Biases distorting priority setting

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Health Policy

jo u rn al h om ep a ge :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

Biases distorting priority setting

Bjørn Hofmann

aInstitutefortheHealthSciencesattheNorwegianUniversityofScienceandTechnology,Gjøvik,Norway

bTheCentreofMedicalEthicsattheUniversityofOslo,Norway

a r t i c l e i n f o

Articlehistory:

Received11May2019 Receivedinrevisedform 24September2019 Accepted24November2019

Keywords:

Prioritysetting Bias Low-valuecare Imperative Rationality

a b s t r a c t

Modernhealth carefacesan ever widening gapbetween technologicalpossibilities and available resources.Tohandlethischallengewehaveconstructedelaboratesystemsforhealthpolicymaking andprioritysetting.Despitesuchsystemsmanyhealthcaresystemsprovideawiderangeofdocu- mentedlow-valuecarewhilebeingunabletoaffordemerginghigh-valuecare.Accordingly,thisarticle setsoutaskingwhyprioritysettinginhealthcarehassopooroutcomeswhilerelevantsystemsarewell developedandreadilyavailable.Itstartstoidentifysomerationalandstructuralexplanationsforthedis- crepancybetweentheoreticaleffortsandpracticaloutcomesinprioritysetting.However,evenifthese issuesareaddressed,practicalprioritysettingmaystillnotobtainitsgoals.Thisisbecauseawiderange ofirrationaleffectsishamperingprioritysetting:biases.Byusingexamplesfromtheliteraturethearticle identifiesandanalysesawiderangeofbiasesindicatinghowtheycandistortprioritysettingprocesses.

Overuse,underuse,andoverinvestment,aswellashampereddisinvestmentandunderminedpriority settingprinciplesarebutsomeoftheidentifiedimplications.Moreover,whilesomebiasesareoperating mainlyononelevel,manyareactiveonthemicro,mesoandonthemacrolevel.Identifyingandanalyzing biasesaffectingprioritysettingisthefirst,butcrucial,steptowardsimprovinghealthpolicymakingand prioritysettinginhealthcare.

©2019TheAuthor(s).PublishedbyElsevierB.V.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Therapidlywideninggapbetweentechnologicalpossibilities andavailableresourceshasboostedtherelevanceofprioritysetting inhealthcare.Principlesforprioritysettingarepostulated[1,2], procedureshavebeenelaborated[3],andmanycountrieshavepri- oritysettingregulationsinplace.Moreover,toolsforassessment, reassessment,anddisinvestmentarewidelyavailable[4–6].

Inparticular,thereisincreasedattentiononeliminatinglow- valuehealthservicesinordertoassureaccesstohigh-valuecare [7–12].Aseriesofdriversofpoormedicalcarehavebeeniden- tified[13–17] and specificsolutions aresuggested [18–25].For example,low-valuecarelistshavebeenelaborated,promotingand facilitatingdisinvestmentandreinvestment[14,15,26–31].Recom- mendationsfromNICE(Do-not-dolist),ChoosingWisely,andin Australia[15]togetheridentify1350specificlow-valuetechnolo- gies[32].Correspondingly,high-valuetechnologiesandservices arenotimplemented[137].However,despitevastchallengesand extensiveefforts, the outcomesof practical priority setting are

∗Correspondingauthorat:InstitutefortheHealthSciencesTheNorwegianUni- versityofScienceandTechnology(NTNU),POBox191,N-2801,Gjøvik,Norway.

E-mailaddress:[email protected]

scarcelydocumented[33–35].Whyisthisso?Thisisthekeyques- tionofthisstudy.Thatis,whyaretheoutcomesofprioritysetting sopoorlydocumented,e.g.,inreducinglow-valuecare,whenthe principles,regulations,andtoolsforprioritysettingarefairlywell developed?

This question is addressed by first briefly reviewing some rational explanations for the discrepancy between theoretical effortsandpracticaloutcomesinprioritysetting.ThenIturnto non-rational explanatins, investigating a series of biasesin the assessmentandimplementationofhealthtechnologiesandser- vicesthattendtohamperpractical prioritysetting.Iarguethat ignoring theseeffects is a mistake in priority setting, and that revealingthemisthefirst,butcrucial,steptowardsmakingpriority settingmorealignedwithitsownaspirations.

2. Whyprioritysettinglackstraction

Theremayofcoursebeawiderangeofreasonswhypriority settingdoesnothavethesametractioninpracticeasintheory.The mostobviousreasonisthattheoutcomesofprioritysettingmaybe difficulttomeasureorthatitsevidencemaybepoor.However,this explanationdoesnothold,aslow-valuecareiswelldocumented [14,15,26–31,36].

https://doi.org/10.1016/j.healthpol.2019.11.010

0168-8510/©2019TheAuthor(s).PublishedbyElsevierB.V.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/

4.0/).

Moreover,theprinciplesofprioritysettingmaybedifficultto specifyandapply[37,38].Theremaybestronginterestsorforces counteringprioritysetting[39],andthestructureandcontextof thehealthcaresystemmayhamperitspractical processes.The rulesandregulationsforprioritysettingmaynotbeknown,dif- ficulttointerpret,disputed,rejected,ignored,ordisrupted.Lackof incentivesorinteractionbetweenthehealthcarelevels(micro-, meso-,andmacro-)andthecomplexityofthehealthservicesmay alsoexplainthelackofsuccess[35,40].Somaythefactthateven smalladjustmentsinpracticalhealthcaremaydemandlarge-scale changes,duetothepervasiveness,depth,andsizeoftheservices [41].

Itmayofcoursealsobearguedthatthesituationwouldhave beenmuchworsewithoutprioritysettingandthatthetheory-to- practicegapmaybeaproblemofabundance,i.e.,thatthehealth careinhighly“developedcountries”haveimplementedallhigh- valuecareandtheiradoptionoflow-value isaresultofexcess.

However,thelattertwoexplanationslackempiricalsupport.Given thefinancialhardshipofallhealthcaresystems,agreatnumberof high-valuecareisnotoffered,andavastvolumeoflowvaluecare stillprovided.Hence,the“excessexplanation”doesnotseemto hold.

Morespecifically,ScotlandandBryangivesixstructuralexpla- nations for why priority setting does not exclude low-value technologies:1)becausecostorcost-effectivenessevidenceisnot consideredin reimbursementdecision making; 2) technologies havebeenadoptedpriortoimplementationofsuchvalue-based approaches;3) indicationcreep; 4)unjustified extrapolation of cost-effectivenessestimates;5)difficultiesinchangingpractitioner behaviortodiscontinueuseoftheolderorobsoletetechnologies;

6)cost-effectivenessofatechnologymaychangeovertime[25].

Whatiscommontomanyoftheseexplanationsforlackofsuc- cessfulprioritysettinginpracticeisthattheycanbecharacterized as rationaland structural. Soare theirsolutions. Theydemand structuralorbehavioralchangesthataresometimeshardtoobtain.

However,thereasonwhythis articlewillnotpursuethemany furtherisbecauseevenifwewouldbeabletoaddresstheseand otherstructuralissues,wemaystillnotbeabletoobtain“success- fulprioritysetting”[35].Thereasonforthisisaseriesofbiasesthat appeartodistortprioritysettinginhealthcare,andthatneedtobe addressedinordertoprovideeffectiveprioritysettinginpractice.

3. Biasesdistortingprioritysetting

Thereare many types of biases, and common toseveral of themisthattheymayleadtowhatisbroadlycalledirrationality:

perceptualdistortion,inaccuratejudgment,illogicalinterpretation [42,43].Itisbeyondthescopeofthisarticletoreviewalldocu- mentedbiaseswithrespecttohowtheymayinfluence priority setting.Iwillonlypresentalimited(butstillquitelargeanddiverse) sampleofbiasesandindicatehowtheyinfluenceprioritysetting bygivingsomeexamplesfromordinaryhealthcare.Fig.1gives anoutlineoftherelationshipbetweenbiasesandprioritysetting whileTable1givesanoverviewofthebiasesandpotentialimplica- tionsforprioritysetting.Whatfollowsisanoverviewofpotentially importantbiasestoaddressinprioritysetting. Theformatdoes notallowanin-depthanalysisofallthebiases,theirimplications, orofpotentialsolutionsonhowtohandlethem.Nonetheless,the overviewmaybeaninitialandinspiringsteptoaddressanimpor- tantissueinhealthpolicymaking.Moreover,someimplications andindicationsofhowsomeofthebiasesmaybeaddressedwill alsobepresentedinthediscussion.

TheIdentifiabilityandSingularityeffectoccurswhenasingle patientinfrontofthehealthcareprofessionaloronthefront-page ofthenewspaperemotionally“takespriority”overthemanythou-

Fig.1. Outlineoftherelationshipbetweenbiasesandphenomena(irrationaldeci- sions)thatoccurinhealthcareandhowtheyundermineprioritysetting.Threetasks appearimportantforavoidingthiseffect,i.e.,revealing,addressing,andhandling biases.

sandsthatalsomaybeinneed[44].Oneexampleiswhenindividual patientsorpatientgroupsgetaccesstoveryexpensivetreatments withoutevidenceaftermediaappearance.Empiricalstudiesshow a“bedsideeffect”inrationing,whererespondentsrationedtoa greaterextentatapolicylevelthanatabedsidelevel[45].When theindividualandproximatepatienttrumpsallnon-presentand moreremotepatientsgeneralprioritysettingprinciples,suchas justiceandequity,areundermined[46].Thisbiasconnectsto“com- passioncollapse,”“empathydecline,”andotherrelatedeffectswell describedinthepsychology,behavioraleconomics,andriskhan- dlingliterature[47].Whilethedutytotheidentifiedandpresent personisunderstandablefromanemotionalandproximityethics pointofview[48],theSingularityeffectmaytrumppriorityset- tingprinciples,suchasseverity,effectiveness,andefficiency,and bypassestablishedproceduresandhencedistortprioritysetting.

AnotherbiaspotentiallydistortingprioritysettingisRejection Dislike,whichstemsfromthefactthatnoonelikesbeingrejected ortorejectothers.Sayingnotoindividualpatientsorpatientgroups ordisinvestinginspecific(low-value)healthservicesmaymean thatsomeserviceswillstopbeingprovided.NotofferingMRIor arthroscopyofthekneearebuttwoexamples[49].Hence,some patientscannotgetwhattheypreviouslyhavebeenoffered,and despitethefactthatitisoflowvalue,itfeelsbadtotakeitaway andtherebyrejectingpeople.Moreover,rejectiondislikeisrelated tonotbeinggenerous,buttobestingy.Therefore,prioritysetting canbeconnectedtothefeelingoftakingsomethingaway,denying awelfaregood,rationing,andbeingstingy.

3.1. Failureembarrassmenteffect

Thisisabiasresultingfromthefactthatnoonelikestoadmit tohavebeenwrongorbehavedfoolishly.Thehistoryofmedicine isfullofexampleswherefutileorevenharmfultreatmentshave provided for a long time, even when inefficiency were known [50,51].Percutaneouscoronaryinterventionperformedforstable coronaryarterydiseaseandhormonetherapyprescribedforpost- menopausalwomen[52]arebuttwoexamples.Prioritysetting, andin particulardisinvestment,impliesthat wemayhave pro- videdpatientswithlowqualitycare,whichisnotcompatiblewith theprofessionalintegrityandself-conceptionofmanyhealthpro- fessionals.Thismaybeoneofmanyreasonswhyclinicians,health managers,aswellashealthdecisionmakersarehesitantwithpri- oritysettingandobtainmodestoutcomes.

Table1

Overviewofvariousbiasesandpotentialimplicationsforprioritysettingandatwhichleveltheymaybemostprominent.

Bias PotentialImplications Level

IdentifiabilityandSingularityeffect Underminingprinciples Micro

RejectionDislike Hamperdisinvestment Micro,meso

FailureEmbarrassmenteffect Overuse Micro(primarily)

ProminenceEffect(OpportunityCostNeglect) Non-warranteduse All

StatusQuoBias Overuse,Underuse All

EndowmentEffect Overuse,Underuse Micro(primarily)

LossAversion Hamperdisinvestment All

AversiontoRisk/Ambiguity Overuse Micro,meso

AvailabilityHeuristics Overuse Micro,meso

SacredValuesandTabootrade-offs Underminingprinciples All

Progressbias Overuse All

AdoptionAddiction Overuse Micro,macro

Complexitybias Underminingprinciples,overuse Micro,meso,macro

Extensionbias Overuse All

Asymmetryofrisksandbenefits Overuse Micro(primarily)

Positivecognitivefeedbackloops Underminingprinciples,overuse Micro,meso,macro

Prestigebias Underminingprinciples,overuse Micro(primarily)

ImperativeofAction Underminingprinciples,overuse Micro(primarily)

TechnologyPlaceboEffect Underminingprinciples,overuse Micro(primarily)

ImperativeofKnowledge Overuse Micro

CompetencyEffect Overuse Micro

MultipleReplacements Overuse Micro

WhiteElephants Overinvestment Micro

BoysandToysEffect Unwarranteduse Micro

Hence,asfarasprioritysettingisassociatedwithrejecting,tak- ingaway,orhavingbehavedfoolishly,wetendtobeinclinedto avoidsuchsituations(bothindividuallyandcollectively).Thiscan helpustoexplainourmoderateoutcomesinprioritysetting,but alsopointtoimportanttasksofprioritysetting.

3.2. Theprominenceeffect

Thisistheeffectfromthetendencythatonedominantfactor determinesthedecision-makers’preferences.Situationsinclini- calpracticeasinhealthpolicymakingarecomplex,andtakingall aspectsintoaccountisdemanding.Hence,reducingcomplexityby highlightingone(orafew)aspectseasestheprocess.However,this hampersrationalprioritysetting.Onewaythatthiscanplayoutin prioritysettingiswhathasbeencalledtheopportunitycostneglect [53].Weassessthebeneficenceforthepresentpatient,butnot whatwecouldhavedoneforthosewhoarenotpresent.Another exampleiscancerscreeningprogramsthathavefocusedonben- efitsintermsof increasedsurvival anddisease-specificreduced mortalitywhileignoringoverdiagnosis[54].

3.3. ThestatusquoBias

Thisisacognitivebiaswhichdescribestheirrationalprefer- enceforanoptiononlybecauseitpreservesthecurrentstateof affairs[55].Manypeoplemayhaveanaversiontochange(conser- vativism)makingpeopleavoid alteration[56].Asfaraspriority settingimplieschanges,thestatusquobiasmayhamperpriority setting.Itmaymakeitdifficulttoabandonfutileorlow-valueser- vices[52]butalsotoadoptnewandefficientones[57].TheStatus QuoBiasisassociatedwiththeEndowmentEffect.

3.4. Theendowmenteffect

Accordingtothiseffectwhichwetendtoovervaluewhatwe alreadyhavegotcomparedtoalternatives.Ineconomicterms:“the factthatpeopleoftendemandmuchmoretogiveupanobjectthan theywouldbewillingtopaytoacquireit”[58].Hence,thetech- nologyorhealthservicethatwehaveassessedandimplemented, beentrainedtouse,becomefamiliarwith,andwhichpartlyconsti- tutesourprofessionalidentitytendstobevaluedhigherthanother

technologies;evenifevidencecanshowthatthealternativetech- nologyisbetter.Arthroscopicsurgeryfordegenerativekneemay bebutoneexample[59].TheEndowmentEffectinturnisrelated toanasymmetryofvalueexpressedasLossAversion.

3.5. Lossaversion

Accordingtothiseffectwefeeluncomfortablewithloosingwhat wehave,orineconomicterms“thedisutilityofgivingupanobject isgreaterthattheutilityassociatedwithacquiringit”[58].Arelated biasisthesunkcosteffect,accordingtowhichwehaveatendencyto continueabehaviorbecausewehaveinvestedresourcesinit,such astime,money,orcompetency[60].Thisisexactlywhatwemay fearishappeninginprioritysetting,especiallyindisinvestmentand rationing.Tostopgivingadrenalineinsituationsofout-of-hospital cardiacarrestisdifficultevenifthereislittleevidenceforthelong- standingpractice[61].

Otherrelatedeffectsareanticipateddecisionregret[62]and bettersafethansorry.Forexample,thefearofdoing toolittle maybegreaterthanthefearofdoingtoomuch(FearAsymme- try),whichmayberelatedtodefensivemedicineandwhat has beencalledthe“popularityparadox”[54,63].Excessivelaboratory testsandunwarranted[64,65]imagingarebuttwoexamplesof this[66,67],andwhereprioritysettingprinciplesmaybebypassed oroverruled.

AversiontoRiskandAversiontoAmbiguity[56]areaversions todangersoruncertaintiesthatmaymakeusresistpriorityset- ting,e.g.,intermsofcurbingtheuseofdiagnostics.Weclingto makingextrabloodtestsorexcessimagingeventhoughtheywill notincreaseourknowledgeorchangetheclinicalpathwaybecause weareafraidofmissingsomething[65].

Othercognitivebiasesthatarerelevantforprioritysettingisthe AnchoringEffect,wherethedecision-makerisrelyingtoomuch oninitialinformation,andnotonmorehard-to-gethighquality evidence[56].

Correspondingly,AvailabilityHeuristics,canmakediagnostics ortreatmentoptionconsideredtobeimportantbecausetheyare available.Thisphenomenoniseasilyobservedinradiology,where thereisastrongcorrelationbetweenavailablemodalitiesandthe numberofexaminations[68,69].Theproverb“scanbecauseyou can”[70,71]istelling.Despiteextensiveawarenessof“Roemer’s

law”(“Abuiltbedisafilledbed”)[72]feweffectivemeasuresare inplacetocounterit.

Yettwootherbiasesarewhathavebeencalledsacredvalues andtabootrade-offs.Accordingtothefirsttherearesomevalues, suchassavingaperson’slife,whichpeopleareknowinglyreluctant totrade-offnomatterwhattheharmsandbenefitsofdoingsomay be[73,74].Correspondingly,totradeoffhealthagainst(material) consumptionisconsideredtobetaboo[53].Clearly,astrongurge tosavelives,nomatterwhat,infringesprioritysettingprinciples.

Thesebiasesrelatetotheidentifiabilityandsingularityeffects.

AccordingtotheProgressBiasweexperienceastrongpropen- sitytopromotewhatisconsideredtobeprogress[75].Although onemightthinkthatastrongbeliefinprogresswouldpromote change,leavingoldtechnologiesobsoletewhen embracingnew ones,thereisanaccumulativeeffectinpractice.Wetendtothink thatscienceingeneralandmedicineinparticularprogressesby addingnewtechnologiesandservices,notbyreducingorremoving oldones.Expansionandadditionispartandparcelofprogress.

3.6. Adoptionaddiction

RelatedtoProgressBiasonecanobserveverystrongbeliefsin positiveoutcomeofadvancedtechnologies[57,76]andanurgeto adoptnewtechnologies[25].Thisbiasesassessmentsanddecision- makingtowardsimplementingandapplyingtechnologiesandis relatedtophenomenasuchas“denialoftheneedfordisinvest- ment”[77]andtousetechnologyforotherpurposesthanintended withoutdocumentationofoutcomes.Diagnosticimagingisagaina goodexample,wheretechnologythatisdevelopedtodetectsomatic disease,suchasMRI,isusedtotreatmentalconditions, suchas healthanxiety,ortoconfirmhealthratherthandetectingdisease [78–80].

3.7. ComplexityBias

Thisisatendencytothinkthatadvancedsystemsandtechnolo- giesarebetterthansimpleones.Agreatnumberoftechnologies identifiedaslow-valuecareareadvancedorhi-tech,whilehigh- valuecarearelow-tech.Complexitybiasprovidesoneexplanation fortheextensiveuseofhi-techlow-valuecare[32].Itseemsto counterourintuitionthatadvanced technologiescouldbeinef- fective,inefficient,orevenharmful.However,suchtendencies(of thought)canunderminerationalprioritysettingbyunwarranted implementationanduseofhealthservices.

TheExtensionBiasisatendencytothinkthatmoreisbetter thanlittle[81],forexampleintermsofmoremonitoringormore tests.Whiletherearemanyexamplesofwheremorediagnostics andmoretreatmentcertainlyaregoodforindividuals’andpopula- tionhealth,lessonsonoverdiagnosisandovertreatmenthastaught usthatthisisnogeneralrule.Extensionbiascertainlychallenges resourceallocation.Moreover,extensionbiasmaybesupportedby lossaversion(seeabove)asmeasurestocounteracttheextension bias,e.g.,byrestrictingaccesstotechnology,maybeseenasval- uesbeingtakenaway.Oneexplanationforthefactthatwetendto thinkthatmoreisgoodcanbefoundinmetaphoricaltheory[82], accordingtowhichwetendtohaveaningrainedtendencytovalue extension.

ThereisalsoanAsymmetryofrisksandbenefitsaswetend tounderstandrisksandbenefitsinvery unbalancedandbiased ways[83,84].Accordingly,technologiesandservicesmaynotbe assessedinanunengagedway[85].Therisksoflow-valuetech- nologiesappeartobeunderestimatedwhilethebenefitsmaybe overestimated.Screeningservicesmaybebutoneexampleofthis [86–88].Certainly,biasesintheassessmentofrisksandbenefitscan

distortprioritysettingandevenmakeitappearcounterintuitiveor unnecessary.

3.8. Positivecognitivefeedbackloops

Theassessmentandhandlingofmedicaltechnologiestendto generateimperatives.Forexample,increasingtheaccuracyofdiag- nostictestsmayleadtothedetectionofmildercases,whichwhen treatedinturnincreasesthesuccessrate[80,89,90]andthereby promotes innovations to increase the diagnostic accuracy. Any measuresthatcounterthisexperienceofsuccessappearcounterin- tuitive,“irrational,”andregressiveandtherebycanhamperpriority setting.Findingandsuccessfullytreatingmorediseaseobviously appearstobeagoodthing.Ifthisresultsinspectrumshift,indi- cationcreep,overdiagnosis,andovertreatmentthenitundermines prioritysetting.

3.9. Prestigebias

Yetanothereffectthatcaninfluenceprioritysettingisthefact thatspecificdiseasesandtechnologiesdifferinstatusandpres- tige.Inparticular,diseases(andthecorrespondingspecialties)that areorgan-specific,actionoriented,acute,andinvolvetheappli- cationof advancedtechnologyhave higherprestigethanothers [91,92].Extensivemonitoringofvitalorgans,evenwhenthereis littleevidencefortheoutcome[93,94],isbutoneexampleofthis.

Thismaycertainlyresultinimplicitandtacitprioritysetting,mak- ingusreluctanttodisinvest inanythingthatisassociated with progress,action,andcontrol,andconversely,toinvestinlow-tech approachestodiffusechronicconditions.

3.10. Imperativeofaction

Anothersuchtendency,isexpressedbythetraditionalmedical phraseutuliquidfiat(somethingmusthappen),i.e.,thatactionis betterthaninaction.Modernhealthcare,andtechnologyinpar- ticular,isassociatedwithactionability,andreducingreadinessto actioncanbeconceivedofasplummetingprofessionalstamina.The extensiveandfutileuseoftechnologyattheendoflife,isbutone exampleofthis[95].ThisImperativeofActioncanbeconnectedto Roemer’sLaw(seeabove)aswellasthetendencytousetechnology asaplacebo.

3.11. Technologyplaceboeffect

It is welldocumented that technologyhas or enhances the placebo effect [96–98]. As already mentioned, we usediagnos- tic technology therapeutically, and sometimes we use somatic diagnostic technology (imaging) to treat mental conditions in physicians(litigationanxiety).WhentheTechnologyPlaceboEffect ishighitsoveralleffectmaybeconsideredtobesignificanteven ifdocumented(placebo-controlled)effectmaybesmall[99].This mayexplaintheextensiveuseofawiderangeoflow-valuetech- nologies,includingseveralkindsofsurgery[98],anditcanhamper orunderminerationalprioritysetting.

3.12. Imperativeofknowledge

Arelatedeffectisfosteredbyprofessionalsexperiencingaseries ofnewtechnologiesenteringtheirprofessionalsceneallthetime.

Newmethodsandtechnologiesareusuallyexperiencedasacon- tinuous progress. This canbe because technologyis associated withinnovation,advance,action,control,andoptimism[100–103].

Accordingly, anyarrangements countering this forward-flow of advancementappearcounterintuitiveandregressive.Hence,tothe extentthatprioritysetting appearsstiflingitisconceived ofas

somethingnegative(andtobeavoided).Inthefieldofdiagnos- ticsthisisexpressedasanImperativeofKnowledge,e.g.,intermsof that“toknowisbetterthannottoknow”[104]Whileknowledge certainlyisagoodthinginhealthcare,falsepositives,incidental findings[105],andoverdiagnosis[90]underminetheuniversality ofthisbenefit.Nonetheless,wewanttoknow,andtendtothink thatearlydetectionisbetterthanlate[106].Therefore,toreduce suchtechnologiesappearscounterintuitive andopposesprofes- sionalnormsand values[107]. Thus,itmayunderminepriority setting.

3.13. Thecompetencyeffect

Thiseffectisconnectedtotheneedoftrainingandeducation.

Inordertomaintaincompetencyintheuseofspecifictechnologies (andthestatusofcertainspecialties)professionalsneedtopractice.

Accordingly,proceduresaresometimescarriedoutthat areless warrantedandoflowvaluetothepatients[31].ThisCompetency Effectcancounterrationalprioritysetting.

Severaleffectscounteringprioritysettingcanbeobservedinthe useandmanagementofmedicaltechnologiesineverydayclinical practice.Double(ormultiple)replacementisbutoneexample:

anultrasoundmachineis“replaced”becauseitis“outdated,”“pro- videslow quality images,”or “isdangerous.” However,the old machineiskeptasabackup.Afterawhile,theoldmachinere-enters thedailypractice,e.g.,duetohighdemand.Aftersometime,itis arguedagainthatitis“outdated,”“provideslowqualityimages,”

and“isdangerous”andneedsreplacementagain.

“WhiteElephants”aretechnologiesthatareimplementedin ordertoattractaspecialgroupofprofessionals,tokeepindividual professionalshappy,ortoenticepatients,butwherethetechnology maynotbeofanyorlittlevaluetopatients’outcome.Varioustypes ofimagingdevicesorequipmentforspecificsurgicalprocedures arebuttwoexamples.Unfortunately,therearemanyexamplesof technologiesthat havebeenacquiredand maintainedfor many yearswithouteverbeingused.Thisgeneratesopportunitycosts andchallengesprioritysetting.

Whathasbeen calledthe “Boys andToys Effect” is where technologies,suchassurgeryrobots,havebeenimplementednot becauseof theireffectivenessorefficiency,but becauseoftheir attractivenesstoprofessionalsandpatients[108].Thiseffectcan berelatedtothefactthattherequirementsfordocumentedeffec- tivenessandefficiencyhasbeendifferentfordevicesthanfordrugs [109].Certainly,thefun-factorisimportantineveryemployees dailylife.However,when whatis funfortheprofessionaldoes notincreasethehealth ofpatients,and,onthecontrary,gener- atesopportunitycosts,itbecomesaproblemforrationalpriority settinginpractice.

4. Discussion

Hence, there are a wide range of biases that can counter, obstruct, or distort priority setting processes. They may result inoveruse,underuse,andoverinvestment,andmayhamperdis- investmentandundermineprioritysettingprinciples.Moreover, biasesareoperationalbothonmicro,mesoandmacrolevel,but thisvarieswiththedifferentbiases.Beingawareofsuchbiasesand theirpotentialeffectonpracticalprioritysettingisthefirststep towardsaddressingandhandlingthem.Assuchthisoverviewcan beuseful.However,itisbynomeansexhaustive.

4.1. Manymorebiases

Ingeneraltherearemorethan150biasesidentifiedinanumber offields[110].Eventhough,notallofthesemayberelevantforpri- oritysetting,manymorethanthoseincludedheremayberelevant.

Certainly,socialpressures(Bandwagoning)frequentlystudiedin HumanRelationscanberelevant[111].ThesamegoesforContext Errorsthatarewellknownfromclinicaldecisionmaking,e.g.,when thephysicianisnotabletoseethecontextofthepatient’scondi- tionandmakeserroneousdiagnosticortherapeuticjudgements [110].Presentbias,discountingfutureevents[112],andmental accountingareyettwoother.

4.2. Thereismuchmoretosayabouteachbias

However,thepointherehasnotbeentogenerateanexhaustive listofbiases,buttogivesomeexamplestoillustratehowdiffer- entbiasesandimperativescanaffectprioritysettingindifferent ways.Moreover,thedescriptionofthebiasesandtheireffectsis quitebrief.Everybiasand itsinfluenceonprioritysettinghave tobeinvestigatedinfurtherdetail.However,thisisbeyondthe scopeofthisarticlethatmainlyaimsatdrawingtheattentionto andprovidinganoverviewoverthebiasesthatcandistortpriority setting.Relatedly,anotherimportantissuebeyondthescopeofthis studyiswhetherallbiasesarebad.Nodoubt,severalbiasesfunction asheuristicshelpingustomakedecisionsfast[42].However,the biasesincludedinthisstudyareselectedbecauseoftheirdistortive potential,andhencemayappearasmorallyandrationallybad(as inTable1).Moreover,manyoftheexamplesarefromexcessive useoftechnology.Asalreadyunderscored,biasesmayalsoham- pertheimplementationofhigh-valuetechnology.Thestatusquo biasisoneexampleofsuchabiasandtelemedicineisoneexam- pleofsuchatechnology[57].Hence,biasescanalsoundermine prioritysettingbynon-adoption.Thereasonwhymostexamples arefromexcessiveuseoftechnologymaybethattheystemfrom healthcareinaffluentcountries(wherethereisarichliterature).

Situationsareverydifferentinotherhealthcaresettings.Thisbias inexamplemaybeonethatthisauthorshareswithmanypeople intheso-called“developedworld.”

4.3. Classificationofbiases

Correspondingly,thepointwiththisstudyhasnotbeentogo intothediverseanddetaileddebatesontheclassificationandrela- tionshipbetweenvarioustypesofbiases,butrathertopointto someeffectsthatappeartoberelevantforexplainingandhandling theapparentlyirrationalprioritysetting.Futureworkmaywantto categorizebiasesinprioritysettinginthesamewayasGretchen Chapmandividesdecisionbiasesinmedicaldecisionmakinginto threedifferenttypes;strategybased,associationbased,andpsy- chophysicalbasedbiases[113]. Whilestrategy basedbiasesare appliedbecausetheymakedecisionsfasteroreasier,association basedbiasesbringtogetherinformation(byassociation)thatisnot relevantforthedecision,andpsychophysicalbasedbiasesresult fromnon-linearmappingofphysicalstimulitopsychologicalrep- resentation[114].Itisalsopossibletoanalyzedistortingfactors toprioritysettingintermsofotherframeworks,suchasimpera- tives[115],inertia[116–119],astechnologicaldrivers/imperatives [78,120–122]andintermsofhumandeficiencies[123].Onemay alsoapplydual-systemtheoriesincognitiveandsocialpsychol- ogy[42,124–126]toanalyzethewaysofthinkingthatmaydistort prioritysetting.Forexample,onemaythinkthatbiasesbelongto thefast,affective,intuitive,andnon-analyticalSystem-1modeof thinkingandthattheydistorttheslow,deliberative,andanalytic System-2modeofthinkinginprioritysetting.However,biasesdo notalwaysresultfromSystem1modesofthinkingand System 2thinkingdoesnotalwaysprovidetherationalanswer[126].No doubt,theseissuesareimportantandinteresting,butbeyondthe scopeofthisarticle.

4.4. Contextmatters:prioritysettingandtheoreticalframework

Moreover,thisstudyhasanalyzedtheeffectsrelevantforprior- itysettingingeneral.Other,related,andmorespecificfieldscould havebeenstudiedaswell,suchasimplementinghigh-valuecare, reassessment,disinvestment,decommissioning,andwithdrawal.

Whiletheeffectsofbiasesonthesemorespecificissuescertainly isofgreatinterest,suchanalysismerittheirownandmorespecific studies.Correspondingly,thespacehasnotallowedanextensive analysisoftheeffectsrevealedhereand“implicitrationing”and

“hiddenrationing.”

Anotherimportantissuethatisnotcoveredhereisplacingthe effectswithinspecifictheoreticalframeworks.Forexample,many oftheeffectscanbeelaboratedfromconceptual-metaphoricalthe- ory[82],accordingtowhichconceptsareestablishedbymetaphors.

For example, the concept of argument is constituted by the metaphor of war, as is evident from statementslike “winning anargument.”Ifthisishow biasesareestablished,i.e.,through metaphors,thismayhaveimplicationsonhowwemayaddress them.Theoreticalframingiscertainlyinterestingandimportant, buthastobeaddressedmoreexplicitlyinmorededicatedstudies.

4.5. Howdothevariousbiaseshamperorunderminepriority setting?

Thisstudyonlyprovidessomeexamplesof howthevarious biasesinterrelateandhamperorundermineprioritysetting.More in-depthanalysesarenecessary,butbeyondthescopeofthisstudy.

Thisstudyisamodestfirststeptoprepareforandmotivatemore elaboratestudies.

Itmaywellbearguedthatprioritysettingisnotarationalor principlebasedmatter,butinvolvesawiderangeofothernon- rationalaspects.I fullyagree withthis. Here Ihave onlytaken therationalandprinciple-basedaccountsofprioritysettinginto accountthatareclaimedbythefielditselfandusedtojustifyits activity.Awiderangeofbiasesorheuristicsmaybewarrantedin prioritysetting,buttheywouldhavetobeexplicitlyjustified.

4.6. Whatcanwedotoavoidorhamperbiasesandpromote rationalprioritysetting?

Certainly,theissueofhowtohandlethebiasesinordertopro- moterationalprioritysettingisgiantnextstepandwellbeyond thescopeof this work.However, somethingcanbe saidabout thisinordertostimulatethisimportantwork.First,therealready existaseriesofadviceondebiasingingeneral[111,114]andfor healthdecisionsintheclinicalsettinginparticular[127–129].Sev- eralofthesemayberelevantforthehealthpolicycontext,such as“stoppingrules,”check-lists,”and“cognitiveforcingstrategies.”

Moreover,specificsuggestionstoreducecognitivebiaseswithin special fields are available, suchas decision support toreduce diagnosticerrors [130–132] and interventionstoimproveclini- calreasoningand decision-makingskills [133].Othersuggested strategiesare“cognitivehuddles,narrativesofpatientharm,value considerationsinclinicalassessments,definingacceptablelevels ofriskofadverseoutcomes,substitution,reflectivepracticeand rolemodelling,normalisationofdeviance,nudgetechniquesand shareddecisionmaking”[134].Additionally,thereexistteststhat areelaboratedtodetectspecificbiases. Forexample,a test has beendevelopedtoidentifyandcounteracttheprogressbias[75].

Ingeneral,identifyingbiasesisafirststeptoaddressthem.Hence, opennessandtransparencyareimportant.However,biasesarenot liketrolls:theydonotexplodewhentheyareexposedtosunshine.

Thereasonforthisisthatbiasesaretrollsinsideus.Butreveal- ingthebiasesamongstandwithinusforcesthemtohidelikethe trollsfor thesun,hopefully doinglessharm.Hence,despitethe

study’slimitswithrespecttoprovidingspecificsolutions,itnour- ishesanunderlyingbeliefthatrevealing,acknowledging,analyzing, andaddressingtheeffectsofbiasesisagoodthingandaprereq- uisitetoimprovingprioritysetting.Hence,thestudyimpliesthat prioritysettingismorethandeliberativeapplicationofprinciples andguidelines–anditexplainswhytheprioritysettingoutcomes havebeenslowandhardtoobtain.Weneedtoaddressdistorting factorsinordertoobtainwell-reasonedprioritysettingmeasures toprovidethebestcaretopatients.Againstthis,onecanofcourse arguethatitisnotpossibletoeliminatebiases[135,136],orthat biasesandheuristicsareefficientwaystohandleuncertainty[138].

Anotherobjection wouldbetoclaimthat“biasesand heuristics poseaseriousthreattoautonomousdecisionmakingandhuman agency”[136]andthatrationalanddeliberateprioritysettingis anutopiangamethatshouldbeabandoned.Correspondingly,one couldarguethat thestrongbeliefinourability toeliminateor reducetheeffectofthevariousbiasesinprioritysettingisitselfan unwarrantedpreconceptionandabias.However,forthetimebeing Ithinkwehavetoopoorempiricalevidencetoabandondeliberative prioritysetting,andthatwemeanwhileimprovethedeliberative processasmuchaswecan.

5. Conclusion

Giventherapidlywideningpossibility-provisiongapand the extensiveuseoflow-value careinthehealth servicesthisarti- cle set out askingwhy the outcomesof priority setting are so poorly documentedinhealth care whileprinciples,regulations, andtoolsforprioritysettingarecomparablywelldevelopedand readilyavailable.Theinitialassessmentidentifiedseveralrational andstructuralexplanationsforthediscrepancybetweentheoreti- caleffortsandpracticaloutcomesinprioritysetting.However,even iftheseandotherbarriersareaddressed,practicalprioritysetting maystillnotobtainitsexplicitgoals.Thereasonisthat awide rangeofbiasescanhamperordistortprioritysetting.Biasescan resultinoveruse,underuse,andoverinvestment;itmayhamper disinvestmentandundermineprioritysettingprinciples.Biasesare operationalbothonmicro,mesoandmacrolevel,dependingon eachbias.Theycanexplaintheextensiveuseoflow-valuecareand directoureffortstofreeresourcesforhigh-valuecare.Addressing thesebiasesiscrucialforimprovingprioritysetting–bothinprac- ticeandfortheory–andespeciallytoprovidegoodhealthcare.A firststeptowardsdoingsoistorevealandacknowledgethebiases involved.

DeclarationofCompetingInterest

Iamthesoleauthorofthismanuscript.Themanuscriptissent exclusivelytoyou,hasnotbeenpreviouslypublishedelsewhere, andisnotcurrentlyunderreviewelsewhere.

Icertifythatthereisnoconflictofinterestinrelationtothis manuscript,andtherearenofinancialarrangementsorarrange- mentswithrespecttothecontent ofthis manuscript withany companiesororganizations.

Icertifythatthereisnoconflictofinterestinrelationtothis manuscript,andtherearenofinancialarrangementsorarrange- mentswithrespecttothecontent ofthis manuscript withany companiesororganizations.

Acknowledgement

IammostgratefultoPaulSlovicfordirectingmyattentionto theworkofMichaelMazarrandtoGustavTinghögforvaluable commentstoanearlierdraftofthismanuscript.Someelementsof

thispaperhavebeenpresentedanddiscussedwiththeparticipants ofthePriorities2018conferenceinLinköpinginSweden.

References

[1]vanExelJ,BakerR, MasonH,DonaldsonC,BrouwerW,TeamE.Public viewsonprinciplesfor healthcareprioritysetting:findingsofa Euro- peancross-countrystudyusingQmethodology.SocialScience&Medicine 2015;126:128–37.

[2]RosenheckRA.Principlesforprioritysettinginmentalhealthservicesand theirimplicationsfortheleastwelloff.PsychiatricServices1999;50:653–8.

[3]DanielsN.Accountabilityforreasonableness:establishingafairprocessfor prioritysettingiseasierthanagreeingonprinciples.BMJ:BritishMedical Journal2000;321:1300.

[4]HarrisC,GreenS,ElshaugAG.SustainabilityinHealthcarebyAllocating Resourceseffectively(SHARE)10:operationalisingdisinvestmentinacon- ceptualframeworkforresourceallocation.BMCHealthServicesResearch 2017;17:632.

[5]Hughes E, McKenny K. Decommissioning and disinvestment toolkit 2013–2014Rayleigh.Essex:CastlePointandRochfordClinicalCommission- ingGroup;2013.

[6]Garcia-ArmestoS,Campillo-ArteroC,Bernal-DelgadoE.Disinvestmentinthe ageofcost-cuttingsoundandfury.ToolsfortheSpanishNationalHealth System.HealthPolicy2013;110:180–5.

[7]ElshaugAG,RosenthalMB,LavisJN,BrownleeS,SchmidtH,NagpalS,etal.

Leversforaddressingmedicalunderuseandoveruse:achievinghigh-value healthcare.TheLancet2017;390:191–202.

[8]BrownleeS,ChalkidouK,DoustJ,ElshaugAG,GlasziouP,HeathI,etal.

Evidence foroveruseofmedical servicesaroundtheworld. TheLancet 2017;390:156–68.

[9]SainiV,BrownleeS,ElshaugAG,GlasziouP,HeathI.Addressingoveruseand underusearoundtheworld.TheLancet2017;390:105–7.

[10]GlasziouP,StrausS,BrownleeS,TrevenaL,DansL,GuyattG,etal.Evi- denceforunderuseofeffectivemedicalservicesaroundtheworld.TheLancet 2017;390:169–77.

[11]Parkinson B,SermetC,ClementF,CrausazS,GodmanB,GarnerS.Dis- investmentandvalue-basedpurchasingstrategiesforpharmaceuticals:an internationalreview.PharmacoEconomics2015:33.

[12]MalikH,MartiJ,DarziA,MossialosE.Savingsfromreducinglow-valuegeneral surgicalinterventions.BritishJournalofSurgery2018;105:13–25.

[13]SainiV,Garcia-ArmestoS,KlempererD,ParisV,ElshaugAG,BrownleeS,etal.

Driversofpoormedicalcare.TheLancet2017;390:178–90.

[14]HollingworthW,ChamberlainC.NICErecommendationsfordisinvestment.

BMJ:BritishMedicalJournal(Online)2011:343.

[15]ElshaugAG,WattAM,MundyL,WillisCD.Over150potentiallylow-value healthcarepractices:anAustralianstudy.MedicineJournalofAustralia 2012;197:556–60.

[16]NivenDJ,MrklasKJ,HolodinskyJK,StrausSE,HemmelgarnBR,JeffsLP,etal.

Towardsunderstandingthede-adoptionoflow-valueclinicalpractices:a scopingreview.BMCMedicine2015;13:255.

[17]ScottIA,DuckettSJ.Insearchofprofessionalconsensusindefiningandreduc- inglow-valuecare.TheMedicalJournalofAustralia2015;203:179–81.

[18]PathiranaT,ClarkJ,MoynihanR.Mappingthedriversofoverdiagnosisto potentialsolutions.Bmj2017;358:j3879.

[19]Ibargoyen-RotetaN,Gutiérrez-IbarluzeaI,AsuaJ.Guidingtheprocessof healthtechnologydisinvestment.HealthPolicy2010;98:218–26.

[20]Schmidt DE. The developmentof a disinvestment frameworkto guide resourceallocationdecisionsinhealthservicedeliveryorganizations.Uni- versityofBritishColumbia;2012.

[21]HarrisC,GreenS,RamseyW,AllenK,KingR.SustainabilityinHealthcareby AllocatingResourceseffectively(SHARE)9:conceptualisingdisinvestmentin thelocalhealthcaresetting.BMCHealthServicesResearch2017;17:633.

[22]Levinson W, Kallewaard M, Bhatia RS, Wolfson D, Shortt S, Kerr EA.

‘Choosing wisely’:agrowinginternationalcampaign.BMJQualitySafety 2015;24:167–74.

[23]GarnerS,LittlejohnsP.Disinvestmentfromlowvalueclinicalinterventions:

NICElydone?Bmj2011;343:d4519.

[24]SorilLJ,MacKeanG,NoseworthyTW,LeggettLE,ClementFM.Achievingopti- maltechnologyuse:aproposedmodelforhealthtechnologyreassessment.

SAGEopenMedicine2017;5:2050312117704861.

[25]ScotlandG,BryanS.Whydohealtheconomistspromotetechnologyadoption ratherthanthesearchforefficiency?Aproposalforachangeinourapproach toeconomicevaluationinhealthcare.MedicalDecisionMaking:AnInterna- tionalJournaloftheSocietyforMedicalDecisionMaking2017;37:139–47.

[26]SchwartzAL,LandonBE,ElshaugAG,ChernewME,McWilliamsJM.Measuring low-valuecareinMedicare.JAMAInternalMedicine2014;174:1067–76.

[27]SelbyK,GaspozJ-M,RodondiN,Neuner-JehleS,PerrierA,ZellerA,etal.

Creatingalistoflow-valuehealthcareactivitiesinSwissprimarycare.JAMA InternalMedicine2015;175:640–2.

[28]GliwaC,PearsonSD.EvidentiaryrationalesfortheChoosingwiselyTop5lists.

Jama2014;311:1443–4.

[29]GapanenkoK,LamD,ParkerM,D’SilvaJ,JohnsonT.Unnecessarycarein Canada.HealthcareQuarterly(Toronto,Ont)2017;20:10.

[30]Ruano-RavinaAVGM,etal.Identification,prioritisationandassessmentof obsoletehealthtechnologies.Amethodolgicalguideline.HTAReports:avalia- tMadrid.MinistryofScience&Innovation;2007.

[31]IacobucciG.NHSproposestostopfunding17“unnecessary”procedures.BMJ 2018:362.

[32]SorilLJJ,SeixasBV,MittonC,BryanS,ClementFM.Movinglowvaluecare listsintoaction:prioritizingcandidatehealthtechnologiesforreassessment usingadministrativedata.BMCHealthServiceRes2018;18:640.

[33]SmithN,MittonC,HiltzM-A,CampbellM,DowlingL,MageeJF,etal.A qualitativeevaluationofprogrambudgetingandmarginalanalysisinaCana- dianPediatricTertiaryCareInstitution.AppliedHealthEconomicsandHealth Policy2016;14:559–68.

[34]SibbaldSL,GibsonJL,SingerPA,UpshurR,MartinDK.Evaluatingpriority settingsuccessinhealthcare:apilotstudy.BMCHealthServicesResearch 2010;10:131.

[35]SibbaldSL,SingerPA,UpshurR,MartinDK.Prioritysetting:whatconstitutes success?Aconceptualframeworkforsuccessfulprioritysetting.BMCHealth ServicesResearch2009;9:43.

[36]ElshaugAG,WattAM,MundyL,WillisCD.Over150potentiallylow-value healthcarepractices:anAustralianstudy.TheMedicalJournalofAustralia 2012;197:556–60.

[37]RichardsonHS.Practicalreasoningaboutfinalends.CambridgeUniversity Press;1997.

[38]RichardsonHS.Specifying,balancing,andinterpretingbioethicalprinciples.

TheJournalofMedicineandPhilosophy:AForumforBioethicsandPhilosophy ofMedicine2000:285–307.OxfordUniversityPress.

[39]GanderJC,ZhangX,RossK,WilkAS,McPhersonL,BrowneT,etal.Associa- tionbetweenDialysisfacilityownershipandaccesstokidneytransplantation.

JAMA:TheJournaloftheAmericanMedicalAssociation2019;322:957–73.

[40]SingerPA,MapaJ.Ethicsofresourceallocation:dimensionsforhealthcare executives.Law&Governance1998:2.

[41]WillsonA.Theproblemwitheliminating‘low-valuecare’.BMJQualityof Safety2015;24:611–4.

[42]KahnemanD,SlovicP.TverskyA.JudgementUnderUncertainty:Heuristics andBiases.NewYork:Cambridge:UniversityPress,Cambridge;1982.

[43]TverskyA,KahnemanD.Judgmentunderuncertainty:heuristicsandbiases.

Science1974;185:1124–31.

[44]WissJ,AnderssonD,SlovicP,VastfjallD,TinghogG.Theinfluenceofidenti- fiabilityandsingularityinmoraldecisionmaking;2015.

[45]PerssonE,AnderssonD,BackL,DavidsonT,JohannissonE,TinghögG.Discrep- ancybetweenhealthcarerationingatthebedsideandpolicylevel.Medical DecisionMaking2018;38:881–7.

[46]DanielsN.Reasonabledisagreementaboutidentifedvs.Statisticalvictims.

HastingsCenterReport2012;42:35–45.

[47]SlovicP.Ifilookatthemassiwillneveract:psychicnumbingpsychicnumbing andgenocidegenocide.Emotionsandriskytechnologies.Springer;2010.p.

37–59.

[48]LevinasE.EmmanuelLevinas:basicphilosophicalwritings.IndianaUniver- sityPress;1996.

[49]JärvinenTL,GuyattGH.Surgery:fallingoutoflovewithkneearthroscopy.

NatureReviewsRheumatology2017;13:515.

[50]WoottonD.Badmedicine:doctorsdoingharmsinceHippocrates.Oxford UniversityPress;2007.

[51]FisherES,WelchHG.Avoidingtheunintendedconsequencesofgrowthin medicalcare:howmightmorebeworse?JAMA:TheJournaloftheAmerican MedicalAssociation1999;281:446–53.

[52]PrasadV,CifuA,IoannidisJP.Reversalsofestablishedmedicalpractices:

evidencetoabandonship.JAMA:ThejournaloftheAmericanMedicalAsso- ciation2012;307:37–8.

[53]TinghögG,VästfjällD.Whypeoplehatehealtheconomics–Twopsychologi- calexplanations.LinköpingUniversity,DivisionofEconomics,Departmentof ManagementandEngineering;2018.

[54]WelchHG,BlackWC.Overdiagnosisincancer.JournaloftheNationalCancer Institute2010;102:605–13.

[55]KahnemanD,TverskyA.Choices,values,andframes.HANDBOOKOFTHE FUNDAMENTALSOFFINANCIALDECISIONMAKING:partI.WorldScientific;

2013.p.269–78.

[56]SaposnikG,RedelmeierD,RuffCC,ToblerPN.Cognitivebiasesassociated withmedicaldecisions:asystematicreview.BMCMedicalInformaticsand DecisionMaking2016;16:138.

[57]GreenhalghT,WhertonJ,PapoutsiC,LynchJ,HughesG,A’CourtC,etal.

Beyondadoption:anewframeworkfortheorizingandevaluatingnonadop- tion,abandonment,andchallengestothescale-up,spread,andsustainability of health and care technologies. Journal of Medical Internet Research 2017;19:e367.

[58]KahnemanD, KnetschJL,ThalerRH.Anomalies:the endowmenteffect, loss aversion, and status quo Bias. Journal of Economic Perspectives 1991;5:193–206.

[59]ThorlundJB,JuhlCB,RoosEM,LohmanderL.Arthroscopicsurgeryfordegen- erativeknee:systematicreviewandmeta-analysisofbenefitsandharms.BMJ (ClinicalResearched)2015;350:h2747.

[60]ArkesHR,BlumerC.Thepsychologyofsunkcost.OrganizationalBehavior andHumanDecisionProcesses1985;35:124–40.

[61]JacobsIG,FinnJC,JelinekGA,OxerHF,ThompsonPL.Effectofadrenaline onsurvival inout-of-hospital cardiacarrest:arandomiseddouble-blind placebo-controlledtrial.Resuscitation2011;82:1138–43.