by  Elske van den Akker , PhD; and Wilbert van den Hout , PhD; Department of Biomedical Data Sciences - Leiden University Medical Center, The Netherlands

In cost-effectiveness analysis the difference in costs between an intervention and usual care is compared to their difference in effects. This results in a so-called cost-effectiveness ratio, preferably expressed as cost per quality-adjusted life year (QALY). This ratio can then be compared to a cost-effectiveness threshold to decide whether the intervention is good value for money.

 

Cost-effectiveness thresholds vary between countries. The short poll in the Winter edition of the SMDM e-newsletter (n=49) shows lower current thresholds in Asia/Australia and higher thresholds in North America, with Europe somewhat in between. Also, within countries reported thresholds vary. This may be due to the lack of explicit thresholds. For example, for North America mainly $50,000 and $100,000 are referenced to and sometimes higher (Neumann et al. 2014). Another cause of variation is the use of additional criteria, as for example a special concern for the worse-off in Norway (Ottersen et al. 2016). 

by Liesbeth M van Vliet , PhD ( [email protected] ); Inge Spronk , PhD; Marianne Heins , PhD; Sandra van Dulmen , PhD

"You matter because you are you, and you matter to the end of your life. We will do all we can, not only to help you die peacefully, but also to live until you die" - Dame Cicely Saunders, founder of the modern Hospice movement.

The confrontation with a life-limiting diagnosis impacts patients and their loved ones profoundly, evoking emotions such as anxiety and uncertainty. Medical practitioners have a role to guide and support patients in their remaining life journey. But within the current medical era, in which treatment options and decisions are becoming increasingly complex, this is no easy task.

Implementation of shared decision making (SDM) is seen as crucial to ensure patients receive care that enables them to live their life meaningfully until the end. SDM is especially relevant when patients face decisions between (further) aggressive treatments that might prolong life whilst also affecting quality of life or less invasive treatments that focus primarily on relieving symptoms and alleviating suffering.

SDM is associated with positive outcomes in palliative care. Patients who are more involved in decision making rate the quality of clinician communication and received care higher, and there are suggestions that they experience a better quality of life.

Despite the relevance and potential benefits of SDM for the palliative care setting, implementation is sparse and inconsistent. Consultation of Dutch experts (i.e., clinicians, patients, and researchers) identified preconditions for SDM that must be met. These preconditions occur on the level of the organization, professional, professional-patient interaction and the patient (see Figure). Some key preconditions relevant on several levels will now briefly be highlighted.

First, time. Organizations need to create time for SDM to occur. Professionals and patients should be given the opportunity to hold multiple, or longer, consultations, and providing patients with enough time for SDM is also a professional’s responsibility. Such recommendations fit within current worldwide reimbursement initiatives (e.g., via Medicare in the US) to discuss patients’ care preferences.

Second, choice awareness. All relevant treatment options, including the option of not starting or foregoing active cancer treatment, need to be explicitly discussed. In clinical care, the option of ‘no treatment’ seems not to be consistently presented to patients, which might contribute to the current situation in which patients often receive aggressive therapy until the end of life, impairing their quality of life.

Third, good communication skills and tailored information. Ideally, professionals should know something about patients’ background and consider cultural differences. This is in line with patients’ expressed desire to be seen as a person instead of a ‘bundle of symptoms’. Caregivers also need to be acknowledged since they might act as contact person and since discrepancies with patient preferences might exist.

While these preconditions can lay a fruitful foundation for SDM to take place, we should not overlook that not all patients (some suggest up to 30%) are willing or able to be involved in the decision-making process. In such cases, when all treatment options have been discussed, clinicians could elicit patients’ priorities and use these to propose a specific choice.

Recognizing these preconditions may enable a more central role for SDM in clinical palliative care. Ultimately, though, SDM is not an aim in itself, but a stepping-stone towards improved patient outcomes. Assisting patients in making decisions, to support them in living their life until they die, is what counts at the end of the day, and the end of life. 

by Muge Capan , PhD; Drexel University

 As national reports call for new partnerships to address major changes of the 21 ^st century in health and medicine, there is a growing focus on disruptive transformation in healthcare. Disruptive transformation relies on harnessing data through multi-disciplinary approaches that draw from computer and information sciences, engineering, economic sciences, biomedical and health services research. The Operations Research Interest Group (OR IG) within the Society of Medical Decision Making (SMDM) is a multidisciplinary interest group of professionals that are passionate about taking an analytical approach to this transformation in healthcare. Our membership has grown significantly since the initiation of the interest group in 2015. Our first publication as a group [1] highlights our interest in leveraging rigorous methodologies for complex decision making problems and presents promising future research areas.

Our members are actively working on development and integration of breakthrough ideas in a variety of areas, e.g., diagnosis and treatment optimization for complex health conditions such as sepsis, translating data to knowledge by addressing the seven V’s of big data (volume, velocity, variety, variability, veracity, visualization and value), and advancement of health information technology, such as clinical decision support systems.

 

We ask the SMDM community - with or without OR background, but with an interest in our mission - to join us as we tackle next-generation decision making problems that require addressing barriers arising from uncertainty inherent to healthcare, heterogeneity of data, and an aging population. Cross-disciplinary collaboration is key to high-risk/high-reward solutions, and being an SMDM OR IG member brings you one step closer to generating value in healthcare through collaboration!

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[1] Capan M, Khojandi A, Denton BT, Williams KD, Ayer T, Chhatwal J, Kurt M, Mason Lobo J, Roberts MS, Zaric G, Zhang S, Schwartz JS (2017) From Data to Improved Decisions: Operations Research in Healthcare. Medical Decision Making. In Press.

by  Eline Krijkamp , MSc; Erasmus University at Rotterdam, and Eva Enns , PhD; University of Minnesota, on behalf of the Decision Analysis in R for Technologies in Health (DARTH) workgroup

In a previous newsletter , Fernando Alarid-Escudero emphasized the increasing popularity of Open-Source Software (OSS), such as the R programming language, in health decision sciences (HDS). The use of R or other open-source programming languages facilitates research transparency, reproducibility, collaboration, and accessibility. However, an important drawback to the use of OSS such as R has been its steep learning curve.

To increase visibility and improve accessibility of R in the HDS community, we created the Decision Analysis in R for Technologies in Health (DARTH) Workgroup during SMDM’s 37th Annual North American Meeting. DARTH is an international collaboration of researchers ^[1] who are committed to enhancing the use of the R programming language in the HDS through tutorial papers, short courses, and the development of new user-friendly, open-source tools for HDS modeling.

To date, DARTH has achieved several accomplishments. We published our first article in Medical Decision Making last year summarizing the existing functionality in R for decision analysis. A tutorial paper describing an implementation framework for microsimulation models in R is forthcoming. Tutorial papers on additional topics, such as implementing decision trees and Markov cohort models in R, are in preparation.

A major accomplishment in improving the usability of R for our community was the creation of OpenTree by DARTH member Dr. Hawre Jalal . OpenTree is an online tool and graphical user-interface for interactively building decision trees and Markov models. OpenTree then translates the user-defined model into R code for integration with more advanced functionality.

Pedagogically, we have created extensive course materials on the use of R in HDS, which we offer regularly as short courses at SMDM meetings and as stand-alone workshops for university and industry audiences. We are gratified by our participants’ enthusiasm for these courses and support for more openness and transparency in medical decision making. All of this motivates us to work even harder, with plans to tackle more advanced topics, such as sensitivity analysis, model calibration, and value of information.

Please visit our website for updates on future course offerings and publications or join our mailing list by emailing [email protected] .

^[1] DARTH Workgroup members: Fernando Alarid-Escudero , PhD, University of Minnesota; Eva Enns , PhD, University of Minnesota; Hawre Jalal , PhD, University of Pittsburgh; Petros Pechlivanoglou , PhD, The Hospital for Sick Children and University of Toronto; Eline Krijkamp , MSc, Erasmus University at Rotterdam; and Myriam Hunink , PhD, MD, Erasmus University at Rotterdam and Harvard T.H. Chan School of Public Health. 

by Mark Liebow , MD, MPH; Mayo Clinic

The Federal government partly shut down for a long weekend in January and for a few hours in February, because the continuing resolutions that had permitted the government to spend money expired. The second shutdown led to another continuing resolution that will last through March 23. The better news is that a bipartisan agreement led to setting budget targets for the rest of Fiscal Year 2018 and for Fiscal Year 2019 that were higher than the original targets. While more of the extra spending will go to discretionary defense spending than to discretionary domestic spending, there’s enough new money for the latter category that some research agencies, notably the National Institutes of Health (NIH), should get extra funding. The NIH could get up to $2 billion more over the two years. Budget targets are not appropriations and the Appropriation Committees in the House and Senate are working to decide exactly what every part of the government should get. However, if an appropriations bill isn’t signed by the President by March 23rd, we’ll need another continuing resolution. The bill that ended the February shutdown also extended the Children’s Health Insurance Program (CHIP) for another four years, i.e., through 2028. It raised the debt ceiling, so we don’t have to worry about the government defaulting on its debt for a year or two (or worry about legislators tying obnoxious legislation onto a bill that raises the debt ceiling).

President Trump’s proposed Fiscal 2019 budget proposes less in funding for Federal research agencies. The NIH would absorb three research agencies, including the Agency for Health Care Research and Quality (AHRQ), without additional funding for them. It also proposes a $48 billion cut over ten years to graduate medical education (GME) by consolidating Medicare, Medicaid and Children’s Hospital GME (CHGME) spending in 2016 into a single, capped grant program funded through the annual appropriations process. This would be the biggest change in GME funding in a generation, but it is not likely to pass. Similarly, a proposed $71 billion cut over 10 years in Medicare is unlikely to go far.

Alex Azar was confirmed as Secretary of the Department of Health and Human Services in January. A week later, Brenda Fitzgerald, the Director of the Centers for Disease Control and Prevention resigned because of financial conflicts of interest, including buying tobacco stocks after she became Director. David Shulkin, MD, the Secretary at the Department of Veterans Affairs is in a pitched battle with some of his subordinates there, in part about how much the health care system should be privatized. Right now, the President is supporting Shulkin, but that may not last. 

Registration is now open for the 17th Biennial European Conference, being held 10 -12 June 2018 in Leiden, The Netherlands. Leiden is a beautiful historic city, and only 20 minutes by direct train from Schiphol International Airport. The 2018 conference special focus is on  Personalized and Value-Based Health Care .

The Keynote speaker is David Spiegelhalter, PhD , who will focus on Communicating the Potential Benefits and Harms of Treatments in an Impartial Way. The conference will feature over 200 oral and poster abstracts, 10 workshops and 14 short courses spanning several topics in medical decision making as well as a proposed symposium on Prediction Models: From the Model to the Consultation.

The 17th Biennial European Conference is a Patients Included™ conference. Learn more about how the conference meets the five Patients Included charter clauses.

Short courses and the Welcome Reception/Poster Session 1 will be held on Sunday 10 June at Leiden University Medical Center. The general conference will be held from 11 - 12 June at the Stadsgehoorzaal. Join us for a fun night of dinner and dancing at the Social Event, which will be held at the Scheltema on Monday evening 11 June . We hope to see you in Leiden!

Conference Co-Chairs: Anne M. Stiggelbout, PhD and Ewout W. Steyerberg, PhD

SMDM is now accepting abstract and short course proposals to be presented at its 40th Annual Meeting in Montreal, Canada. The deadline to submit proposals is Tuesday, May 15, 2018. All submissions will be reviewed and notifications sent out in late July 2018.

For more than four decades, SMDM members have sought to improve the health care experiences and health of people at every stage of life. There are differences in the health issues confronting people at different life stages, and there are also commonalities bridging different stages. As SMDM reaches middle age and looks ahead to the next 40 years and beyond, the 2018 Annual Meeting will bring together patients, families, health professionals, policymakers, researchers, and other stakeholders to discuss the latest evidence about making better decisions for better health.

The 40th Annual Meeting will be a Patients Included™ meeting, where patients will be in attendance and appear as presenters. Additionally, SMDM is a multidisciplinary society and welcomes attendees such as policymakers. Please do your best to write about and present your work in a way that is understandable to an audience of peers and other experts.

Meeting co-chairs: Holly Witteman, PhD; William Dale , MD, PhD; Isabel Jordan , Parent/Patient Partner and Beverly Canin , Patient Partner

As of April 1, 2018, John F P Bridges, PhD, has taken up a new position as Professor in the Departments of Biomedical Informatics and Surgery within the Ohio State University College of Medicine. At OSU, he will be core faculty within the newly created Center for the Advancement of Team Science, Analytics and Systems Thinking in Health Systems Research and Implementation Science (CATALYST) and the Center for Surgical Health Assessment, Research and Policy (SHARP). At OSU, John will focus on conducting research to promote the translation and implementation of advances in medicine through informed decision making. He will continue to conduct research to advance and apply methods to promote a greater understanding of the preferences of patients and other stakeholders in medicine, especially as it relates to regulatory science. He will also build new partnerships to promote precision medicine, including demonstrating how “economics” can contribute to a multi-omics view of human disease and treatment. If you need to find John, his new email i s [email protected].

Researchers with the Center for Health Decision Science at the Harvard T.H. Chan School of Public Health are conducting a survey on best practices for cost-effectiveness research. We are recruiting respondents who have taken at least one class on cost-effectiveness research and/or written at least one publication using cost-effectiveness analysis. The survey should take 7-10 minutes to complete and can be accessed through this link . At the end of the survey, participants will be given an opportunity to enter their emails for a chance to a $25 Amazon gift card; we will give out 5 gift cards in total. Please contact Ankur Pandya ( [email protected] ) or Alyssa Bilinski ( [email protected] ) with any questions.

Proposals Due: Friday 20 April 2018, 12:00 noon CET

The European Cooperation in Science and Technology (COST)  is the longest-running European framework supporting trans-national cooperation among researchers, engineers and scholars across Europe.  Interested parties are invited to submit proposals for COST Actions contributing to the scientific, technological, economic, cultural or societal knowledge advancement and development of Europe. Multi and interdisciplinary proposals are encouraged. The call process is open year-round with the next round of proposals entering the evaluation process in late April 2018.

As an interdisciplinary academic research society with members throughout Europe, SMDM would welcome the chance to discuss this funding source. Our Biennial European Conference and other activities may serve as a resource for groups preparing to submit a proposal to COST. Please contact SMDM President Uwe Siebert  or Executive Director  Jill Metcalf  if you would like to further discuss this opportunity.

University of Utah - Assistant Professor, Division of Health System Innovation and Research

Postdoc Position at Mass General/Harvard

Senior Health Systems Scientist, New York

FDA: Associate Director for Scientific Staffing

Research Fellow - Healthcare Policy & Research, Mayo Clinic College of Medicine

Research Assistant Professor, Department of Health Policy and Management (HPM), University of Pittsburgh: Open Until Filled