Prospective Cohort Study

NUDGE: IMPROVING DECISIONS ABOUT HEALTH, WEALTH, AND HAPPINESS by Richard H. Thaler and Cass R. Sunstein Penguin Books, 2009, 312 pp, ISBN 978-0-14-311526-7This book is best described formally as a general explanation of and advocacy for libertarian paternalism, a term coined by the authors in earlier publications. Informally, it is about how leaders, systems, organizations, and governments can nudge people to do the things the nudgers want and need done for the betterment of the nudgees, or of society. It is paternalism in the sense that "it is legitimate for choice architects to try to influence people's behavior in order to make their lives longer, healthier, and better", (p. 5) It is libertarian in that "people should be free to do what they like - and to opt out of undesirable arrangements if they want to do so", (p. 5) The built-in possibility of opting out or making a different choice preserves freedom of choice even though people's behavior has been influenced by the nature of the presentation of the information or by the structure of the decisionmaking system. I had never heard of libertarian paternalism before reading this book, and I now find it fascinating.Written for a general audience, this book contains mostly social and behavioral science theory and models, but there is considerable discussion of structure and process that has roots in mathematical and quantitative modeling. One of the main applications of this social system is economic choice in investing, selecting and purchasing products and services, systems of taxes, banking (mortgages, borrowing, savings), and retirement systems. Other quantitative social choice systems discussed include environmental effects, health care plans, gambling, and organ donations. Softer issues that are also subject to a nudge-based approach are marriage, education, eating, drinking, smoking, influence, spread of information, and politics. There is something in this book for everyone.The basis for this libertarian paternalism concept is in the social theory called "science of choice", the study of the design and implementation of influence systems on various kinds of people. The terms Econs and Humans, are used to refer to people with either considerable or little rational decision-making talent, respectively. The various libertarian paternalism concepts and systems presented are tested and compared in light of these two types of people. Two foundational issues that this book has in common with another book, Network of Echoes: Imitation, Innovation and Invisible Leaders, that was also reviewed for this issue of the Journal are that 1 ) there are two modes of thinking (or components of the brain) - an automatic (intuitive) process and a reflective (rational) process and 2) the need for conformity and the desire for imitation are powerful forces in human behavior. …

Nudge: Improving Decisions about Health, Wealth, and Happiness

Additional co-authors: Endre Czeiter, Marek Czosnyka, Ramon Diaz-Arrastia, Jens P Dreier, Ann-Christine Duhaime, Ari Ercole, Thomas A van Essen, Valery L Feigin, Guoyi Gao, Joseph Giacino, Laura E Gonzalez-Lara, Russell L Gruen, Deepak Gupta, Jed A Hartings, Sean Hill, Ji-yao Jiang, Naomi Ketharanathan, Erwin J O Kompanje, Linda Lanyon, Steven Laureys, Fiona Lecky, Harvey Levin, Hester F Lingsma, Marc Maegele, Marek Majdan, Geoffrey Manley, Jill Marsteller, Luciana Mascia, Charles McFadyen, Stefania Mondello, Virginia Newcombe, Aarno Palotie, Paul M Parizel, Wilco Peul, James Piercy, Suzanne Polinder, Louis Puybasset, Todd E Rasmussen, Rolf Rossaint, Peter Smielewski, Jeannette Soderberg, Simon J Stanworth, Murray B Stein, Nicole von Steinbuchel, William Stewart, Ewout W Steyerberg, Nino Stocchetti, Anneliese Synnot, Braden Te Ao, Olli Tenovuo, Alice Theadom, Dick Tibboel, Walter Videtta, Kevin K W Wang, W Huw Williams, Kristine Yaffe for the InTBIR Participants and Investigators

/pdf/traumatic-brain-injury-integrated-approaches-to-improve-29obvlh2iu.pdf

Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research

BACKGROUND: The Institute of Medicine calls for physicians to engage patients in making clinical decisions, but not every patient may want the same level of participation. OBJECTIVES: 1) To assess public preferences for participation in decision making in a representative sample of the U.S. population. 2) To understand how demographic variables and health status influence people’s preferences for participation in decision making. DESIGN AND PARTICIPANTS: A population-based survey of a fully representative sample of English-speaking adults was conducted in concert with the 2002 General Social Survey (N=2,765). Respondents expressed preferences ranging from patient-directed to physician-directed styles on each of 3 aspects of decision making (seeking information, discussing options, making the final decision). Logistic regression was used to assess the relationships of demographic variables and health status to preferences. MAIN RESULTS: Nearly all respondents (96%) preferred to be offered choices and to be asked their opinions. In contrast, half of the respondents (52%) preferred to leave final decisions to their physicians and 44% preferred to rely on physicians for medical knowledge rather than seeking out information themselves. Women, more educated, and healthier people were more likely to prefer an active role in decision making. African-American and Hispanic respondents were more likely to prefer that physicians make the decisions. Preferences for an active role increased with age up to 45 years, but then declined. CONCLUSION: This population-based study demonstrates that people vary substantially in their preferences for participation in decision making. Physicians and health care organizations should not assume that patients wish to participate in clinical decision making, but must assess individual patient preferences and tailor care accordingly.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1525-1497.2005.04101.x

Not all patients want to participate in decision making. A national study of public preferences.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1524-4733.2004.75003.x

Use of Cost‐Effectiveness Analysis in Health‐Care Resource Allocation Decision‐Making: How Are Cost‐Effectiveness Thresholds Expected to Emerge?

Life expectancy in Sweden is high and the country performs well in comparisons related to disease-oriented indicators of health service outcomes and quality of care. The Swedish health system is committed to ensuring the health of all citizens and abides by the principles of human dignity, need and solidarity, and cost-effectiveness. The state is responsible for overall health policy, while the funding and provision of services lies largely with the county councils and regions. The municipalities are responsible for the care of older and disabled people. The majority of primary care centres and almost all hospitals are owned by the county councils. Health care expenditure is mainly tax funded (80%) and is equivalent to 9.9% of gross domestic product (GDP) (2009). Only about 4% of the population has voluntary health insurance (VHI). User charges fund about 17% of health expenditure and are levied on visits to professionals, hospitalization and medicines. The number of acute care hospital beds is below the European Union (EU) average and Sweden allocates more human resources to the health sector than most OECD countries. In the past, the Achilles heel of Swedish health care included long waiting times for diagnosis and treatment and, more recently, divergence in quality of care between regions and socioeconomic groups. Addressing long waiting times remains a key policy objective along with improving access to providers. Recent principal health reforms over the past decade relate to: concentrating hospital services; regionalizing health care services, including mergers; improving coordinated care; increasing choice, competition and privatization in primary care; privatization and competition in the pharmacy sector; changing co-payments; and increasing attention to public comparison of quality and efficiency indicators, the value of investments in health care and responsiveness to patients needs. Reforms are often introduced on the local level, thus the pattern of reform varies across local government, although mimicking behaviour usually occurs.

Sweden health system review.

The Swedish health care system is largely the product of past Social Democratic governments, which emphasized equity and reliance on the public sector. But since 1990, more centrist governments have turned to privatization, competition, and greater consumer choice.

The Public–Private Pendulum — Patient Choice and Equity in Sweden

Patient views on choice and participation in primary health care

http://doc.rero.ch/record/203023/files/crivelli_HP_2012.pdf

Leadership and governance in seven developed health systems

Swedish health care, run by local governments at both the regional (county) and the municipal levels, has been under pressure during the last 15 years, following increased scrutiny of performance and demand for cost-containment. Health-care expenditures per capita and levels of resource inputs have grown, but more slowly than in other EU countries. At the same time, the number of elderly people has increased, as have options for medical treatment. In the late 1980s, several local governments referred to long waiting-lists for elective treatment and anecdotal evidence of inefficiency and poor responsiveness when arguing for market-oriented reforms. A purchaser-provider split followed, and so did changes in the payment systems for health-care providers. According to the available evidence, these reforms yielded an increased volume of services in the short run; but traditional hierarchical management soon replaced the new incentives. Moreover, evidence suggests that changes introduced by the national government, and the deteriorating funding conditions together with a continued use of new medical technology, have had more far-reaching effects on health-care output and outcome than local-government reforms.

Anders Anell

Papers

Sweden health system review.

The Public–Private Pendulum — Patient Choice and Equity in Sweden

Patient views on choice and participation in primary health care

Leadership and governance in seven developed health systems

Swedish healthcare under pressure