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Brad Spellberg - One of the best experts on this subject based on the ideXlab platform.
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antibiotic judo working gently with prescriber psychology to overcome inappropriate use
JAMA Internal Medicine, 2014Co-Authors: Brad SpellbergAbstract:Within the past year, the US Centers for Disease Control and Prevention (CDC), the European CDC, the World Health Organization, and the World Economic Forum all have released reports raising alarm over the ongoing global crisis of antibiotic-resistant infections. Resistance to our most powerful antibiotics continues to grow worse, and the pipeline of new antibiotics remains on life support.1 Something has to give. Antibiotics have a critical characteristic that makes them unique among all drugs and indeed all medical interventions: they suffer from transmissible loss of efficacy over time due to the spread of resistance. Every individual’s use of antibiotics contributes to loss of their efficacy over time for everyone else. Effective antibiotics are thus a community property or trust, and abuse of antibiotics is an example of the tragedy of the commons: when one person takes an antibiotic for an infection that is probably viral, with a small possibility that it is bacterial, there may be a small potential benefit to that person, balanced against a slight collective harm to society. When this happens frequently, the collective potential benefit to the users remains small, but harm to society grows. When it occurs hundreds of millions of times per year, as for antibiotic prescriptions for outpatients in the United States,2 the aggregate harm to society is catastrophic. Since the tragedy of the commons results from inherent conflict between what is perceived by individuals to be best for themselves over the short term vs what is harmful to the collective group over the long term, combating the tragedy of the commons is difficult from a policy perspective. Directly confronting physicians and patients to convince them to alter behavior that is perceived to be in their self-interest does not seem to address the Psychological underpinnings that lead to inappropriate prescriptions. Indeed a recent meta-analysis of 39 studies found that direct educational approaches generally have not resulted in sustained reductions in antibiotic prescriptions.3 As a result, nearly 8 decades after Alexander Fleming warned the public that penicillin was being misused and deaths from resistant infections would result, up to 50% of antibiotic prescriptions in the United States continue to be unnecessary and/or inappropriate.4,5 In 2011, the Infectious Diseases Society of America (IDSA) published a position paper6 resulting from a workshop on antibiotic resistance that was jointly sponsored by the IDSA, the US Food and Drug Administration, and the US National Institute of Allergy and Infectious Diseases. In discussing how we can transform antibiotic stewardship, the paper concluded that “few studies have defined the relative impact of…drivers of inappropriate antibiotic prescription, or have investigated how to positively intervene to improve such behaviors. Primary research…is needed to better understand effective interventions to prevent such prescriptions.”6(pS414) In the current issue of JAMA Internal Medicine, Meeker et al7 provide us with the results of just such disruptive research. The authors developed a novel intervention that was based on a sophisticated understanding of how to overcome the psychology that drives behavior linked to inappropriate antibiotic prescriptions. Rather than direct confrontation with the force of education or nagging, they sought a gentler “nudging” approach that worked harmoniously with the underlying psychology of both patient and clinician. Their nudge not to prescribe inappropriate antibiotics was based on the Psychological Principle of “public commitment.” The authors summarize previous research that indicates that public commitment can be an effective means to modulate human behavior. To implement their program, the investigators had outpatient clinicians sign a written commitment not to prescribe antibiotics for likely viral syndromes. The signed commitment was visibly posted so that both patient and clinician could see it in the examination room. The impact of the intervention was modest, an approximately 20% reduction in antibiotic prescriptions over 3 months during influenza season compared with an active control group. Nevertheless, the results were significant, and the intervention was easy to implement. It required no complex algorithms, no special technology, and no infrastructure or enforcement. Furthermore, a similar reduction from a baseline of 258 million outpatient prescriptions per year in the United States2 extrapolates to a potential avoidance of millions prescriptions per year if the results can be generalized. Thus, the potential return on investment from this easy, gentle approach is large. Judo is a Japanese martial art that can be translated as “gentle way” and focuses on using an opponent’s force against itself rather than directly confronting it with opposing force. A common axiom in Judo is “maximum efficiency with minimum effort.” Meeker et al7 have created a clever Judo-like approach that works with patient and clinician psychology to reduce antibiotic prescriptions. Meaningful gains can be achieved with minimal effort and cost. How sustainable and how generalizable to other practice settings this gentle nudge approach is cannot be determined from the study, and it merits additional investigation. Furthermore, even with the Judo-like nudge, the majority of the baseline antibiotic use did remain. Other novel approaches will be needed to further reduce antibiotic prescriptions. New approaches may emerge from further primary research into understanding the psychology that underlies inappropriate prescriptions. We also need to push into the clinic use of rapid diagnostics that empower providers to withhold antibiotics for viral infections and give the correct antibiotic for bacterial infections.1,6 Finally, policies that align the economics of self-interest with societal need, such as publicly reporting antibiotic use with modification of reimbursement based on the volume of antibiotics used (bonuses for low use, penalties for high use) would likely lead to sustained decreases in prescriptions.1 We all bear responsibility to protect the public resource of antibiotic efficacy. We do need to continue critical, traditional antibiotic stewardship efforts, including education, restrictions, de-escalation, electronic reminders, etc. But new ideas, such as the simple and gentle public commitment concept Meeker and colleagues7 have developed, are needed to work in concert with traditional approaches to help us change the future state of antibiotic resistance.
Calcagni Gianluca - One of the best experts on this subject based on the ideXlab platform.
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Behavior Stability and Individual Differences in Pavlovian Extended Conditioning
'Frontiers Media SA', 2020Co-Authors: Calcagni Gianluca, Caballero-garrido E., Pellón R.Abstract:20 pags., 8 figs., 7 tabs.How stable and general is behavior once maximum learning is reached? To answer this question and understand post-acquisition behavior and its related individual differences, we propose a Psychological Principle that naturally extends associative models of Pavlovian conditioning to a dynamical oscillatory model where subjects have a greater memory capacity than usually postulated, but with greater forecast uncertainty. This results in a greater resistance to learning in the first few sessions followed by an over-optimal response peak and a sequence of progressively damped response oscillations. We detected the first peak and trough of the new learning curve in our data, but their dispersion was too large to also check the presence of oscillations with smaller amplitude. We ran an unusually long experiment with 32 rats over 3,960 trials, where we excluded habituation and other well-known phenomena as sources of variability in the subjects' performance. Using the data of this and another Pavlovian experiment by Harris et al. (2015), as an illustration of the Principle we tested the theory against the basic associative single-cue Rescorla–Wagner (RW) model. We found evidence that the RW model is the best non-linear regression to data only for a minority of the subjects, while its dynamical extension can explain the almost totality of data with strong to very strong evidence. Finally, an analysis of short-scale fluctuations of individual responses showed that they are described by random white noise, in contrast with the colored-noise findings in human performance.The experiment was run at the Animal Behavior Lab, Departamento de Psicología Básica I, Facultad de Psicología, Universidad Nacional de Educación a Distancia, Madrid, Spain, and was supported by grant PSI2016-80082- P from Ministerio de Economía y Competitividad, Secretaría de Estado de Investigación, Desarrollo e Innovación, Spanish Government (RP)
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Behavior stability and individual differences in Pavlovian extended conditioning
'Frontiers Media SA', 2020Co-Authors: Calcagni Gianluca, Caballero-garrido Ernesto, Pellón RicardoAbstract:How stable and general is behavior once maximum learning is reached? To answer this question and understand post-acquisition behavior and its related individual differences, we propose a Psychological Principle that naturally extends associative models of Pavlovian conditioning to a dynamical oscillatory model where subjects have a greater memory capacity than usually postulated, but with greater forecast uncertainty. This results in a greater resistance to learning in the first few sessions followed by an over-optimal response peak and a sequence of progressively damped response oscillations. We detected the first peak and trough of the new learning curve in our data, but their dispersion was too large to also check the presence of oscillations with smaller amplitude. We ran an unusually long experiment with 32 rats over 3960 trials, where we excluded habituation and other well-known phenomena as sources of variability in the subjects' performance. Using the data of this and another Pavlovian experiment by Harris et al. (2015), as an illustration of the Principle we tested the theory against the basic associative single-cue Rescorla-Wagner (RW) model. We found evidence that the RW model is the best nonlinear regression to data only for a minority of the subjects, while its dynamical extension can explain the almost totality of data with strong to very strong evidence. Finally, an analysis of short-scale fluctuations of individual responses showed that they are described by random white noise, in contrast with the colored-noise findings in human performance.Comment: 29 pages, 8 figures, 7 tables; v2-v3: theoretical motivation clarified, data of Harris et al. (2015) included in improved analysis, conclusions strengthened, typos corrected, references added, technicalities and data analysis moved into Supplementary Material (46 pages, 22 figures, 7 tables; available at https://www.frontiersin.org/articles/10.3389/fpsyg.2020.00612/full#supplementary-material
Charbonneau James - One of the best experts on this subject based on the ideXlab platform.
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ComPAIR: A flexible teaching technology for facilitating peer evaluation
Scholarship@Western, 2019Co-Authors: Charbonneau James, Potter Tiffany, Englund Letitia, Luo Pan, Moosvi FirasAbstract:We will demonstrate ComPAIR1, an open source, peer feedback and teaching technology developed at University of British Columbia. ComPAIR is currently being used in over 40 courses at University of British Columbia and at 6 institutions outside of University of British Columbia, including Western University. ComPAIR makes use of students’ inherent ability and desire to compare: according to the Psychological Principle of comparative judgement2, novices are much better at choosing the “better” of two answers than they are at giving those answers an absolute score. By scaffolding peer feedback through comparisons, ComPAIR provides an engaging, simple, and safe environment that supports two distinct outcomes: 1) students learn how to assess their own work and that of others in a way that 2) facilitates the learning of subtle aspects of course content through the act of comparing. In this session I\u27ll discuss why comparisons facilitate learning3 and I\u27ll do a demonstration of what students see when they use ComPAIR and talk about the wide variety of courses that use ComPAIR. You\u27ll also have the opportunity to follow along the demonstration using our ComPAIR demo site. I\u27ll also talk about some limitations of the software (i.e., it\u27s not peer grading). To explore ComPAIR check out our sandbox site: https://compairdemo.ctlt.ubc.ca/ Details on how to set up ComPAIR at your own institution can be found here: https://lthub.ubc.ca/guides/compair/ 1Potter, Tiffany et al. ComPAIR: A New Online Tool Using Adaptive Comparative Judgement to Support Learning with Peer Feedback. Teaching & Learning Inquiry, [S.l.], v. 5, n. 2, p. 89-113, sep. 2017 2Thurstone, L.L. (1927). A law of comparative judgement. Psychological Review, 34, 273-286.3Bransford, J., & Schwartz, D. (1999). Rethinking Transfer: A Simple Proposal with Multiple Implications. Review of Research in Education, 24, 61-100
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A tool that changes the way students learn through peer assessment: The ComPAIR Project at UBC
Scholarship@Western, 2017Co-Authors: Charbonneau JamesAbstract:This presentation introduces ComPAIR, an innovative peer feedback and teaching technology being developed at UBC that could change the way we interact with students, and how they interact with each other. Particularly in introductory courses, the effectiveness of peer feedback can be limited by the relative newness of students to both the course content and the skills involved in providing good feedback. ComPAIR’s novel design makes use of students’ inherent ability and desire to compare: according to the Psychological Principle of comparative judgement, novices are much better at choosing the “better” of two answers than they are at giving those answers an absolute score. By scaffolding peer feedback through comparisons, ComPAIR provides an engaging, simple, and safe environment that supports two distinct outcomes: 1) students learn how to assess their own work and that of others in a way that 2) facilitates the learning of subtle aspects of course content through the act of comparing. We will review the results of an extended assessment of student experience with ComPAIR through three pilot courses in English, Physics and Math at UBC and give the session participants a chance to play with the software. We will also share the unique agile participatory development process of the software, which is changing the way faculty and programmers interact here at UBC
Pellón R. - One of the best experts on this subject based on the ideXlab platform.
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Behavior Stability and Individual Differences in Pavlovian Extended Conditioning
'Frontiers Media SA', 2020Co-Authors: Calcagni Gianluca, Caballero-garrido E., Pellón R.Abstract:20 pags., 8 figs., 7 tabs.How stable and general is behavior once maximum learning is reached? To answer this question and understand post-acquisition behavior and its related individual differences, we propose a Psychological Principle that naturally extends associative models of Pavlovian conditioning to a dynamical oscillatory model where subjects have a greater memory capacity than usually postulated, but with greater forecast uncertainty. This results in a greater resistance to learning in the first few sessions followed by an over-optimal response peak and a sequence of progressively damped response oscillations. We detected the first peak and trough of the new learning curve in our data, but their dispersion was too large to also check the presence of oscillations with smaller amplitude. We ran an unusually long experiment with 32 rats over 3,960 trials, where we excluded habituation and other well-known phenomena as sources of variability in the subjects' performance. Using the data of this and another Pavlovian experiment by Harris et al. (2015), as an illustration of the Principle we tested the theory against the basic associative single-cue Rescorla–Wagner (RW) model. We found evidence that the RW model is the best non-linear regression to data only for a minority of the subjects, while its dynamical extension can explain the almost totality of data with strong to very strong evidence. Finally, an analysis of short-scale fluctuations of individual responses showed that they are described by random white noise, in contrast with the colored-noise findings in human performance.The experiment was run at the Animal Behavior Lab, Departamento de Psicología Básica I, Facultad de Psicología, Universidad Nacional de Educación a Distancia, Madrid, Spain, and was supported by grant PSI2016-80082- P from Ministerio de Economía y Competitividad, Secretaría de Estado de Investigación, Desarrollo e Innovación, Spanish Government (RP)
Lisa A Faulkner - One of the best experts on this subject based on the ideXlab platform.
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is there a kink in consumers threshold value for cost effectiveness in health care
Health Economics, 2002Co-Authors: Bernie J Obrien, Kirsten Gertsen, Andrew R Willan, Lisa A FaulknerAbstract:Background: A reproducible observation is that consumers' willingness-to-accept (WTA) monetary compensation to forgo a program is greater than their stated willingness-to-pay (WTP) for the same benefit. Several explanations exist, including the Psychological Principle that the utility of losses weighs heavier than gains. We sought to quantify the WTP–WTA disparity from published literature and explore implications for cost-effectiveness analysis accept–reject thresholds in the south-west quadrant of the cost-effectiveness plane (less effect, less cost). Methods: We reviewed published studies (health and non-health) to estimate the ratio of WTA to WTP for the same program benefit for each study and to determine if WTA is consistently greater than WTP in the literature. Results: WTA/WTP ratios were greater than unity for every study we reviewed. The ratios ranged from 3.2 to 89.4 for environmental studies (n=7), 1.9 to 6.4 for health care studies (n=2), 1.1 to 3.6 for safety studies (n=4) and 1.3 to 2.6 for experimental studies (n=7). Conclusions: Given that WTA is greater than WTP based on individual preferences, should not societal preferences used to determine cost-effectiveness thresholds reflect this disparity? Current convention in cost-effectiveness analysis is that any given accept–rejection criterion (e.g. $50 k/QALY gained) is symmetric – a straight line through the origin of the cost-effectiveness plane. The WTA–WTP evidence suggests a downward ‘kink’ through the origin for the south-west quadrant, such that the ‘selling price’ of a QALY is greater than the ‘buying price’. The possibility of ‘kinky cost-effectiveness’ decision rules and the size of the kink merits further exploration. Copyright © 2002 John Wiley & Sons, Ltd.
