MÉTODOS Y MODELOS EN EL ESTUDIO DEL CONFORT TÉRMICO

The key to optimal drug prescribing and variety seeking on the part of the physician is their capability to compare all possible drug alternatives based on the attributes that determine patient outcomes. Alternative drugs, time pressure and limited information processing capability lead to decision-making costs for optimal prescribing. In general, four distinct types of cost (communication, cognition, coordination, and capability) hinder the tailoring of medication at the patient level (Frank and Zeckhauser, 2007). These costs are closely related to the cost of thinking from the choice literature (Shugan, 1980).

Communication costs are related to the challenges faced by physicians in eliciting information from patients for determining optimal therapy. The patients often visit with the models of illness, agendas, and expectations from the treatment (Kleinman 1987). The physicians face the task of persuading the patients to accept the proposed medication or accurately gathering additional medical information. On the other side of the consultation the freely available medical information from the internet, educates patients on drug efficacy and side effects and encourages them to

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express their preference in the prescription decision. The coordination costs are related to the exchange of medical information between patient and physician for monitoring medical progress or sharing drug-related information.

The third cost associated with a prescription decision process is the cost of learning about a newer or less accustomed therapy. General practitioners prescribe drugs for a variety of patient conditions, but they may have gained substantial experience in some selected therapies. Hence, when prescribing a newer class of treatment, the physician may need to gather information from some external sources.

Finally, in drug prescribing the cognition costs are related to the effort a physician expends to discriminate between various alternatives and diagnostic information. This cost is directly proportional to the number of attributes (m) across all possible drugs (n) being compared (Figure 1). Under a linear compensatory process, the decision-making costs monotonically increase with the number of comparisons. The higher cognitive effort in the rational calculation of the utility of various alternatives, also leads the physicians to resort to satisficing behavior (Simon 1958) or the use of heuristics (Tversky and Kahneman, 1974, Frank 1987) such as the prescription of a most recently prescribed or most popular drug which may in fact be a suboptimal choice for the specific patient.

The capabilities of a physician to manage these four costs determine the level of personalization based on patient symptoms and possible preferences. The physician may choose not to personalize treatments when the returns from customizing are lower than the cognitive efforts of a highly customized prescription. To minimize the cost of thinking, doctors select a minimal number of attributes (m) across the drugs for comparison. They often resort to established norms or rule of thumbs when there is: a) uncertainty over patient diagnosis and their

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responsiveness to various treatments, b) treatment is of short duration c) when the possible treatments are comparable d) high information gathering cost (Tversky and Kahneman, 1974; Frank 1987;Frank & Zeckhauser, 2007).

The advances in information technology and the use of computers and digital media since the early 1990s have influenced the medical practice and have significantly reduced the four costs described earlier. Before the adoption of computers, patient records were recorded on paper and stored at a central location contributing to higher information search and cost. The nature of computer data entry today facilitates efficient updating of patient records, problems and prescription lists. Providers often allow patients to view information such as medication lists, problem lists, allergies, lab results and other customized materials through secure patient portals. The availability of online information streamlines doctor-patient communication, reduces errors and empowers patients to play an active role in decision-making.

The diffusion of internet over time has reduced decision costs for obtaining clinical information and guidance through email services, electronic databases, and the Internet. Healthcare authorities across the globe are taking steps to coordinate clinical research through IT- enabled networks. In the context of the prescription decision costs described earlier, diffusion of IT lowers learning costs by providing access to codified knowledge, while, digital communication channels (enabled through IT) reduce the costs of communicating with patients and coordinating with other physicians. IT facilitates efficient updating of patient records, problems and prescription lists thus contributing to lower cognition cost. The engagement of patients in the prescription process is also enhanced by the availability of medication lists, contra-indications, lab results and other customized materials through secure patient portals.

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The use of computers and the emergence of online information sources and information sharing using digital media have reduced 4 C's linked to the prescription decision process. The popularity of online resources amongst the physicians to seek patient related information (e.g. diagnosis, treatment, and prognosis) or drug has been documented (Davis 2007). Online forums provide outlets for physicians and patients alike to learn about clinical findings and experiences of other patients sharing the same treatments. Healthcare authorities across the nations are also taking steps to support the coordination of clinical and research activities in regional or inter-regional networks of institutions. While information search and thinking, costs encourage physicians to stick to their prior prescriptions or most popular drug, the cost reducing effect of internet use encourages self-learning and patient engagement in the prescribing process. Therefore, the internet diffusion undermines the impact of drug popularity and prescribing inertia on the prescription choices.

H1(a): The effect of drug popularity on prescription choice will reduce with the increase in internet penetration.

H1(b): The physician’s prescribing inertia will reduce with increase in the internet penetration

Previous studies in marketing and psychology have also found that the ability to process complex information encourages exploratory behavior amongst the customer and influences brand choice (Houston and Mednick 1963, Pearson and Maddi 1966). In addition, the influence of technology-enabled social learning on a choice decision is studied in detail in the context of sponsored health-plan options (Sorensen, 2006) or retirement plan choice (Duflo and Saez, 2003). Other studies in public health literature have provided evidence of similarity between drug prescriptions of physicians within the same hospital or neighborhood (Epstein and Nicholson,

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2009) and the negative impact of health information technology adoption by hospitals on adverse reaction (Roberts et al., 2010). However, we are not aware of any study that empirically investigated the effect of technology use on the drug choices of the physicians.