Opt-out Decision Research Articles

The effects of SNAP emergency allotments on state-level SNAP benefits and enrollment during the COVID-19 pandemic.

During the COVID-19 pandemic, all US states provided emergency allotments (EA) to enrollees of the Supplemental Nutrition Assistance Program (SNAP) to alleviate rising food insecurity. However, 18 states opted out of the SNAP-EA program before its official expiration in February 2023. Using a staggered difference-in-differences model to account for state-level variation in the timing of the SNAP-EA opt-out decisions, we analyzed SNAP and SNAP-EA data from the US Department of Agriculture Food and Nutrition Service to quantify the impact of state opt-out decisions on SNAP benefit size and enrollment. We found that the average SNAP monthly benefit among 18 SNAP opt-out states was reduced by $183 (95% confidence interval [CI]: -$214, -$152) per beneficiary. The percentage of the state population enrolled in the SNAP program among the opt-out states modestly decreased by 0.35 (95% CI: -0.61, -0.10) percentage points. Additionally, we employed logistic regression models to associate state opt-out decisions with state-level characteristics. We found that the state governor's political party being Republican was the only significant predictor for the state's opt-out decisions. Our findings help explain why opting out of SNAP-EA has been associated with higher food insufficiency and shed light on the impact of political decisions to opt out of SNAP-EA on the lives of millions of Americans.

Majority rule can help solve difficult tasks even when confident members opt out to serve individual interests

When sharing a common goal, confident and competent members are often motivated to contribute to the group, boosting its decision performance. However, it is unclear whether this process remains effective when members can opt in or out of group decisions and prioritize individual interests. Our laboratory experiment (n = 63) and cognitive modeling showed that at the individual level, confidence, competence, and a preference for risk motivated participants’ opt-out decisions. We then analyzed the group-level accuracy of majority decisions by creating many virtual groups of 25 members resampled from the 63 participants in the experiment. Whereas the majority decisions by voters who preferred to participate in group decision making were inferior to individual decisions by loners who opted out in an easy task, this was reversed in a difficult task. Bootstrap-simulation analyses decomposed these outcomes into the effects of a decrease in group size and a decrease in voters’ accuracy accruing from the opt-in/out mechanism, demonstrating how these effects interacted with task difficulty. Our results suggest that the majority rule still works to tackle challenging problems even when individual interests are emphasized over collective performance, playing a functional as well as a democratic role in consensus decision making under uncertainty.

Dissecting Optional Micro-Decisions in Online Transactions: Perceptions, Deceptions, and Errors

Online firms frequently increase profit by selling optional extras. However, opt-in rates tend to be low. In response, questionable design practices have emerged to nudge consumers into inadvertent choices. Many of these design constructs are presented using an opt-out design. Using eye tracking and think-aloud data techniques, this research investigates the impact of the framing and optionality of micro-decisions on user perceptions and error rates. Focusing on opt-out decisions, the study found: up to one in three users make errors in decision-making; there is a higher error rate for rejection-framed opt-out decisions; users widely misinterpret decision framing; and failure to read decision text results in rushed and unsighted decisions, even leading users to automatically construe un-ticked checkboxes as opt-in decisions. In talking afterwards about their experiences, users expressed strong negative emotions, feeling confused, manipulated and resentful. Many suggested they would, in practice, steer away from similar encounters toward more unambiguous and honest sites. These findings might alert managers and developers, tempted to use dark patterns, that such a strategy might backfire over time.

Local Prohibitions on Marijuana Businesses With On-Site Consumption: Evidence from New York State

As several US states have legalized recreational marijuana over the past decade, local approval of commercial marijuana activities has faced opposition in a non-negligible share of communities. A common provision in state laws often grants local governments the authority to prohibit marijuana businesses from locating within their jurisdictions. This paper analyzed determinants of local government policies in New York State following the legalization of recreational marijuana in 2021. A key feature of New York’s law authorized municipal governments to pass an “opt-out” ordinance prohibiting marijuana retail stores, on-site consumption establishments, or both. Based on results from multilevel logistic regression models, the likelihood of allowing commercial marijuana activities was higher for local governments representing communities with larger Black populations, fewer evangelical Protestants, and lower levels of household income. While slightly more municipalities prohibited on-site consumption, determinants of opt-out decisions were similar for both retail and consumption businesses.

421.6: Rates of Effective Intent-To-Donate in Nova Scotia: Mitigation of Differences by Gender and Age After Enactment of Deemed Consent Legislation

Introduction: Some of the highest rates of deceased donation activity in the world are observed in European countries with deemed consent legislation.(1) On January 18, 2021, Nova Scotia became the first jurisdiction in North America to implement a deemed consent model with the enactment of Human Organ and Tissue Donation Act (HOTDA). This study aimed to establish rates of effective intent-to-donate before and after enactment of deemed consent legislation in Nova Scotia. Method: Analysis of aggregate data obtained from the Nova Scotia Organ and Tissue Donation Registry. The effective intent-to-donate (%) was determined as either the proportion of eligible Nova Scotians registering an opt-in decision pre-HOTDA or the proportion of eligible Nova Scotians registering an opt-in decision or not registering an opt-out decision post-HOTDA (January 18, 2021). Donor registration data was available from April 2018 (34 months pre-HOTDA) to February 2022 (12 months post-HOTDA). This data included a demographic breakdown by gender and age ranges (19-29, 30-48, 49-64, 65+) of eligible Nova Scotians. Results: Rates of effective intent-to-donate increased from 49.0% to 51.9% in the 34 months leading up to HOTDA enactment, and from 51.9% to 99.1% in the month of enactment (Figure 1). In the 12 months post-HOTDA, rates of opt-out increased by 0.3% to 0.5% per month resulting in an effective intent-to-donate rate of 94.4% one year following enactment. At enactment, more females than males had registered an opt-in decision (54.7% vs. 49.1%). One year following enactment, rates of effective intent-to-donate were similar in both groups (94.8% females vs. 94.6% males). At enactment, a lower proportion of people 65+ had registered an opt-in decision (40.3%) relative to other age groups (19-29 = 54.6%; 30-48 = 59.8%; 49-64 = 54.4%). One year following enactment, rates of effective intent-to-donate were similar in all age groups (19-29 = 94.7%; 30-48 = 95.7%; 49-64 = 94.6%; 65+ = 92.5%). Conclusion: This work evaluates the impact of deemed consent legislation on effective intent-to-donate in Nova Scotia. Enactment of deemed consent legislation increased rates of effective intent-to-donate and appears to have mitigated pre-existing differences by gender and age group. Future research into the relationship between the dramatic increase in rates of effective intent-to-donate and consent rates is ongoing.

WE6.1 A Sustainable Appendicectomy

Abstract Background and Aim Equipment consumption is the third largest contributor to the carbon footprint of surgery. Laparoscopic surgery is particularly resource intensive. The aim of this quality improvement project is to reduce the carbon footprint of laparoscopic appendicectomies performed at this high volume trust. Methods The laparoscopic appendicectomy was process-mapped and carbon footprint calculations performed. Three areas of change were identified: elimination of single use gowns and drapes, elimination of peri-operative catheterisation, and rationalisation of the equipment tray from 119 to 49 items. A staff survey was used to identify practices and gain feedback on the proposed changes. Changes were implemented from January 2022. Surgeons are able to ask for a ‘sustainable appendicectomy pathway’ at team brief. Procedures were monitored for one week. Results Survey feedback indicated 100% (n=19) supported the proposed changes. The interventions save an estimated 7.48kgCO2e and £25.1 per procedure. No extra equipment was required during the procedures monitored. Conclusions The interventions are predicted to save annually 3.9TCO2e and £13,081 in the approximately 500 appendicectomies performed in this trust, and can be extrapolated to many types of procedures. Support from all members of the operating department is vital to sustaining the momentum of interventions. Following initial positive results, changes were extended to only use reusable gowns in one of the CEPOD theatres which perform around 2400 procedures/year. This will lead to a saving of at least 6386 disposable gowns/year (1.43T of waste). Further plans within this trust are to make the ‘sustainable appendicectomy pathway’ an opt-out decision.

Investigating the Effects of Threatening Language, Message Framing, and Reactance in Opt-Out Organ Donation Campaigns.

BackgroundUnder opt-out organ donation policies, individuals are automatically considered to have agreed to donate their organs in the absence of a recorded opt-out decision. Growing evidence suggests that the language used within organ donation campaigns influences donor intentions and decision-making.PurposeAs awareness campaigns to promote opt-out consent in the UK are ongoing, the objectives of this study were to investigate the effect of language and message framing used in opt-out organ donation campaigns on donor intentions and psychological reactance.MethodsIndividuals from Scotland and England (N = 1,350) completed this online experiment. Participants were randomized to view one of four messages, designed in the format of a newspaper article, which described the upcoming opt-out system. This followed a 2 × 2 design whereby the degree of threatening language (high threat vs. low threat) and message framing (loss vs. gain) of the newspaper article was experimentally manipulated. Measures of intention (pre-exposure and postexposure) and postmessage reactance (threat to freedom and anger and counter-arguing) were obtained.ResultsA mixed analysis of variance revealed a significant Group × Time interaction on donor intentions; post hoc analysis revealed that intentions significantly decreased for individuals exposed to the High threat × Loss frame article but significantly increased for those exposed to the High threat × Gain frame article.ConclusionsIn campaigns to promote opt-out legislation, high-threat language combined with loss-frame messages should be avoided. If high-threat language is used, gain-frame messaging that highlights the benefits of organ donation should also be incorporated.

Using Integrative Implementation Theory to Understand New Jersey's 2015 Opt-Out Movement

Background/ContextIn the spring of 2015, about 135,000 New Jersey students—almost 20% of the test-eligible children—did not take the state's test. Opposition of this magnitude directly contradicted a central stipulation of the federal No Child Left Behind Act of 2001 (NCLB), which required states to test 95% of their eligible students to receive federal education funding. This article examines what happened in New Jersey in 2015 to produce such a large change in the implementation of state testing policy.Purpose/Objective/Research Question/Focus of StudyIn this article, I use Richard Matland's integrative policy implementation theory to explain the circumstances that produced such a large change in the enactment of New Jersey testing policy in 2015. More specifically, I focus on two research questions: (1) What were the major national, state, and local factors that contributed to parent and student opt-out decisions in New Jersey in 2015? (2) How does integrative implementation theory help us to understand the different circumstances contributing to the opt-out movement in New Jersey in 2015?Population/Participants/SubjectsThe article is based upon extensive document review and 33 interviews with New Jersey state policymakers, professional education association representatives, advocacy group leaders, school administrators, teachers, parents, and students. Intervention/Program/Practice: Since the 1990s, testing has become an increasingly important function of state education policy. High-stakes state testing policies were further expanded under the NCLB, which required states to test 95% of their eligible students to receive streams of federal education funding. The opt-out movement across the nation in 2015 was a major departure from this well-established policy.Research DesignThis study employs qualitative interpretive research to examine how multiple actors at different levels of the New Jersey education system understood and interpreted the 2015 opt-out movement. Using Matland's ambiguity-conflict model of policy implementation I interpret the interactions between the policy design and local implementers’ beliefs and goals.Findings/ResultsThe findings illuminate the shifting national, state, and local factors that contributed to district opt-out rates as well as variation across school levels and districts with different socioeconomic conditions. The combination of increased federal press on states, New Jersey's fast timelines for new standards and assessment adoption even as it ratcheted up accountability, and inconsistent state policy signals all contributed to backlash from teachers, community members, and anti-testing advocates. These factors illuminate many of the changing circumstances in New Jersey that fueled the dramatic opt-out movement in 2015.Conclusions/RecommendationsWhile Matland's integrative implementation model helps to explain the dynamics of the 2015 New Jersey opt-out movement, it does not account for additional contributing factors including changes over time, dynamics at different system levels, and consideration of a broader range of actors beyond policymakers and policy targets. Incorporating these factors can help make integrative implementation theories even more robust.

POS-717 PUBLIC PERCEPTIONS OF PRESUMED CONSENT FOR ORGAN DONATION IN CANADA: A QUALITATIVE DESCRIPTIVE STUDY OF PUBLIC COMMENTS FROM NEWS ARTICLES

In 2019, two Canadian provinces (Alberta and Nova Scotia) became the first jurisdictions in North America to pass presumed consent legislation to increase deceased donor organ transplantation. Under this law, adults will be presumed to consent to organ donation unless they register an opt-out decision. Public trust and support for the policy is critical to its success and fears and misconceptions need to be identified and addressed.

Referral Rates for Cardiac Rehabilitation Among Eligible Inpatients After Implementation of a Default Opt-Out Decision Pathway in the Electronic Medical Record

This quality improvement study assesses referral rates for cardiac rehabilitation after a default opt-out option is added to the decision pathway in the electronic medical record.

Regulating Optional Rules: About the Many Opportunities a Legislator Has

In regulating contract law, the legislator has a plurality of choices. He is not confined to either prescribe a default from which the parties can unconditionally opt out or prohibit all alternative arrangements by a mandatory rule. Instead he can design the options created by a default rule in various ways. The most important ones are, first, opt-out conditions according to which an opt-out is accepted only in case certain conditions like keeping a written form are met. Second, contract law might demand one party to make an option offer to the other party. In this case the consumer or another weaker party can decide whether the contract shall follow the default rule or deviate from it. The consumer might have a financial incentive to opt out but is not required to follow it. Third, there is the opportunity of response rules which so far escaped academic attention. They leave the parties’ opt-out decision intact but modify or supplement them with additional rules. Unlike ordinary default rules they do not apply, unless the parties have made another choice, but only in case that they made a particular choice. Finally, the legislator can adapt opt-in rules. Their application depends on the parties’ choice. Unlike the rules that the parties choose as an alternative to the default they are unquestionably valid, due to their statutory status. The paper discusses and explores these options in order to show that mandatory rules are only means of last resort.

Rethinking Nudge: An Information-Costs Theory of Default Rules

Policymakers and scholars — both lawyers and economists — have long been pondering the optimal design of default rules. From the classic works on “mimicking” defaults for contracts and corporations to the modern rush to set “sticky” default rules to promote policies as diverse as organ donations, retirement savings, consumer protection, and data privacy, the optimal design of default rules has featured as a central regulatory challenge. The key element driving the design is opt-out costs — how to minimize them, or alternatively how to raise them to make the default sticky. Much of the literature has focused on “mechanical” opt-out costs — the effort people incur to select a non-default alternative. This focus is too narrow. A more important factor affecting opt-out is information — the knowledge people must acquire to make informed opt-out decisions. But, unlike high mechanical costs, high information costs need not make defaults stickier; they may instead make the defaults “slippery.” This counterintuitive claim is due to the phenomenon of uninformed opt-out, which we identify and characterize. Indeed, the importance of uninformed opt-out requires a reassessment of the conventional wisdom about Nudge and asymmetric or libertarian paternalism. We also show that different defaults provide different incentives to acquire the information necessary for informed opt-out. With the ballooning use of default rules as a policy tool, our information-costs theory provides valuable guidance to policymakers.

'It's like being conscripted, one volunteer is better than 10 pressed men': A qualitative study into the views of people who plan to opt-out of organ donation.

ObjectivesTo overcome the shortage of organ donors, Scotland and England are introducing an opt‐out organ donor registration system in 2020. This means individuals will be automatically considered to consent for donation unless they actively opt‐out of the register. Research has found that emotional barriers play a key role in donor decisions under opt‐in legislation, yet little is known about factors that influence donor decisions under opt‐out consent. Our objectives were to investigate attitudes towards organ donation and opt‐out consent from individuals who plan to opt‐out, and to explore the reasons why they plan to opt‐out.DesignQualitative interview study.MethodsSemi‐structured interviews were conducted with 15 individuals from Scotland (n = 14) and England (n = 1) who self‐reported the intention to opt‐out of the register following the legislative change to opt‐out. The interviews were transcribed verbatim and analysed using thematic analysis.ResultsThree main themes were identified: (1) consent versus coercion, which describes the perception of freedom of choice under an opt‐in system and fears of ‘government interference’ and threatened autonomy under opt‐out, (2) self‐protection, encompassing fears of medical mistrust, bodily integrity concerns, and apprehension regarding the recipient selection process, and lastly, (3) ‘riddled with pitfalls’, which includes the notion that opt‐out consent may increase susceptibility of stigma and reproach when registering an opt‐out decision.ConclusionsThis study reinforces existing opt‐in literature surrounding medical mistrust and bodily integrity concerns. A threat to one’s autonomous choice and heightened reactance arising from perceptions of unwarranted government control have emerged as novel barriers. Statement of contribution What is already known about this subject? Although around 90% of individuals in the United Kingdom support organ donation, just 40% are actively registered as donors. As part of measures to improve rates of organ transplantation, Scotland and England are moving to an opt‐out organ donation consent system in 2020.Existing research has shown that feelings and emotions are important factors that influence donor relevant decisions under the current opt‐in system, but little research has explored potential deterrents under the new plans for opt‐out consent.Minimizing the number of people opting out of the donor register is key to ensure sustained rates of transplantation. What does this study add? This study explored why people plan to opt‐out of the new system in Scotland and England.Medical mistrust and bodily integrity concerns remain as salient barriers under opt‐out laws.Fears of unwarranted government control and a perceived threat to one’s freedom of choice emerged as a novel barrier.

\u2018If I donate my organs it\u2019s a gift, if you take them it\u2019s theft\u2019: a qualitative study of planned donor decisions under opt-out legislation

BackgroundThere is a worldwide shortage of donor organs for transplantation. To overcome this, several countries have introduced an opt-out donor consent system. This system, soon planned for Scotland and England means individuals are automatically deemed to consent for organ donation unless they register an opt-out decision. This study was designed to explore the reasons underpinning donor choices for people who plan to actively opt-in to the register, take no action and be on the register via deemed consent, opt-out, and those who are unsure of their decision.MethodsThis study reports the analysis of free-text responses obtained from a large survey of intentions towards opt-out legislation in Scotland, England and Northern Ireland (n = 1202). Of the n = 1202 participants who completed the questionnaire, n = 923 provided a free text response explaining their views. Thematic analysis was used to explore the reasons why participants plan to: opt-in (n = 646), follow deemed consent (n = 205), opt-out (n = 32) and those who were not sure (n = 40).ResultsA key theme for people planning to opt-in is that it ensures one’s donor choice is explicitly clear and unequivocal. Some regarded deemed consent as unclear and open to ambiguity, thus actively opting-in was viewed as a way of protecting against family uncertainty and interference. For the deemed consent group, a key theme is that it represents a simple effortless choice. This is important from both a pragmatic time-saving point of view and because it protects ambivalent participants from making a challenging emotive choice about organ donation. Key themes for those planning to opt-out relate to fears around medical mistrust and bodily integrity. Notably, both participants who plan to opt-out and opt-in perceived presumed consent as “authoritarian” and a method of increasing Government control of organs. In response, registering an active decision protected their freedom of choice.ConclusionsThe findings highlight the importance of registering deliberate active consent for people who choose opt-in, due to concerns over possible family refusal under deemed consent. These findings could inform the development of communication campaigns that encourage family communication before the implementation of opt-out legislation.

Assessing the Clinical Impact of Risk Models for Opting Out of Treatment.

Decision curves are a tool for evaluating the population impact of using a risk model for deciding whether to undergo some intervention, which might be a treatment to help prevent an unwanted clinical event or invasive diagnostic testing such as biopsy. The common formulation of decision curves is based on an opt-in framework. That is, a risk model is evaluated based on the population impact of using the model to opt high-risk patients into treatment in a setting where the standard of care is not to treat. Opt-in decision curves display the population net benefit of the risk model in comparison to the reference policy of treating no patients. In some contexts, however, the standard of care in the absence of a risk model is to treat everyone, and the potential use of the risk model would be to opt low-risk patients out of treatment. Although opt-out settings were discussed in the original decision curve paper, opt-out decision curves are underused. We review the formulation of opt-out decision curves and discuss their advantages for interpretation and inference when treat-all is the standard.

Universal tumor screening for Lynch syndrome: perspectives of Canadian pathologists and genetic counselors.

Universal screening of all newly diagnosed colorectal cancer tumors can identify individuals at high risk for Lynch syndrome (LS), a hereditary cancer syndrome predisposing carriers to increased risk of colorectal, endometrial, and other cancers. To inform planning of a universal tumor screening program for LS in our jurisdiction, we undertook online surveys of Canadian pathologists and genetic counselors to describe existing tumor screening programs. Online surveys were hosted on SurveyMonkey between October 2016 and March 2017. Fifty-three pathologists and 66 genetic counselors completed surveys (total n = 119). While attitudes towards tumor screening were positive, considerable variability was observed in the existence of tumor screening, test ordering criteria, and practices. Most respondents indicated consent was not obtained for tumor screening nor were educational materials provided to patients; however, opting out of additional mutation testing in the event of a positive tumor screen was endorsed. Results add to the growing literature on providers' perspectives on population-based tumor screening programs and inform ways to offer these. Findings highlight the need to develop methods of patient education that allow meaningful opt-out decisions. The variability we observed also suggests the need for national standards and guidance on tumor screening for LS.

PHP156 - Recommendations In Clinical Guidelines, ‘No Benefit’ Ratings, And Opt-Out Decisions In Germany Since The Introduction Of The Amnog Law In 2011: How Do The Pieces Fit Together?

PHP156 - Recommendations In Clinical Guidelines, ‘No Benefit’ Ratings, And Opt-Out Decisions In Germany Since The Introduction Of The Amnog Law In 2011: How Do The Pieces Fit Together?

Support for public provision of a private good with top-up and opt-out: A controlled laboratory experiment

This paper presents the results of a revealed-choice experiment testing the theoretical predictions of political economy models regarding public support for a publicly provided private good financed with proportional income taxes when individuals can purchase the good privately and either continue to consume public provision (‘top-up’) or forego public provision (‘opt-out’), but in each case continue to pay income taxes. Our laboratory results confirm behavior is consistent with the predicted majority-preferred tax rate under mixed financing with top-up, but we identify preferences for significantly higher rates of public provision than predicted under mixed financing with opt-out. Using non parametric regression analysis, we explore the relationship between individuals’ top-up and opt-out decisions and both their income levels and the implemented tax rates.

Modeling Customer Opt-In and Opt-Out in a Permission-Based Marketing Context

The rise of new media is helping marketers evolve from digital to interactive marketing, which facilitates a two-way communication between marketers and customers without intruding on their privacy. However, while research has examined the drivers of customers’ opt-in and opt-out decisions, it has investigated neither the timing of the two decisions nor the influence of transactional activity on the length of time a customer stays with an e-mail program. In this study, the authors adopt a multivariate copula model using a pair-copula construction method to jointly model opt-in time (from a customer's first purchase to the opt-in decision), opt-out time (from the opt-in decision to the opt-out decision), and average transaction amount. Through such multivariate dependences, this model significantly improves the predictive performance of the opt-out time in comparison with several benchmark models. The study offers several important findings: (1) marketing intensity affects opt-in and opt-out times, (2) customers with certain characteristics are more or less likely to opt in or opt out, and (3) firms can extend customer opt-out time and increase customer spending level by strategically allocating resources.

The British opt-out from the European Monetary Union: empirical evidence from monetary policy rules

We analyse the current state of monetary integration in Europe, focusing on the United Kingdom’s position regarding the European Monetary Union (EMU). The interest rate decisions of the European Central Bank and the Bank of England are compared through different specifications of the Taylor rule. Comparison of the monetary conduct of these two institutions provides useful guidance in identifying the differences that the British Government claims motivating its refusal to join the EMU. Testing for forward-looking behaviour and possible asymmetries in policy responses, we show evidence supporting the opt-out decision taken by the British Government.