Diagnoses by general practitioners: Accuracy and reliability

Only 10% of the results of consultations in primary care can be assigned to a confirmed diagnosis, while 50% remain “symptoms” and 40% are classified as “named syndromes” (“picture of a disease”). Moreover, less than 20% of the most frequent diagnoses account for more than 80% of the results of consultations. This finding, confirmed empirically during the last fifty years, suggests a power law distribution, with critical consequences for diagnosis and decision making in primary care.Our results prove that primary care has a severe “black swan” element in the vast majority of consultations. Some critical cases involving “avoidable life-threatening dangerous developments” (ALDD) such as myocardial disturbance, brain bleeding, and appendicitis may be masked by those often vague symptoms of health disorders ranked in the 20% most frequent diagnoses. The Braun distribution predicts the frequency of health disorders on a phenomenological level and reveals the “black swan” problem, but is not a tool by itself for arriving at accurate diagnoses. To improve predictions and enhance the reliability of diagnoses we propose standards of documentation and a systematic manner by which the risk facing a patient with an uncertain diagnosis can be evaluated (diagnostic protocols).Accepting a power law distribution in primary care implies the following: (1) primary care should no longer be defined only by “low prevalence” properties, but also by its black-swan-incidence-problem. This includes rethinking malpractice and the requirements of malpractice litigations; (2) at the level of everyday practice, diagnostic protocols are tools to make diagnoses more reliable; (3) at the level of epidemiology, Braun’s system of classification is useful for generating valid information by which predictions of risks can be improved.     

Budget decision making in large public school systems

This paper reviews and discusses results of a study of the budget process in fourteen large city school districts. Topics covered include incremental decision making, the use of “ratios” and “norms” in school budgeting, public participation in budgeting, relevant structural arrangements of local government, and the influence of boards of education on the allocation of resources. Finally, implications for the improvement of school management practices in large school districts are discussed.     

Determination of a hospital management policy using conjoint analysis in the analytic network process

When making management performance decisions, administrators frequently utilize balanced scorecard (BSC) to measure performance because the BSC does not excessively focus on financial measures and seeks a balance among customer perspectives, learning and growth, internal business processes and financial measures. A growing number of studies have applied the analytic hierarchical process (AHP) method to choose BSC metrics for management performance. These AHP methods assume that criteria are independent. Saaty (Decision making with dependence and feedback: the analytic network process. RWS Publications, Pittsburgh, 1996) presented the analytic network process (ANP) method to solve the limitations that criteria are independent. Conventional ANP methods involve complex calculations when the number of criteria increases. Hence, this study attempts to integrate conjoint analysis (CA) and the ANP method to simplify the ANP calculation procedure. Additionally, the decision of management policy is utilized with BSC to determine whether the situation at a hospital demonstrates the feasibility of integrating CA with ANP. Study results reveal that the proposed methodology increases the efficiency of decision making among policymakers and reduces associated risks     

物流企业并购方向决策

结合物流业发展情况,就战略性并购方向决策流程、考虑因素及优选决策方法进行了研究,并建立了物流企业并购方向决策层次分析评价模型的指标体系。     

A new pattern of risk management: The Hyogo Framework for Action and Italian practise

On January 2005, the World Conference on Disaster Reduction adopted the “Hyogo Framework for Action 2005–2025: Building the Resilience of Nations and Communities to Disasters” [UN-ISDR (United Nations, International Strategy for Disaster Reduction), Disaster Risk and Sustainable Development: understanding the links between development, environment and natural hazards leading to disasters, World Summit on Sustainable Development, August–September 2002, Johannesburg, 2002]. This “white paper” seeks to promote “an effective integration of disaster risk considerations into sustainable development policies, planning and programming at all levels” [UN-ISDR (United Nations, International Strategy for Disaster Reduction), Disaster Risk and Sustainable Development: understanding the links between development, environment and natural hazards leading to disasters, World Summit on Sustainable Development, August–September 2002, Johannesburg, 2002. p. 1] outlining a strategic and systematic approach to reduce vulnerabilities and risks to hazards.

The current paper discusses each aspect of the Hyogo approach in relation to the Italian experience. Italy represents an interesting case because of its multiple hazard environment, and the fact that it has developed an integrated approach to risk reduction planning. Strengths and weaknesses of the “Italian way” of dealing with risk are identified, and compared with the theoretical processes suggested by the framework. Implementation of selected key actions in Italy has helped identify a series of obstacles to progress, further defining the gap that still exists between theoretical framework and actual practise.

The various activities constituting “risk management” (viz., assessment, prevention, mitigation, monitoring, early warning, preparedness) are here considered in a comprehensive framework wherein each phase is connected to the others. The paper focuses on natural hazards, which are more frequent in Italy (landslides, floods, earthquakes, volcanic eruptions, natural soil erosion). The main results include:

• A new process for dealing with risk, using the framework for guidance, is identified. We track the reasons for Italy gradually adopting this process in dealing with her vulnerabilities to natural hazards.

• Those factors that appear to interfere with an integrated approach to risk management are identified as a function of selected experiences.

• Guidelines for analysing vulnerabilities to disaster in a multi-hazard, integrated context are proposed.

Information systems outsourcing: Replicating an existing framework in a different cultural context

In order for any field of study to refine the promising concepts and weed out the weaker concepts it is necessary that researchers revisit earlier studies from time to time and evaluate their general applicability to new contexts. Replication is an important technique for researchers to embrace in order to achieve this goal. In this study, we test one of the frameworks of technology outsourcing developed in the West, by changing the cultural context. Following Kodak's historic outsourcing decision, technology outsourcing has assumed significant importance among researchers and practitioners. Most of the research in relation to technology outsourcing has been conducted in the Western culture (including the USA and the UK), so our goal in this study is to extend the understanding of technology outsourcing research conducted in the West to another culture-that of Korea, through replication.We focused on information systems (IS) outsourcing decision making as a case in point and found both similarities and dissimilarities in relation to the current understanding of the same. These similarities and differences in turn, reveal the distinctions between the Western and the Korean approaches toward achieving outsourcing success. The similarities are the partial preference for short-term contracts and contracting out to external vendors. However, the two cultures differed in their decision making in the way they pursue contractual completeness, whether in-house departments competes or not, design of contract to include partnership measures, criticality of tasks outsourced, familiarity with the outsourced task, postponing a few outsourcing decisions, and withholding a piece of a contract as bait. We also found “trust” and “task partitioning to gain advantage of varied expertise” to be important for achieving outsourcing success in the Korean organization. In addition, we observed that outsourcing success is achieved by maximizing reliability and relationship in the Korean context rather than by maximizing flexibility and control, as was observed in the Western context. We argue that this difference is a function of cultural diversity.     

A behavioral study of supply manager decision-making: Factors influencing make versus buy evaluation

This paper investigates behavioral factors influencing a supply manager's decision to insource or outsource the manufacture of a product component. To do so we posit a theoretical framework that integrates the heretofore distinct operational make–buy literature and the behavioral decision-making literature. Within the framework three factors influencing the make–buy decision are brought into account: the decision-maker's perception of supply risk or “strategic vulnerability”, the degree of core competency represented by the product component under consideration and the formality of the information about supply alternatives. The results of a controlled experimental survey show that: strategic vulnerability and core competency do influence the make–buy decision, strategic vulnerability has greater influence than core competency and information formality moderates the make–buy decision when the strategic vulnerability and core competency conditions are mixed. The practical implications of these results include the notion that management can ensure a more rational make–buy decision if they understand the biases that influence the decision and point these biases out to the decision maker.     

On the socially optimal size of a life-saving facility

The paper examines the simultaneous problem of finding an optimal size of an intensive care unit and an optimal amount of social investment in preventive medicine. The “demand” for ICU services is assumed stochastic. The approach used is to minimize social costs involved in operating the facility and social loss stemming from deaths of untreated patients.

After deriving the optimality conditions the results are applied to recent British data     

Disposable versus reusable linen: back to the future

Decisions regarding health care practices and technology are never static. As new information becomes available, and internal and external forces shift, new decisions may have to be made. Such is the decision regarding reusable versus disposable linen. Until very recently, reusable linens were not comparable with disposable linen in the quality characteristics that directly impact patient and staff safety and health. Given the current test results on the latest generation of reusable fabrics, it is time to go back to reconsider this decision for the future.     

层次分析法在企业财务决策中的应用探讨

本文在介绍了层次分析法原理的基础上,讨论了其在企业财务决策中的应用,指出它是解决企业财务决策中多目标复杂问题的定性与定量相结合一种很好的决策分析方法。     

Information theoretic approach to migration analysis

Information theory is employed to look at certain aspects of migration. It is suggested that the dividedness of a population into “movers” and “stayers” is better assessed by migration entropy. The notion of “migration inequality” is introduced and the principle of minimum entropy suggested as a criterion for fitting migrations models. Canadian census data are utilized for illustration purposes.     

Redistricting reformulated: A maximum interaction/minimum separation objective

Alternative objective functions to the population centroid type commonly employed in computerized political districting algorithms are suggested and discussed. Districtings based on maximum overlap of individuals' “action spaces” or on minimum aggregate length of interpersonal separations better represent the spatio-political notion of “compactness” than do those based on centroid measures. The traditional analogy between the warehouse location problem and the optimal districting problem may thus be an inappropriate one. The proposed reformulated optimal districting problem with a spatial interaction or interpersonal separation objective may be formally stated as a quadratic integer program. The solution to the program is seen, however, to be only one of several possible “optimal” political partitionings. Regardless of the specific compactness measure chosen, separate “mean” and “modal” districtings may exist.     

FINANCIAL EDUCATION AND BEHAVIORAL FINANCE: NEW INSIGHTS INTO THE ROLE OF INFORMATION IN FINANCIAL DECISIONS

Recent empirical evidence based on surveys and experimental activities within the fields of behavioral finance and financial education has offered economists new empirically based insights into how individuals use information in making financial decisions. Specifically, the importance of information in financial decisions may be reduced or eliminated by psychological aspects of the individual, such as a state of overconfidence that is individual or shared with a group, or by the individual's limited ability to process complex and abundant information. This paper aims to complement this emerging body of literature by studying how individuals perceive and process information when making financial decisions. We review these contributions and suggest a number of broad guidelines that can provide a framework for future discussion of this topic within financial decision theory.     

A voucher plan for financing health care delivery

There seems to be a growing consensus in this country that everyone should have guaranteed access to at least a minimum level of preventive and curative medical care. The real controversy is over the method by which such care would be assured.

I have proposed elsewhere that each individual be given a voucher; ‘good’ for either full premium payment for membership in a comprehensive prepaid health plan in a specified period, or for a predetermined amount toward one's health insurance premium if it is desired to maintain consumption of care in a fee-for-service (ffs) mode.

The purpose of the present paper will be to provide a preliminary examination of some of the operational characteristics of such a voucher which may be implemented on an ‘area’ basis, such an area containing some number of somehow identifiable ‘regions’. In each of the regions a governing board would make management decisions taking into account its peculiarities and needs. The regional board would then be responsible to some area Health Council. This, of course, parallels the kinds of decision-making bodies specified both in national proposals such as Senator Kennedy's, and statewide plans such as California Senate Bill 770 proposed by Senator Moscone (D., San Francisco).

An analytical model of the decision process of such regional boards and Health Councils is developed and the optimal selection of voucher redemption levels and capital subsidy programs is characterized.     

OR vice: Forecasting and classification techniques for narcotics interdiction

Counternarcotics interdiction efforts have traditionally relied on historically determined sorting criteria or “best guess” to find and classify suspected smuggling traffic. We present a more quantitative approach which incorporates customized database applications, graphics software and statistical modeling techniques to develop forecasting and classification models. Preliminary results show that statistical methodology can improve interdiction rates and reduce forecast error. The idea of predictive modeling is thus gaining support in the counterdrug community. The problem is divided into sea, air and land forecasting, only part of which will be addressed here. The maritime problem is solved using multiple regression in lieu of multivariate time series. This model predicts illegal boat counts by behavior and geographic region. We developed support software to present the forecasts and to automate the process of performing periodic model updates. During the period, the model was in use at. Coast Guard Headquarters. Because of deterrence provided by improved intervention, the vessel seizure rate declined from 1 every 36 hours to 1 every 6 months. Due in part to the success of the sea model, the maritime movement of marijuana has ceased to be a major threat. The air problem is more complex, and required us to locally design data collection and display software. Intelligence analysts are using a customized relational database application with a map overlay to perform visual pattern recognition of smuggling routes. We are solving the modeling portion of the air problem using multiple regression for regional forecasts of traffic density, and discriminant analysis to develop tactical models that classify “good guys” and “bad guys”. The air models are still under development, but we discuss some modeling considerations and preliminary results. The land problem is even more difficult, and data collection is still in progress.     

An extremal and information-theoretic characterization of some interzonal transfer models

The paper develops a method of deriving gravity models from extremal principles. The prototype result yields the most popular gravity flow model characterized by an extremal principle. This principle is also for the first time elucidated as an information-theoretic one of choosing the distribution of interzonal transfers which gives least “information” (in the technical sense) for discrimination against a distribution reflecting the “facility” (reciprocal of the “difficulty”) of travel between zones.     

An econometric model of an episode of mental health care for patients with mild conditions: implications for caregiver substitution.

This article presents a model of the number of hours of mental health care, the concurrent improvement in the patient's condition, the probability the patient will receive medications, and the reasons for treatment termination. The variables related to these aspects of mental health care are analyzed separately for patients of psychiatrists, psychologists, and social workers. Estimates of the average length of treatment, the average price and income elasticities, and the average cost of treatment are obtained from the model. The major conclusions from this study are that psychiatrists do not have a benefit-cost advantage in the treatment of relatively mild conditions, and that consumer responsiveness to variations in price appear to be largely confined to the decision to seek treatment. These and other findings provide a basis for making tentative recommendations about personnel substitution and reimbursement policies in mental health.     

Knotting the action net, or organizing between organizations

This paper presents a study of a successful organizing process, namely the knotting together of different types of action by “translating” them into one another. The connections thus established were then stabilized to form a unit that can be designated as an “action net”. This instance of organizing occurred in the course of a project in the Swedish health care sector, with a view to establishing coordination between care units in three separate organizations. Different laws regulated their tasks, their operations were financed by different principals, and the everyday work of their members was undertaken at different point in time and in different places. Despite this, the participants in the studied project were able to establish a lasting net of connections that contributed, in the eyes of the environment, to an instance of “good care”. In this paper we examine in detail the creation of an action net, and offer a tentative theory of organizing in action nets.     

Linear learning in changing environments

The decision maker receives signals imperfectly correlated with an unobservable state variable and must take actions whose payoffs depend on the state. The state randomly changes over time. In this environment, we examine the performance of simple linear updating rules relative to Bayesian learning. We show that a range of parameters exists for which linear learning results in exactly the same decisions as Bayesian learning, although not in the same beliefs. Outside this parameter range, we use simulations to demonstrate that the consumption level attainable under the optimal linear rule is virtually indistinguishable from the one attainable under Bayes’ rule, although the respective decisions will not always be identical. These results suggest that simple rules of thumb can have an advantage over Bayesian updating when more complex calculations are more costly to perform than less complex ones. We demonstrate the implications of such an advantage in an evolutionary model where agents “learn to learn.”