarding the effectiveness of medical technology.
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Affiliation(s)
- Bingxiao Wu
- Department of Economics, Rutgers University, 75 Hamilton St, New Brunswick, NJ, 08901 USA.
| | - Guy David
- Department of Health Care Management, The Wharton School, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 305 Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA, 19104 USA.
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Su M, Zhou Z, Si Y, Fan X. The Association Between Patient-Centered Communication and Primary Care Quality in Urban China: Evidence From a Standardized Patient Study. Front Public Health 2022; 9:779293. [PMID: 35186869 PMCID: PMC8854212 DOI: 10.3389/fpubh.2021.779293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 12/22/2021] [Indexed: 11/23/2022] Open
Abstract
Background Effective patient-physician communication has been considered a central clinical function and core value of health system. Currently, there are no studies directly evaluating the association between patient-centered communication (PCC) and primary care quality in urban China. This study aims to investigate the association between PCC and primary care quality. Methods The standardized patients were used to measure PCC and the quality of health care. We recruited 12 standardized patients from local communities presenting fixed cases (unstable angina and asthma), including 492 interactions between physicians and standardized patients across 63 CHCs in Xi'an, China. PCC was scored on three dismissions: (1) exploring disease and illness experience, (2) understanding the whole person, and (3) finding common ground. We measured the quality of the primary care by (1) accuracy of diagnosis, (2) consultation time, (3) appropriateness of treatment, (4) unnecessary exams; (5) unnecessary drugs, and (6) medical expenditure. Ordinary least-squares regression models with fixed effects were used for the continuous variables and logistic regression models with fixed effects were used for the categorical variables. Results The average score of PCC1, PCC2, and PCC3 was 12.24 ± 4.04 (out of 64), 0.79 ± 0.64 (out of 3), and 10.19 ± 3.60 (out of 17), respectively. The total score of PCC was 23.22 ± 6.24 (out of 84). We found 44.11% of the visits having a correct diagnosis, and 24.19% of the visits having correct treatment. The average number of unnecessary exams and drugs was 0.91 ± 1.05, and 0.45 ± 0.82, respectively. The average total cost was 35.00 ± 41.26 CNY. After controlling for the potential confounding factors and fixed effects, the PCC increased the correct diagnosis by 10 percentage points (P < 0.01), the correct treatment by 7 percentage points (P < 0.01), the consultation time by 0.17 min (P < 0.01), the number of unnecessary drugs by 0.03 items (P < 0.01), and the medical expenditure by 1.46 CNY (P < 0.01). Conclusions This study revealed pretty poor communication between primary care providers and patients. The PCC model has not been achieved, which could be one source of the intensified physician-patient relationship. Our findings showed the PCC model in the primary care settings has positive associations with the quality of the primary care. Interactions with a higher score of PCC were more likely to have a correct diagnosis and correct treatment, more consultation time, more unnecessary drugs, and higher medical expenditure. To improve PCC, the clinical capacity and communication skills of primary care providers need to be strengthened. Also, strategies on reforming the pay structure to better reflect the value of physicians and providing a stronger motivation for performance improvement are urgently needed.
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Affiliation(s)
- Min Su
- School of Public Administration, Inner Mongolia University, Hohhot, China
| | - Zhongliang Zhou
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China
- *Correspondence: Zhongliang Zhou
| | - Yafei Si
- School of Risk & Actuarial Studies and CEPAR, University of New South Wales, Sydney, NSW, Australia
| | - Xiaojing Fan
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China
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Kristiansen IL. Consequences of serious parental health events on child mental health and educational outcomes. HEALTH ECONOMICS 2021; 30:1772-1817. [PMID: 33931927 DOI: 10.1002/hec.4278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 03/28/2021] [Accepted: 03/29/2021] [Indexed: 06/12/2023]
Abstract
I show that serious, yet common, parental health events in childhood have immediate and lasting effects on mental health and educational outcomes for children. Following a parental health event, the children are more likely to receive therapy and consume anti-depressant (AD) medication. More so, the children achieve lower test scores and have lower school enrollment rates. The effect immediately occurs following the event and persists at least into early adulthood. I find that the effect on test scores doesn't differ significantly across family income, but that children from low-income families are more likely to be prescribed ADs following the event, while children from high-income families are more likely to receive therapy. Exploiting differences in general practitioners' behavior in prescribing AD and referring children to therapy, I find suggestive evidence that children who are more exposed to medical treatment of mental health issues have lower educational attainments in early adulthood.
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Dubois P, Tunçel T. Identifying the effects of scientific information and recommendations on physicians' prescribing behavior. JOURNAL OF HEALTH ECONOMICS 2021; 78:102461. [PMID: 33991803 PMCID: PMC8384687 DOI: 10.1016/j.jhealeco.2021.102461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 06/12/2023]
Abstract
We investigate how the prescribing behavior of physicians reacts to scientific information and recommendations released by public authorities. Taking the example of antidepressant drugs, we use French panel data on exhaustive prescriptions made by a representative sample of general practitioners to more than 110,000 depressed patients between 2000 and 2008. New results revealing an increase in suicidal thinking among children taking selective serotonin reuptake inhibitors (SSRIs) were reported in 2004 and prompted the release of new guidelines by public health authorities. We identify the effect of this unexpected warning on physicians' drug choices while addressing the possibility that patients heterogeneity may be correlated with unobserved physician characteristics. While the warning decreased the average probability of prescribing SSRIs, we find that physicians' responses to the warning were very heterogeneous and larger if the physician had a higher preference for prescribing SSRIs before the warning.
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Affiliation(s)
- Pierre Dubois
- Toulouse School of Economics, Université de Toulouse Capitole, Toulouse, France.
| | - Tuba Tunçel
- Department of Applied Economics, HEC Montreal, Canada.
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Cuddy E, Currie J. Treatment of mental illness in American adolescents varies widely within and across areas. Proc Natl Acad Sci U S A 2020; 117:24039-24046. [PMID: 32958646 PMCID: PMC7533674 DOI: 10.1073/pnas.2007484117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Many mental health disorders first manifest in adolescence, and early treatment may affect the course of the disease. Using a large national database of insurance claims, this study focuses on variations in the type of care that adolescent patients receive when they are treated for an initial episode of mental illness. We found large variations in the probability that children receive follow-up care and in the type of follow-up care received across zip codes. We also found large variations in the probability that children receive drug treatments that raise a red flag when viewed through the lens of treatment guidelines: Overall, in the first 3 mo after their initial claim for mental illness, 44.85% of children who receive drug treatment receive benzodiazepines, tricyclic antidepressants, or a drug that is not Food and Drug Administration-approved for their age. On average, these children are 12 y old. While the supply of mental health professionals impacts treatment choices, little of the overall variation is explained by supply-side variables, and at least half of the variation in treatment outcomes occurs within zip codes. These results suggest that other factors, such as physician practice style, may play an important role in the types of treatment that children receive.
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Affiliation(s)
- Emily Cuddy
- Department of Economics, Princeton University, Princeton, NJ 08540
| | - Janet Currie
- Center for Health and Wellbeing, Princeton University, Princeton, NJ 08540
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Currie JM, Macleod WB. UNDERSTANDING DOCTOR DECISION MAKING: THE CASE OF DEPRESSION TREATMENT. ECONOMETRICA : JOURNAL OF THE ECONOMETRIC SOCIETY 2020; 88:847-878. [PMID: 32981946 PMCID: PMC7514077 DOI: 10.3982/ecta16591] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Treatment for depression is complex, requiring decisions that may involve trade-offs between exploiting treatments with the highest expected value and experimenting with treatments with higher possible payoffs. Using patient claims data, we show that among skilled doctors, using a broader portfolio of drugs predicts better patient outcomes, except in cases where doctors' decisions violate loose professional guidelines. We introduce a behavioral model of decision making guided by our empirical observations. The model's novel feature is that the trade-off between exploitation and experimentation depends on the doctor's diagnostic skill. The model predicts that higher diagnostic skill leads to greater diversity in drug choice and better matching of drugs to patients even among doctors with the same initial beliefs regarding drug effectiveness. Consistent with the finding that guideline violations predict poorer patient outcomes, simulations of the model suggest that increasing the number of possible drug choices can lower performance.
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