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A simple decision model that introduces the 10 ingredients of good decisions, the grammar of decision making, and a five-step framework for creating decision models.
Event trees show decisions to take now that can mitigate subsequent unfavourable events defining the risk of a situation, whereas fault trees assume an unfavourable event has occurred, with decisions to be taken that reduce the undesirable consequences and their likelihood of occurring if a fault occurs in a complex system. Two case studies provide examples. Scenario analysis provides a way to understand deep uncertainty.
The people who started decision theory, how they identified the key quantifiable ingredients of good decisions: values, trade-offs and probabilities, then turned this mathematical beginning into the applied discipline of decision analysis.
• Thinking strategically means considering what and why before deciding how and when, shaped by context, the organisation’s mission and vision, focused by strategic intent, and made practical by intermediate goals or challenges. A case study shows how this approach helped an umbrella organisation to reshape its future to better serve its members in providing health care. A final case study integrated three model types enabling the US response to unrest in the Middle East.
The choice between transcatheter and surgical pulmonary valve replacement for young adults with repaired tetralogy of Fallot who develop significant pulmonary valve insufficiency is challenging. Decision analytic modelling may be used to simulate long-term outcomes and suggest influential clinical thresholds for decision-making. A Markov model was constructed to compare the 5-year outcomes for a hypothetical cohort of 18-year-old patients.
Methods:
A Markov model was constructed to simulate 10,000 hypothetical patients undergoing either transcatheter pulmonary valve replacement or surgical pulmonary valve replacement. Model inputs were abstracted from contemporary literature on the 5-year horizon. Outputs were used to derive an incremental cost-effectiveness ratio. Sensitivity and threshold analyses were performed to identify factors that would hypothetically change management.
Results:
From modelling, surgical pulmonary valve replacement had superior survival, lower incidence of endocarditis, and lower reintervention rate compared to transcatheter pulmonary valve replacement at 5 years. Surgical pulmonary valve replacement yielded lower cumulative postprocedural costs ($10,767 versus $14,528) and greater quality-adjusted life years (3.16 versus 3.12 QALYs) than transcatheter pulmonary valve replacement. The calculated incremental cost-effectiveness ratio (−88,743$/QALY) identified surgical pulmonary valve replacement as the preferred strategy at baseline. Sensitivity analysis demonstrated that transcatheter pulmonary valve replacement would be the preferred strategy if either the post-transcatheter pulmonary valve replacement endocarditis rate or the post-transcatheter pulmonary valve replacement surgical reintervention rate were reduced to 0%/month.
Conclusions:
Comprehensive modelling of diverse outcomes showed that surgical pulmonary valve replacement had superior mid-term cost-effectiveness outcomes compared to transcatheter pulmonary valve replacement for young adults with repaired tetralogy of Fallot and pulmonary valve regurgitation. Sensitivity analysis found that the prevalence of post-transcatheter pulmonary valve replacement endocarditis and post-transcatheter pulmonary valve replacement surgical reintervention were influential outcomes for centres to consider when choosing between these strategies.
In today's data-driven world, this book offers clear, accessible guidance on the logical foundations of optimal decision making. It introduces essential tools for decision analysis and explores psychological theories that explain how people make decisions in both professional and personal contexts. Using real-world examples, the book covers topics such as decision making under uncertainty, decision trees, strategies of risk management, decisions that are gambles, heuristics, trade-offs, decision making under stress, game theory, decision making in a dispute or conflict, and multi-attribute decision analysis. Readers will identify common decision traps and learn how to avoid them, understand the causes of indecisiveness and find out how to deal with it, gain insights into their own decision-making processes, and build confidence in their ability to make and defend informed decisions across a range of scenarios.
Rare diseases (RD)-related policies have received significant attention due to the pressing medical requirements associated with these medical conditions and the substantial impact and treatments they may have on healthcare budgets. Nevertheless, policymakers frequently encounter difficulties in managing issues concerning resource allocation and prioritization within this population. Realizing the need to address such problems, this study was conducted to develop a framework based on the multicriteria decision analysis to improve RD reimbursement prioritization in Malaysia.
Methods
Primarily, a scoping review was performed to identify the methods and criteria used for the reimbursement of RD treatment, followed by strategic stakeholder engagement and a deliberative process on determining the best approach for the framework, including criteria identification, elicitation of weights, and a pilot assessment using the framework.
Results
The findings reflected the priorities and perspectives of the stakeholders, which identified eight key criteria and their associated weights, namely effectiveness (19.6 percent), disease severity (15.6 percent), safety (14.2 percent), access to treatment (12.6 percent), economic consideration (12.2 percent), type of therapeutic treatment (11.5 percent), availability of alternatives (8.3 percent), and population group (6 percent).
Conclusions
In summary, the developed framework was well-accepted by the Rare Disease Committee, which will be applied as part of the committee deliberation for transparent and equitable decision making on fund allocation and reimbursement of orphan and RD treatment in Malaysia.
A clinical tool to estimate the risk of treatment-resistant schizophrenia (TRS) in people with first-episode psychosis (FEP) would inform early detection of TRS and overcome the delay of up to 5 years in starting TRS medication.
Aims
To develop and evaluate a model that could predict the risk of TRS in routine clinical practice.
Method
We used data from two UK-based FEP cohorts (GAP and AESOP-10) to develop and internally validate a prognostic model that supports identification of patients at high-risk of TRS soon after FEP diagnosis. Using sociodemographic and clinical predictors, a model for predicting risk of TRS was developed based on penalised logistic regression, with missing data handled using multiple imputation. Internal validation was undertaken via bootstrapping, obtaining optimism-adjusted estimates of the model's performance. Interviews and focus groups with clinicians were conducted to establish clinically relevant risk thresholds and understand the acceptability and perceived utility of the model.
Results
We included seven factors in the prediction model that are predominantly assessed in clinical practice in patients with FEP. The model predicted treatment resistance among the 1081 patients with reasonable accuracy; the model's C-statistic was 0.727 (95% CI 0.723–0.732) prior to shrinkage and 0.687 after adjustment for optimism. Calibration was good (expected/observed ratio: 0.999; calibration-in-the-large: 0.000584) after adjustment for optimism.
Conclusions
We developed and internally validated a prediction model with reasonably good predictive metrics. Clinicians, patients and carers were involved in the development process. External validation of the tool is needed followed by co-design methodology to support implementation in early intervention services.
We investigate the reengineeering of interbank networks with a specific focus on capital increase. We consider a scenario where all other components of the network’s infrastructure remain stable (a practical assumption for short-term situations). Our objective is to assess the impact of raising capital on the network’s robustness and to address the following key aspects. First, given a predefined target for network robustness, our aim is to achieve this goal optimally, minimizing the required capital increase. Second, in cases where a total capital increase has been determined, the central challenge lies in distributing this increase among the banks in a manner that maximizes the stability of the network. To tackle these challenges, we begin by developing a comprehensive theoretical framework. Subsequently, we formulate an optimization model for the network’s redesign. Finally, we apply this framework to practical examples, highlighting its applicability in real-world scenarios.
There is growing evidence to support the use of the psychedelic drug psilocybin for difficult-to-treat depression. This paper compares the cost-effectiveness of psilocybin-assisted psychotherapy (PAP) with conventional medication, cognitive behavioural therapy (CBT), and the combination of conventional medication and CBT.
Methods:
A decision model simulated patient events (response, remission, and relapse) following treatment. Data on probabilities, costs and quality-adjusted life years (QALYs) were derived from previous studies or from best estimates. Expected healthcare and societal costs and QALYs over a 6-month time period were calculated. Sensitivity analyses were used to address uncertainty in parameter estimates.
Results:
The expected healthcare cost of PAP varied from £6132 to £7652 depending on the price of psilocybin. This compares to £3528 for conventional medication alone, £4250 for CBT alone, and £4197 for their combination. QALYs were highest for psilocybin (0.310), followed by CBT alone (0.283), conventional medication alone (0.278), and their combination (0.287). Psilocybin was shown to be cost-effective compared to the other therapies when the cost of therapist support was reduced by 50% and the psilocybin price was reduced from its initial value to £400 to £800 per person. From a societal perspective, psilocybin had improved cost-effectiveness compared to a healthcare perspective.
Conclusions:
Psilocybin has the potential to be a cost-effective therapy for severe depression. This depends on the level of psychological support that is given to patients receiving psilocybin and the price of the drug itself. Further data on long-term outcomes are required to improve the evidence base.
A case study review of a formal decision analysis involving a 10 year old girl. She had just faced the death of a close adult friend, and had become filled with uncertainty and emotion while facing the decision as to whether or not to attend his funeral. The study demonstrates that formal analysis can provide the sensitivity and caring basis for such decision making, thus counteracting some of the criticisms of decision analysis.
When there are multiple competing objectives in a decision-making process, Multi-Attribute Choice scoring models are excellent tools, permitting the incorporation of both subjective and objective attributes. However, their accuracy depends upon the subjective techniques used to construct the attribute scales and their concomitant weights. Conventional techniques using local scales tend to overemphasize small differences in attribute measures, which may yield erroneous conclusions. The Range Sensitivity Principle (RSP) is often invoked to adjust attribute weights when local scales are used. In practice, however, decision makers often do not follow the prescriptions of the Range Sensitivity Principle and under-adjust the weights, resulting in potentially poor decisions. Examples are discussed as is a proposed solution: the use of global scales instead of local scales.
How do people make everyday decisions in order to achieve the most successful outcome? Decision making research typically evaluates choices according to their expected utility. However, this research largely focuses on abstract or hypothetical tasks and rarely investigates whether the outcome is successful and satisfying for the decision maker. Instead, we use an everyday decision making task in which participants describe a personally meaningful decision they are currently facing. We investigate the decision processes used to make this decision, and evaluate how successful and satisfying the outcome of the decision is for them. We examine how well analytic, attribute-based processes explain everyday decision making and predict decision outcomes, and we compare these processes to associative processes elicited through free association. We also examine the characteristics of decisions and individuals that are associated with good decision outcomes. Across three experiments we found that: 1) an analytic decision analysis of everyday decisions is not superior to simpler attribute-based processes in predicting decision outcomes; 2) contrary to research linking associative cognition to biases, free association generates valid cues that predict choice and decision outcomes as effectively as attribute-based approaches; 3) contrary to research favouring either attribute-based or associative processes, combining both attribute-based and associates best explains everyday decisions and most accurately predicts decision outcomes; and 4) individuals with a tendency to attempt analytic thinking do not make more successful everyday decisions. Instead, frequency, simplicity, and knowledge of the decision predict success. We propose that attribute-based and associative processes, in combination, both explain everyday decision making and predict successful decision outcomes.
An experienced decision aider reflects on how misaligned priorities produce decision research that is less useful than it could be. Scientific interest and professional standing may motivate researchers — and their funders and publishers — more powerfully than concern to help people make better
Almost stochastic dominance has been receiving a great amount of attention in the financial and economic literatures. In this paper, we characterize the properties of almost first-order stochastic dominance (AFSD) via distorted expectations and investigate the conditions under which AFSD is preserved under a distortion transform. The main results are also applied to establish stochastic comparisons of order statistics and receiver operating characteristic curves via AFSD.
This article describes a methodology for a risk-informed benefit–cost analysis that includes (i) risk analysis to quantify risk reduction benefits and (ii) uncertainty analyses to quantify probability distributions over costs and benefits. It also summarizes the lessons from 25 applications of this methodology to evaluate R&D projects of the Science and Technology Directorate of the Department of Homeland Security. The article then illustrates the methodology with a specific application to evaluate the benefits and costs of the Advanced Personal Protection System (APPS), a new garment system developed to protect wildland firefighters. The goals of the APPS project were to reduce risk and to improve comfort. The cost analysis revealed that the APPS garments are more expensive by about $279 per garment system. Total costs were roughly $7.3 million, including the upfront project cost and the increased 5 year cost of purchasing the APPS. Benefits from reduced injuries and fatalities resulted in 5 year benefits of about $19.3 million, with an NPV of $13.6 million in 2019 dollars. In the base case, the benefit–cost ratio was 2.87 and the return on investment was 187 % over 5 years. Taking the perspective of a decision-maker when the project was first funded in 2011, NPVs are $11,993,728, $10,025,519, and $7,967,479 in 2011 dollars for discount rates of 0, 3, and 7 % respectively. An uncertainty analysis of the NPV showed a large variability, ranging from the 5th percentile of $6.4 million to a median of $19.3 million to the 95th percentile of $43.7 million in 2019 dollars. This large range was primarily due to the uncertainty about the reduction of fatality and injury risks and the market penetration rates of the new garments.
South Africa's commitment to progressively achieve universal health coverage can lead to the effective and appropriate use of Health Technology Assessment (HTA) to strengthen the healthcare system. The study aimed to analyze the challenges faced in the formal implementation and utilization of HTA in the public health sector.
Methods
Review and analysis of health technology policies and legislation introduced in South Africa since 1965 serves as the backbone of this study. Walt and Gilson's health policy triangle framework and Kingdon's model were used for data analysis. In addition, a semi-structured survey was conducted among key stakeholders, including those attending HTA workshops that were held in 2016 and 2017.
Results
The document review identified appropriate legislative and policy framework for informing healthcare decisions. Survey participants (n = 55) reported limited political support, local capacity, and awareness of HTA as barriers to implementing HTA. They noted that adequate financial resources and availability and sharing of quality data are primary drivers for HTA development. Effective governance, collaboration, and cooperation between key stakeholders of the healthcare system were suggested as possible ways forward for the institutionalization of HTA.
Conclusion
The South African government's goal to introduce the national health insurance program provides an excellent opportunity to formally introduce the use of HTA in decision making. Individual capacity development supported by institutional and organizational environments is urgently needed to achieve its full potential.
A simulation model based on the theory of clinical decision analysis was used to compare outcomes and costs when treating patients with major depressive episodes using either a selective serotonin re-uptake inhibitor (SSRI) or a tricyclic antidepressant (TCA), in comparison with milnacipran (a serotonin), and a norepinephrine re-uptake inhibitor (SNRI). The clinical data used were taken from published meta-analyses. This analysis supports: (1) a comparable efficacy of milnacipran and TCA with a better tolerance; and, (2) an advantage of milnacipran over SSRI for efficacy with a comparable tolerance. Based on these findings, a decision tree was constructed with the assistance of a panel of psychiatrists in order to provide a model of usual clinical practice. Estimates not available from clinical studies were obtained either from literature analysis or from the panel.
Economic appraisal was performed according to the viewpoint of the French national sickness fund (sécurité sociale), and expenditure assessment was limited to direct costs (hospitalizations, antidepressant medications, visits, and laboratory tests). The results suggest that milnacipran is a cost-effective alternative: the expected cost of treatment per depressive episode is lower than either a French representative panel of TCAs (a saving of 288 FF), or SSRIs (a savings of 961 FF). The expected length of clinical remission is slightly higher than comparators. The robustness of these findings was supported by sensitivity analyses.
“Uncertain futures” refers to a set of policy problems that possess some combination of the following characteristics: (i) they potentially cause irreversible changes; (ii) they are widespread, so that policy responses may make sense only on a global scale; (iii) network effects are difficult to understand and may amplify (or moderate) consequences; (iv) time horizons are long; and (v) the likelihood of catastrophic outcomes is unknown or even unknowable. These characteristics tend to make uncertain futures intractable to market solutions because property rights are not clearly defined and essential information is unavailable. These same factors also pose challenges for benefit-cost analysis (BCA) and other traditional decision analysis tools. The diverse policy decisions confronting decision-makers today demand “dynamic BCA,” analytic frameworks that incorporate uncertainties and trade-offs across policy areas, recognizing that: perceptions of risks can be uninformed, misinformed, or inaccurate; risk characterization can suffer from ambiguity; and experts’ tendency to focus on one risk at a time may blind policymakers to important trade-offs. Dynamic BCA – which recognizes trade-offs, anticipates the need to learn from experience, and encourages learning – is essential for lowering the likelihoods and mitigating the consequences of uncertain futures while encouraging economic growth, reducing fragility, and increasing resilience.
Protected area managers often face uncertainty when managing invasive plants at the landscape scale. Crested wheatgrass, a popular forage crop in the Great Plains since the 1930s, is an aggressive invader of native grassland and a problem for land managers in protected areas where seeded roadsides and abandoned fields encroach into the native mixed-grass prairie. Given limited resources, land managers need to determine the best strategy for reducing the cover of crested wheatgrass. However, there is a high degree of uncertainty associated with the dynamics of crested wheatgrass spread and control. To compare alternative management strategies for crested wheatgrass in the face of uncertainty, we conducted a decision analysis based on information from Grasslands National Park. Our analysis involves the use of a spatially explicit model that incorporates alternative management strategies and hypotheses about crested wheatgrass spread and control dynamics. Using a decision tree and assigning probabilities to our alternative hypotheses, we calculated the expected outcome of each management alternative and ranked these alternatives. Because the probabilities assigned to alternative hypotheses are also uncertain, we conducted a sensitivity analysis of the full probability space. Our results show that under current funding levels it is always best to prioritize the early detection and control of new infestations. Monitoring the effectiveness of control is paramount to long-term success, emphasising the need for adaptive approaches to invasive plant management. This type of decision analysis approach could be applied to other invasive plants where there is a need to find management strategies that are robust to uncertainty in the current understanding of how these plants are best managed.