Dynamic Treatment Regimes: Interventions for Chronic Conditions (such as Poverty or Criminality?) - PowerPoint PPT Presentation

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Dynamic Treatment Regimes: Interventions for Chronic Conditions (such as Poverty or Criminality?)

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Title: comparison of 3 learning methods Author: sam Last modified by: samurphy Created Date: 3/11/2003 4:02:18 PM Document presentation format: On-screen Show – PowerPoint PPT presentation

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Title: Dynamic Treatment Regimes: Interventions for Chronic Conditions (such as Poverty or Criminality?)


1
Dynamic Treatment Regimes Interventions for
Chronic Conditions (such as Poverty or
Criminality?)
  • S.A. Murphy
  • Univ. of Michigan
  • In Honor of Clifford C. Clogg

2
Outline
  • Dynamic Treatment Regimes
  • Dynamic Treatment Regimes in Social Science
  • Considerations in Constructing Dynamic Treatment
    Regimes
  • Discussion

3
Dynamic Treatment Regimes
4
  • Challenges in managing the chronic forms of
    addiction and mental disorders and HIV
    (poverty?, unemployment?, criminality?)
  • High variability across patients in response to
    any one intervention
  • May need a sequence of interventions prior to
    improvement
  • No Cure
  • Relapse is likely without either continuous or
    intermittent treatment for a large proportion of
    people.

5
  • Challenges in managing the chronic forms of
    addiction and mental disorders and HIV
    (poverty?, unemployment?, criminality?)
  • Treatment is burdensome.
  • Adherence is a problem.
  • Reduce intensity of intervention whenever
    possible.
  • Co-occurring disorders are common.

6
  • Dynamic Treatment Regimes are individually
    tailored interventions, with treatment type and
    dosage changing with subject outcomes.
  • Brooner et al. (2002) Treatment of Opioid
    Addiction
  • Breslin et al. (1999) Treatment of Alcohol
    Addiction
  • Prokaska et al. (2001) Treatment of Tobacco
    Addiction
  • Rush et al. (2003) Treatment of Depression

7
Example of a Dynamic Treatment Regime Treatment
of alcohol dependence. Goal is to reduce
drinking. Following graduation from the
intensive outpatient program the patient is
prescribed naltrexone. The patient is monitored
weekly over the next two months. If the patient
experiences 2 or more heavy drinking days during
this period then the patients medication is
augmented by CBI. If the patient is able to make
the entire 2 months with 1 or no heavy drinking
days then the patient is continued on naltrexone
and is provided telephone disease management.
8
  • Components of a dynamic treatment regime
  • Tailoring Variables (which ones and how to
    measure?)
  • Decisions/Interventions (what are the options at
    this time?)
  • Decision Rules (input the tailoring variables and
    output a decision) one per key decision
  • A dynamic treatment regime is a sequence of
    decision rules that input tailoring variables and
    output recommended decisions

9
  • The Message
  • Dynamic Treatment Regimes operationalize the
    adaptive, sequential, decision making that occurs
    in clinical practice. (by welfare case
    managers? by social workers? by the judicial
    system?)
  • The operationalization of the decisions allows
    them to be studied and thus improved upon.
  • In practice, decision rules become best practice
    guidelines.

10
  • The Big Questions
  • What is the best sequencing of interventions?
  • What is the best timings of alterations in
    interventions?
  • What information do we use to make these
    decisions?

11
Dynamic Treatment Regimes in Social Science
12
  • Dynamic Treatment Regimes in Social Science
    Practice
  • Dynamic treatment regimes are being implemented!
  • Sometimes little or no evidence is available
    concerning what information should be used in
    decision making. (tailoring variables)
  • Sometimes little or no evidence is available
    concerning how to use available information in
    decision making. (best practice guidelines)

13
Example of a Dynamic Treatment Regime
  • Jobs First Program in Connecticut
  • Tailoring Variables characteristics of the
    individual (offensesnon-cooperation with
    Employment Services..), characteristics of the
    environment (domestic violence, incapacitated
    family member, )
  • Interventions amount of cash benefit
  • Goal maximizing social/monetary gain.

14
(No Transcript)
15
  • Dynamic Treatment Regimes in Social Science
    Research
  • Education Papers by S. Raudenbush, D. Cohen
  • Economics J. Abbring G. van den Berg M.
    Lechner and colleagues J. Rust J. Heckman and
    colleagues
  • (cites are provided on notes pages)

16
  • Dynamic Treatment Regimes
  • As an inferential goal How do I best construct
    a dynamic treatment regime so as to create a high
    quality welfare program?
  • Data-generating mechanism What causal structure
    led to the selection of the time varying
    treatments I have recorded in my data?

17
How does Social Science research inform the
construction of dynamic treatment regimes?
  • Understanding the interaction between the social
    context and intervention on individual responses.
  • Designing intervention components that improve
    the social context of the individual.
  • Suggest environmental, social triggers for a need
    to change/intensify/taper-off the present
    intervention

18
Considerations in Constructing Dynamic Treatment
Regimes
19
Important considerations in constructing dynamic
treatment regimes
  • In deciding which intervention to provide at a
    given time, we should pay attention to the range
    of feasible future decisions/interventions.
  • Sometimes the best decision leads to a worsening
    of the situation (but lays the foundation for an
    improved long term benefit).

20
Examples
  • Sometimes the best decision does not lead to an
    improved situation (but lays the foundation for
    an improved long term benefit). Consider women
    receiving welfare.
  • -- An intervention designed to improve competency
    in dealing with change may not lead to improved
    employment in the short run but
  • -- The same intervention followed by training and
    job search skill development may lead to greater
    employment.

21
Examples
  • Sometimes the best decision does not lead to an
    improved situation (but lays the foundation for
    an improved long term benefit). Consider children
    in the criminal justice system.
  • Detention may lead to increased societal
    alienation as compared to detention diversion.
    However when these are followed by an
    intervention designed to alter peer group
    affiliation, detention may be more effective in
    reducing recidivism than detention diversion.

22
Examples
  • In deciding which intervention to provide at a
    given time, pay attention to the range of
    feasible future decisions/interventions.
  • Detention with standard follow-up may be worse in
    reducing recidivism/cost than a detention
    diversion program followed by a standard
    follow-up.
  • yet
  • Detention followed by an intervention designed to
    alter peer group affiliation may be more
    effective in reducing recidivism/cost than
    detention diversion followed by an intervention
    designed to alter peer group affiliation.

23
Can you think of more realistic examples?
  • In deciding which intervention to provide at a
    given time, we should pay attention to the range
    of feasible future decisions or interventions.
  • Sometimes the best decision does not immediately
    lead to an improvement (but lays the foundation
    for an improved long term benefit).

24
Discussion
  • Conceptually it is important to pay attention to
    subsequent interventions when evaluating the
    present intervention. The analog holds for the
    methodology.
  • The methodology must allow for the best decision
    leading to a worsening of the situation but
    laying the foundation for an improved long term
    benefit.

25
  • This seminar can be found at
  • http//www.stat.lsa.umich.edu/samurphy/seminars/P
    SUSociology10-05.ppt
  • My email address
  • samurphy_at_umich.edu

26
Conceptual Structure in the Behavioral/Social/Medi
cal Sciences
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