The pros and cons of funnel plots as an aid to risk communication and patient decision making

Funnel plots, which simultaneously display a sample statistic and the corresponding sample size for multiple cases, have a range of applications. In medicine, they are used to display treatment outcome rates and caseload volume by institution, which can inform strategic decisions about health care delivery. We investigated lay people's understanding of such plots and explored their suitability as an aid to individual treatment decisions. In two studies, 172 participants answered objective questions about funnel plots representing the surgical outcomes (survival or mortality rates) of institutions varying in caseload, and indicated their preferred institutions. Accuracy for extracting objective information was high, unless question phrasing was inconsistent with the plot's survival/mortality framing, or participants had low numeracy levels. Participants integrated caseload‐volume and outcome‐rate data when forming preferences, but were influenced by reference lines on the plot to make inappropriate discriminations between institutions with similar outcome rates. With careful choice of accompanying language, funnel plots can be readily understood and are therefore a useful tool for communicating risk. However, they are less effective as a decision aid for individual patient's treatment decisions, and we recommend refinements to the standard presentation of the plots if they are to be used for that purpose.     

Sources of Normativity: How Multicultural Values Emerge

Currently, the common theoretical models of "preferred" decision-making relationships do not correspond well with clinical experience. This interview study of congestive heart failure (CHF) patients documents the variety of patient preferences for decision-making, and the necessity for attention to family involvement. In addition, these findings illustrate the confusion as to the designation of surrogate decision-makers and physicians in charge. We conclude that no single model of physician-patient decision-making should be preferred, and that physicians should first ask patients how they want medical information and decision-making to be handled.     

Physician-patient relations: no more models

Currently, the common theoretical models of "preferred" decision-making relationships do not correspond well with clinical experience. This interview study of congestive heart failure (CHF) patients documents the variety of patient preferences for decision-making, and the necessity for attention to family involvement. In addition, these findings illustrate the confusion as to the designation of surrogate decision-makers and physicians in charge. We conclude that no single model of physician-patient decision-making should be preferred, and that physicians should first ask patients how they want medical information and decision-making to be handled.     

Surrogate consent to non-beneficial research: erring on the right side when substituted judgments may be inaccurate

Part of the standard protection of decisionally incapacitated research subjects is a prohibition against enrolling them unless surrogate decision makers authorize it. A common view is that surrogates primarily ought to make their decisions based on what the decisionally incapacitated subject would have wanted regarding research participation. However, empirical studies indicate that surrogate predictions about such preferences are not very accurate. The focus of this article is the significance of surrogate accuracy in the context of research that is not expected to benefit the research subject. We identify three morally relevant asymmetries between being enrolled and not being enrolled in such non-beneficial research, and conclude that when there is a non-negligible probability that surrogates’ predictions are wrong, it will generally be better to err on the side of not authorizing enrollment.     

Heredity and experience: their relative importance in the development of taste preference in man.

Heritability estimates for sucrose, lactose, and sodium chloride taste preferences were uniformly low in a sample of 311 monozygotic and like-sex dizygotic twin pairs between 9 and 15 years of age. Black children preferred more concentrated solutions of all three tastants than did Caucasian children. This effect was independent of socioeconomic status in the total sample. Males preferred more concentrated solutions of sucrose and lactose than did females- but there were no sex differences in sodium chloride preference. The possibility that early intake experiences may play a role in the determination of enduring taste preferences in Homo sapiens is discussed.     

Do we make decisions for other people based on our predictions of their preferences? evidence from financial and medical scenarios involving risk

Abstract

The ways in which the decisions we make for others differ from the ones we make for ourselves has received much attention in the literature, although less is known about their relationship to our predictions of the recipient’s preferences. The latter question is of particular importance given real-world occurrences of surrogate decision-making which require surrogates to consider the recipient’s preferences. We conducted three experiments which explore this relationship in the medical and financial domains. Although there were mean discrepancies between surrogate predictions and choices, we identified a predictive relationship between the two. Moreover, when participants took high risks for themselves, it seems that they were not willing to do so for others, even when they believed that the recipient’s preferences were similar to their own. We discuss these findings relative to current theories and real-world instances of surrogate decision-making.     

Does young adults’ preferred role in decision making about health,money, and career depend on their advisors’ leadership skills?

Few empirical data exist on how decision making about health differs from that in other crucial life domains with less threatening consequences. To shed light on this issue we conducted a study with 175 young adults (average age 19 years). We presented the participants with scenarios involving advisors who provided assistance in making decisions about health, money, and career. For each scenario, participants were asked to what extent they wanted the advisor to exhibit several leadership styles and competencies and what role (active, collaborative, or passive) they preferred to play when making decisions. Results show that decision making about health is distinct from that in the other domains in three ways. First, most of the participants preferred to delegate decision making about their health to their physician, whereas they were willing to collaborate or play an active role in decision making about their career or money. Second, the competencies and leadership style preferred for the physician differed substantially from those desired for advisors in the other two domains: Participants expected physicians to show more transformational leadership—the style that is most effective in a wide range of environments—than those who provide advice about financial investments or career. Finally, participants’ willingness to share medical decision making with their physician was tied to how strongly they preferred that the physician shows an effective leadership style. In contrast, motivation to participate in decision making in the other domains was not related to preferences regarding advisors’ leadership style or competencies. Our results have implications for medical practice as they suggest that physicians are expected to have superior leadership skills compared to those who provide assistance in other important areas of life.     

Finding your Soulmate: Homosexual and heterosexual age preferences in online dating

Heterosexual age preferences have been extensively studied by evolutionary psychologists, social psychologists, and demographers. Much less is known about such preferences in homosexual men and women. Around two decades ago, D. T. Kenrick, R. C. Keefe, A. Bryan, A. Barr, and S. Brown (1995) examined heterosexual and homosexual mating preferences for age in men and women. Our study aimed to replicate these findings by examining age preferences in a larger UK online dating sample. Dating advertisements of 996 male and female heterosexuals and homosexuals were coded. Age preferences were assessed via generalized linear models with robust standard errors and bootstrapping. Results showed that the relation between own age and preferred age differed substantially between the groups. With increasing age, heterosexual men preferred younger partners. Older heterosexual men (> 50 years) exclusively sought (much) younger women than themselves, whereas younger heterosexual men sought both older and younger women. Male and female homosexuals followed this general trend of preferring increasingly younger mates with increasing age. However, they displayed a higher upper age tolerance and greater range of acceptable ages than both heterosexual men and women. Female heterosexuals' age preferences were distinct from the other groups, in that they displayed a male older norm with no substantial interest expressed in males younger than themselves. Our findings thus largely corroborate those of Kenrick et al. with some exceptions, such as a larger tolerance of age ranges in homosexual men and women compared to heterosexual men and women. Results are discussed with reference to the current literature on similarities and differences in heterosexual and homosexual mate preferences.     

Influence of time on social preferences: implications for life-span development

Socioemotional selectivity theory holds that the reliable decline in social contact in later life is due, in part, to older people's preferences for emotionally meaningful social partners and that such preferences are due not to age, per se, but to perceived limitations on time. Confirming the theory, in both the United States and Hong Kong, older people showed a preference for familiar social partners, whereas younger people did not show this preference. However, when asked to imagine an expansive future, older people's bias for familiar social partners disappeared. Conversely, in the face of a hypothesized constraint on time, both younger and older people preferred familiar social partners. Moreover, social preferences in Hong Kong differed before and after the 1997 handover of Hong Kong to the People's Republic of China, which was construed as a sociopolitical time constraint. One year prior to the handover, only older people displayed preferences for familiar partners. Two months before the handover, both age groups showed such preferences. One year after the handover, once again, only older Hong Kong people preferred familiar social partners.     

A systematic evaluation of preferences identified through person-centered planning for people with profound multiple disabilities

Person-centered planning is becoming a popular means of designing supports for people with disabilities. However, very little research evaluating person-centered planning exists. We evaluated the degree to which items and activities reported to be preferred in person-centered plans represented accurate preferences based on how individuals responded when presented with the items and activities. Person-centered planning meetings were conducted with 4 individuals with profound multiple disabilities to develop preference maps and to identify leisure-related preferences. A sample of the reported preferences in the plans was then systematically assessed by observing each participant's approach and avoidance responses to the items and activities. Of the sampled items and activities reported to be preferred in the plans, 42% represented moderate preferences based on the latter assessment process and 33% represented strong preferences. With 2 participants, several preferences identified in the plans were nonpreferred items and activities based on the preference assessments, and some were frequently avoided. These results suggested that although person-centered plans may identify some accurate preferences for people with profound multiple disabilities, this approach should be used cautiously. Results also suggested that such plans should be supplemented with systematic preference assessments to ensure the accuracy of identified preferences. Future research areas focus on evaluating other aspects of person-centered planning.     

Preferences for involvement in medical decision making: comparing British and German views

Despite beneficial outcomes of patients' involvement in medical decision processes, it has been claimed that patients are generally not interested in medical decision making (MDM). Whereas current research focuses on actual MDM, this research explored the impact of nationality and perceptual processes of MDM. Preferences for involvement in decision making were examined in a sample of 204 German and 143 British university students. Hierarchical multiple regressions were employed to explore the link between socio-demographic information, individuals' perceived relationship with their GP, Health Locus of Control - Powerful Others, perceptions regarding the frequency and sufficiency of information provision and involvement in MDM, and individuals' preferred level of involvement and information. A significant amount of the variance in individuals preferences for involvement could be explained (Adjusted R2 = .59, p < .001). Independent t-test analyses showed that British and German perceptions of care differed significantly on a variety of different measures. Separate analyses for the German and British group highlighted cross-national differences in care and preferences for involvement. The study suggests that preferences to become involved might depend more on perceptual processes than actual involvement in decision making, and that communication and national health policy could play an important role.     

How readers experience characters’ decisions

When people read narratives, they have ample opportunities to encode mental preferences about characters’ decisions. In our present project, we examined how readers’ preferences for characters’ decisions structure their experiences of story outcomes. In Experiment 1, participants read brief stories and explicitly rated which of two potential decisions they thought the characters should make. The actual decision that each character made was either preferred or nonpreferred by readers. By the end of each story, readers learned whether there was a positive or negative outcome to these decisions. Decisions and outcomes either matched (e.g., a preferred decision followed by a positive outcome) or did not match (e.g., a nonpreferred decision followed by a negative outcome). Participants took longer to read outcome sentences when there was a mismatch. In Experiment 2, we replicated this finding with a task that allowed more natural reading. These results provide converging evidence that readers encode responses to characters’ decisions and that these responses affect the time course with which they assimilate story outcomes.     

Do assortative preferences contribute to assortative mating for adiposity?

Assortative mating for adiposity, whereby levels of adiposity in romantic partners tend to be positively correlated, has implications for population health due to the combined effects of partners' levels of adiposity on fertility and/or offspring health. Although assortative preferences for cues of adiposity, whereby leaner people are inherently more attracted to leaner individuals, have been proposed as a factor in assortative mating for adiposity, there have been no direct tests of this issue. Because of this, and because of recent work suggesting that facial cues of adiposity convey information about others' health that may be particularly important for mate preferences, we tested the contribution of assortative preferences for facial cues of adiposity to assortative mating for adiposity (assessed from body mass index, BMI) in a sample of romantic couples. Romantic partners' BMIs were positively correlated and this correlation was not due to the effects of age or relationship duration. However, although men and women with leaner partners showed stronger preferences for cues of low levels of adiposity, controlling for these preferences did not weaken the correlation between partners' BMIs. Indeed, own BMI and preferences were uncorrelated. These results suggest that assortative preferences for facial cues of adiposity contribute little (if at all) to assortative mating for adiposity.     

Age and health care beliefs: self-efficacy as a mediator of low desire for control

The relation between individuals' age, desire for control, information, and perceived self-efficacy was examined using a cross-sectional comparison of 116 noninstitutionalized adults, ages 20 to 99. We found that individuals over 60 years of age desired less health-related control than did younger adults, and preferred that health professionals make decisions for them. Differences in desire for health-related information were in the same direction but were not significant. Older adults also desired less control in general day-to-day living. Perceived self-efficacy was also lower for individuals over 60 years of age. Results suggested that perceived self-efficacy mediated the age differences in health-related desire for control. Mediation of general desire for control, however, was not strong. Cohort and developmental explanations are provided for these findings. It is suggested that those individuals most at risk for chronic illnesses and hospitalization are also those who are most likely to fail to take an active role in their health care.     

The Secrecy Heuristic: Inferring Quality from Secrecy in Foreign Policy Contexts

Three experiments demonstrate that in the context of U.S. foreign policy decision making, people infer informational quality from secrecy. In Experiment 1, people weighed secret information more heavily than public information when making recommendations about foreign political candidates. In Experiment 2, people judged information presented in documents ostensibly produced by the Department of State and the National Security Council as being of relatively higher quality when those documents were secret rather than public. Finally, in Experiment 3, people judged a National Security Council document as being of higher quality when presented as a secret document rather than a public document and evaluated others' decisions more favorably when those decisions were based on secret information. Discussion centers on the mediators, moderators, and broader implications of this secrecy heuristic in foreign policy contexts.     

Prenatal and postnatal anxiety in Mexican women giving birth in Los Angeles

Examined psychosocial factors related to prenatal and postnatal anxiety in 291 primiparous Mexican women giving birth in Los Angeles. Characteristics of health care providers preferred by more anxious and less anxious women were also assessed. Higher prenatal anxiety was associated with less desire for an active role during labor, lower assertiveness, higher pain expectation at delivery, lack of support from family members other than the husband, and preferences for health care providers who are female and Latino. All groups of women preferred health care providers who provided good medical explanations and who were knowledgeable, friendly, and sympathetic. Postnatal anxiety was significantly lower than prenatal anxiety. Negative attitudes toward the baby and number of complications during labor and delivery, however, were related to postnatal anxiety adjusted for prenatal anxiety.     

Men's fabric preferences related to age, inherent color vision, and perceptual disembedding ability

Non-random samples of 27 color-normal and 27 color-blind men between the ages of 18 and 52 were administered measures of color vision, fabric preferences, and perceptual disembedding (field dependence). Pearson product-moment correlation and analysis of variance were used to test associations among the variables. Results showed the rank order of men's fabric preferences from least to most preferred were pattern, large design, tint, textured, small design, shade, smooth, and plain. There was one significant relationship between age and a preference for tints. No significant relationships were found among fabric preferences and color vision, fabric preference and field dependence, or age and field dependence. Color-blind men were significantly more field-independent than color-normal men in the sample. It was concluded that social as opposed to inherent factors helped to determine men's fabric preferences.     

Ceding and Succeeding: How the Altruistic Can Benefit from the Selfish in Joint Decisions

We examine how the interplay of two partners’ interpersonal orientations (selfish vs. altruistic) in a decision‐making dyad impacts the extent to which the joint decision matches each partners’ individual a priori preferences. Two experiments, in which we manipulate and measure interpersonal orientations, as well as examine real consumption decisions, demonstrate the benefit of mismatching interpersonal orientations (selfish‐altruistic) in dyadic decisions. Specifically, altruistic and selfish consumers reach joint decisions that better reflect their individual preferences when working with a partner who has the opposite interpersonal orientation (heterogeneous dyad) versus a matching one (homogeneous dyad). Initial evidence suggests that this effect occurs because homogeneous dyads are more prone to engage in negotiation (communication that involves departure from one's initial position to a mutually serving position) than heterogeneous dyads. This leads homogeneous dyads to focus more on equally preferred options than on their own most preferred options, which pushes them further down both partners’ preferences lists. This research contributes to the literature on joint decision making and has important implications for consumer well‐being.     

Patient preferences for psychological counsellors: Evidence of a similarity effect

This study sought to examine the individual difference variables that affect potential patient preferences for hypothetical psychological counsellors. A representative British sample of 257 adults indicated their preferences for eight psychological counsellors differentiated by sex, age, and training location. A five-way mixed analysis of variance (participant sex and age as within variables, and counsellor sex, age, ethnicity as between variables) indicated a significant main effect for only counsellors’ ethnicity. There were also sex and age interactions showing evidence of a matching hypothesis: participants preferred counsellors of their own sex and age. The implications of these findings are considered.     

Psychosocial Predictors of Health Status and Health Care Costs among People with Fibromyalgia

The purpose of the present study was to examine the effects of psychosocial characteristics on health status and the relationship between health status and health care use and costs in a group of people with fibromyalgia (FMS) over a 1-year period. The participants were 600 members of a large health maintenance organization. Demographic characteristics (age, education, employment status, ethnicity and income), need variables (comorbid conditions and baseline health status), and psychosocial variables (self-efficacy, helplessness, coping, and depression) were examined. Better health status at baseline, use of emotion-focused coping, and higher self-efficacy predicted better health status the following year. Higher health care use at baseline, being Caucasian, being older, and having more co-morbid conditions predicted higher health care use at 1 year. Only health care costs at baseline predicted health care costs the following year. Our results indicate that health care use and cost tend to be stable. Intense interventions focused on changing patterns of health care use and methods for coping with the change need to be developed and tested.