The Development and Validation of a Tool to Measure Self-Confidence and Anxiety in Nursing Students While Making Clinical Decisions

ERIC Educational Resources Information Center

White, Krista Alaine

2011-01-01

Clinical decision making (CDM) is a cornerstone skill for nurses. Self-confidence and anxiety are two affective influences that impact the learning and adeptness of CDM. Currently, no instruments exist that measure perceived self-confidence and anxiety level of undergraduate nursing students related to CDM. The purpose of this research was to…

Knowledge of Fecal Calprotectin and Infliximab Trough Levels Alters Clinical Decision-making for IBD Outpatients on Maintenance Infliximab Therapy.

PubMed

Huang, Vivian W; Prosser, Connie; Kroeker, Karen I; Wang, Haili; Shalapay, Carol; Dhami, Neil; Fedorak, Darryl K; Halloran, Brendan; Dieleman, Levinus A; Goodman, Karen J; Fedorak, Richard N

2015-06-01

Infliximab is an effective therapy for inflammatory bowel disease (IBD). However, more than 50% of patients lose response. Empiric dose intensification is not effective for all patients because not all patients have objective disease activity or subtherapeutic drug level. The aim was to determine how an objective marker of disease activity or therapeutic drug monitoring affects clinical decisions regarding maintenance infliximab therapy in outpatients with IBD. Consecutive patients with IBD on maintenance infliximab therapy were invited to participate by providing preinfusion stool and blood samples. Fecal calprotectin (FCP) and infliximab trough levels (ITLs) were measured by enzyme linked immunosorbent assay. Three decisions were compared: (1) actual clinical decision, (2) algorithmic FCP or ITL decisions, and (3) expert panel decision based on (a) clinical data, (b) clinical data plus FCP, and (c) clinical data plus FCP plus ITL. In secondary analysis, Receiver-operating curves were used to assess the ability of FCP and ITL in predicting clinical disease activity or remission. A total of 36 sets of blood and stool were available for analysis; median FCP 191.5 μg/g, median ITLs 7.3 μg/mL. The actual clinical decision differed from the hypothetical decision in 47.2% (FCP algorithm); 69.4% (ITL algorithm); 25.0% (expert panel clinical decision); 44.4% (expert panel clinical plus FCP); 58.3% (expert panel clinical plus FCP plus ITL) cases. FCP predicted clinical relapse (area under the curve [AUC] = 0.417; 95% confidence interval [CI], 0.197-0.641) and subtherapeutic ITL (AUC = 0.774; 95% CI, 0.536-1.000). ITL predicted clinical remission (AUC = 0.498; 95% CI, 0.254-0.742) and objective remission (AUC = 0.773; 95% CI, 0.622-0.924). Using FCP and ITLs in addition to clinical data results in an increased number of decisions to optimize management in outpatients with IBD on stable maintenance infliximab therapy.

Distributive justice and infertility treatment in Canada.

PubMed

Nisker, Jeff

2008-05-01

An exploration of distributive justice in Canadian infertility treatment requires the integration of ethical, clinical, and economic principles. In 1971, American philosopher John Rawls proposed a theoretical model for fair decision-making in which "rational" and "self-interested" citizens are behind a "veil of ignorance" with respect to both their own position and the position of other decision-makers. Rawls proposed that these self-interested decision-makers, fearing that they are among the least advantaged persons who could be affected by the decision, will agree only upon rules that encode equality of opportunity and that bestow the greatest benefit on the least advantaged citizens. Regarding health policy decision-making, Rawls' model is best illustrated by Canadian philosopher Warren Bourgeois in his panel of "volunteers." These rational and self-interested volunteers receive an amnestic drug that renders them unaware of their health, social, and financial position, but they know that they are representative of diverse spheres of citizens whose well-being will be affected by their decision. After describing fair decision-making, Bourgeois considers the lack of a distributive justice imperative in Canada's Assisted Human Reproduction Act, in contrast to legislation in European nations and Australia, summarizes the economic and clinical considerations that must be provided to the decision-makers behind the "veil of ignorance" for fair decisions to occur, and considers altruism in relation to equality of access. He concludes by noting that among countries with legislation governing assisted reproduction Canada is alone in having legislation that is void of distributive justice in providing access to clinically appropriate infertility care.

Affective forecasting: an unrecognized challenge in making serious health decisions.

PubMed

Halpern, Jodi; Arnold, Robert M

2008-10-01

Patients facing medical decisions that will impact quality of life make assumptions about how they will adjust emotionally to living with health declines and disability. Despite abundant research on decision-making, we have no direct research on how accurately patients envision their future well-being and how this influences their decisions. Outside medicine, psychological research on "affective forecasting" consistently shows that people poorly predict their future ability to adapt to adversity. This finding is important for medicine, since many serious health decisions hinge on quality-of-life judgments. We describe three specific mechanisms for affective forecasting errors that may influence health decisions: focalism, in which people focus more on what will change than on what will stay the same; immune neglect, in which they fail to envision how their own coping skills will lessen their unhappiness; and failure to predict adaptation, in which people fail to envision shifts in what they value. We discuss emotional and social factors that interact with these cognitive biases. We describe how caregivers can recognize these biases in the clinical setting and suggest interventions to help patients recognize and address affective forecasting errors.

Clinical decision-making by midwives: managing case complexity.

PubMed

Cioffi, J; Markham, R

1997-02-01

In making clinical judgements, it is argued that midwives use 'shortcuts' or heuristics based on estimated probabilities to simplify the decision-making task. Midwives (n = 30) were given simulated patient assessment situations of high and low complexity and were required to think aloud. Analysis of verbal protocols showed that subjective probability judgements (heuristics) were used more frequently in the high than low complexity case and predominated in the last quarter of the assessment period for the high complexity case. 'Representativeness' was identified more frequently in the high than in the low case, but was the dominant heuristic in both. Reports completed after each simulation suggest that heuristics based on memory for particular conditions affect decisions. It is concluded that midwives use heuristics, derived mainly from their clinical experiences, in an attempt to save cognitive effort and to facilitate reasonably accurate decisions in the decision-making process.

Self-Stigma and Consumer Participation in Shared Decision Making in Mental Health Services.

PubMed

Hamann, Johannes; Bühner, Markus; Rüsch, Nicolas

2017-08-01

People with mental illness struggle with symptoms and with public stigma. Some accept common prejudices and lose self-esteem, resulting in shame and self-stigma, which may affect their interactions with mental health professionals. This study explored whether self-stigma and shame are associated with consumers' preferences for participation in medical decision making and their behavior in psychiatric consultations. In a cross-sectional study conducted in Germany, 329 individuals with a diagnosis of a schizophrenia spectrum disorder or an affective disorder and their psychiatrists provided sociodemographic and illness-related information. Self-stigma, shame, locus of control, and views about clinical decision making were assessed by self-report. Psychiatrists rated their impression of the decision-making behavior of consumers. Regression analyses and structural equation modeling were used to determine the association of self-stigma and shame with clinical decision making. Self-stigma was not related to consumers' participation preferences, but it was associated with some aspects of communicative behavior. Active and critical behavior (for example, expressing views, daring to challenge the doctor's opinion, and openly speaking out about disagreements with the doctor) was associated with less shame, less self-stigma, more self-responsibility, less attribution of external control to powerful others, and more years of education. Self-stigma and shame were associated with less participative and critical behavior, which probably leads to clinical encounters that involve less shared decision making and more paternalistic decision making. Paternalistic decision making may reinforce self-stigma and lead to poorer health outcomes. Therefore, interventions that reduce self-stigma and increase consumers' critical and participative communication may improve health outcomes.

Gendered Uncertainty and Variation in Physicians' Decisions for Coronary Heart Disease: The Double-Edged Sword of "Atypical Symptoms"

ERIC Educational Resources Information Center

Welch, Lisa C.; Lutfey, Karen E.; Gerstenberger, Eric; Grace, Matthew

2012-01-01

Nonmedical factors and diagnostic certainty contribute to variation in clinical decision making, but the process by which this occurs remains unclear. We examine how physicians' interpretations of patient sex-gender affect diagnostic certainty and, in turn, decision making for coronary heart disease. Data are from a factorial experiment of 256…

Medical Decision Making for Patients Without Proxies: The Effect of Personal Experience in the Deliberative Process.

PubMed

Robichaud, Allyson L

2015-01-01

The number of admissions to hospitals of patients without a proxy decision maker is rising. Very often these patients need fairly immediate medical intervention for which informed consent--or informed refusal--is required. Many have recommended that there be a process in place to make these decisions, and that it include a variety of perspectives. People are particularly wary of relying solely on medical staff to make these decisions. The University Hospitals Case Medical Center recruits community members from its Ethics Committee to serve on a subcommittee, the Patients Without Proxies (PWP) Committee, which works with medical staff during the decision-making process for these patients. Generally, the community members go to the bedside to observe patients. This article looks at how those unused to observing hospitalized patients who are sick and/or dying are affected, comparing them to mock jurors in a research study who are exposed to graphic photographs related to a fabricated crime scene. Judgments made by the mock jurors are affected by viewing such images. The personal experience of witnessing unfamiliar and shocking scenes affects their subsequent judgments. While it may be difficult to tease out whether observing patients causes PWP members to be benefited or harmed, they are affected by what they see. If a variety of perspectives is desirable to reduce possible bias or error, this article argues that at least one community member should refrain from seeing the patient in order to add a different and valuable voice to the decision-making process. Members of the subcommittee base their judgments on the various kinds of information available. Sometimes the things they see, hear, or feel may affect them particularly deeply, and affect their judgments as well. In this article I explore the idea that something like this may be happening in a particular kind of clinical ethics case consultation. Copyright 2015 The Journal of Clinical Ethics. All rights reserved.

Improving performance with clinical decision support.

PubMed

Brailer, D J; Goldfarb, S; Horgan, M; Katz, F; Paulus, R A; Zakrewski, K

1996-07-01

CADU/CIS (Clinical and Administrative Decision-support Utility and Clinical Information System) is a clinical decision-support workstation that allows large volumes of clinical information systems data to be analyzed in a timely and user-friendly fashion. CARE PROCESS MEASUREMENT: For any given disease, subgroups of patients are identified, and automated, customized "clinical pathways" are generated. For each subgroup, the best practice norms for use of test and therapies are identified. Practice style variations are then compared to outcomes to focus inquiry on decisions that significantly affect outcomes. INTESTINAL OBSTRUCTION: Graduate Health Systems, a multisite integrated provider in the Philadelphia area, has used CADU/CIS to improve quality problems, reduce treatment-intensity variations, and improve clinical participation in care process evaluation and decision making. A task force selected intestinal obstruction without hernia as its first study because of the related high-volume and high-morbidity complications. Use of a ten-step method for clinical performance improvement showed that the intravenous administration of unnecessary fluids to 104 patients with intestinal obstruction induced congestive heart failure (CHF) in 5 patients. Task force members and other practicing physicians are now developing guidelines and other interventions aimed at fluid use. Indeed, the task force used CADU/CIS to identify an additional 250 patients in one year whose conditions were complicated by CHF. A clinical decision support tool can be instrumental in detecting problems with important clinical and economic implications, identifying their important underlying causes, tracking the associated tests and therapies, and monitoring interventions.

Clinical and practical considerations in the pharmacologic management of narcolepsy.

PubMed

Thorpy, Michael J; Dauvilliers, Yves

2015-01-01

Despite published treatment recommendations and the availability of approved and off-label pharmacologic therapies for narcolepsy, the clinical management of this incurable, chronic neurologic disorder remains challenging. While treatment is generally symptomatically driven, decisions regarding which drug(s) to use need to take into account a variety of factors that may affect adherence, efficacy, and tolerability. Type 1 narcolepsy (predominantly excessive daytime sleepiness with cataplexy) or type 2 narcolepsy (excessive daytime sleepiness without cataplexy) may drive treatment decisions, with consideration given either to a single drug that targets multiple symptoms or to multiple drugs that each treat a specific symptom. Other drug-related characteristics that affect drug choice are dosing regimens, tolerability, and potential drug-drug interactions. Additionally, the patient should be an active participant in treatment decisions, and the main symptomatic complaints, treatment goals, psychosocial setting, and use of lifestyle substances (ie, alcohol, nicotine, caffeine, and cannabis) need to be discussed with respect to treatment decisions. Although there is a lack of narcolepsy-specific instruments for monitoring therapeutic effects, clinically relevant subjective and objective measures of daytime sleepiness (eg, Epworth Sleepiness Scale and Maintenance of Wakefulness Test) can be used to provide guidance on whether treatment goals are being met. These considerations are discussed with the objective of providing clinically relevant recommendations for making treatment decisions that can enhance the effective management of patients with narcolepsy. Copyright © 2014 The Authors. Published by Elsevier B.V. All rights reserved.

Whole mind and shared mind in clinical decision-making.

PubMed

Epstein, Ronald Mark

2013-02-01

To review the theory, research evidence and ethical implications regarding "whole mind" and "shared mind" in clinical practice in the context of chronic and serious illnesses. Selective critical review of the intersection of classical and naturalistic decision-making theories, cognitive neuroscience, communication research and ethics as they apply to decision-making and autonomy. Decision-making involves analytic thinking as well as affect and intuition ("whole mind") and sharing cognitive and affective schemas of two or more individuals ("shared mind"). Social relationships can help processing of complex information that otherwise would overwhelm individuals' cognitive capacities. Medical decision-making research, teaching and practice should consider both analytic and non-analytic cognitive processes. Further, research should consider that decisions emerge not only from the individual perspectives of patients, their families and clinicians, but also the perspectives that emerge from the interactions among them. Social interactions have the potential to enhance individual autonomy, as well as to promote relational autonomy based on shared frames of reference. Shared mind has the potential to result in wiser decisions, greater autonomy and self-determination; yet, clinicians and patients should be vigilant for the potential of hierarchical relationships to foster coercion or silencing of the patient's voice. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Impaired cognition and decision-making in bipolar depression but no 'affective bias' evident.

PubMed

Rubinsztein, J S; Michael, A; Underwood, B R; Tempest, M; Sahakian, B J

2006-05-01

Depression is usually the predominant affective state in bipolar disorder. There are few studies, with discrepant views, examining the extent of cognitive impairment in patients with bipolar depression. To our knowledge, there are no previous studies examining decision-making ability or whether there is an affective attentional bias in bipolar depression. We ascertained 24 depressed bipolar I patients from acute psychiatric hospital wards and out-patient clinics and 26 age- and IQ-matched healthy controls. Using computerized tests we evaluated their performance on 'neutral' (non-emotional) cognitive tasks (i.e. memory, attention and executive function) and on novel tasks of emotional cognition (i.e. the decision-making task and the affective go/no-go task). Accuracy measures were significantly impaired on tests of visual and spatial recognition and attentional set-shifting in bipolar depression compared with age- and IQ-matched controls. The quality of decision-making was also significantly impaired in the patients. A mood-congruent attentional bias for 'sad' targets was not evident on the affective go/no-go task. We found widespread evidence of significant cognitive impairment and impaired quality of decision-making in symptomatically severe depressed bipolar patients. This cognitive impairment may contribute to difficulties with daily living, decision-making and the ability to engage and comply with psychological and drug treatments.

Practitioner approaches to the integration of clinical decision support system technology in critical care.

PubMed

Weber, Scott; Crago, Elizabeth A; Sherwood, Paula R; Smith, Tara

2009-11-01

The aim of this study was to explore the experiences of nurses and physicians who use a clinical decision support system (CDSS) in the critical care area, focusing on clinicians' motives and values related to decisions to either use or not use this optional technology. Information technology (IT) has been demonstrated to positively impact quality of patient care. Decision-support technology serves as an adjunct to, not as a replacement for, actual clinical decision making. Nurse administrators play an imperative role in the planning and implementation of IT projects and can benefit from understanding clinicians' affective considerations and approaches to the technology. This qualitative study used grounded theory methods. A total of 33 clinicians participated in in-depth structured interviews probing their professional concerns with how the technology is used. Data were analyzed using the constant comparative method. Medical staff were frustrated by perceived lack of planning input before system implementation. Both nurse and physician cohort groups were dissatisfied with preimplementation education. Barriers to system use were identified in significant detail by the participants. Both nurses and physicians should be involved in preimplementation planning and ongoing evaluation of CDSSs. There is a need for a systematic review or Cochrane meta-analysis describing the affective aspects of successful implementations of decisional technology in critical care, specifically from the perspective of nursing administrators.

Comparing and using assessments of the value of information to clinical decision-making.

PubMed Central

Urquhart, C J; Hepworth, J B

1996-01-01

This paper discusses the Value project, which assessed the value to clinical decision-making of information supplied by National Health Service (NHS) library and information services. The project not only showed how health libraries in the United Kingdom help clinicians in decision-making but also provided quality assurance guidelines for these libraries to help make their information services more effective. The paper reviews methods and results used in previous studies of the value of health libraries, noting that methodological differences appear to affect the results. The paper also discusses aspects of user involvement, categories of clinical decision-making, the value of information to present and future clinical decisions, and the combination of quantitative and qualitative assessments of value, as applied to the Value project and the studies reviewed. The Value project also demonstrated that the value placed on information depends in part on the career stage of the physician. The paper outlines the structure of the quality assurance tool kit, which is based on the findings and methods used in the Value project. PMID:8913550

Studying the effect of clinical uncertainty on physicians' decision-making using ILIAD.

PubMed

Anderson, J D; Jay, S J; Weng, H C; Anderson, M M

1995-01-01

The influence of uncertainty on physicians' practice behavior is not well understood. In this research, ILIAD, a diagnostic expert system, has been used to study physicians' responses to uncertainty and how their responses affected clinical performance. The simulation mode of ILIAD was used to standardize the presentation and scoring of two cases to 46 residents in emergency medicine, internal medicine, family practice and transitional medicine at Methodist Hospital of Indiana. A questionnaire was used to collect additional data on how physicians respond to clinical uncertainty. A structural equation model was developed, estimated, and tested. The results indicate that stress that physicians experience in dealing with clinical uncertainty has a negative effect on their clinical performance. Moreover, the way that physicians respond to uncertainty has positive and negative effects on their performance. Open discussions with patients about clinical decisions and the use of practice guidelines improves performance. However, when the physician's clinical decisions are influenced by patient demands or their peers, their performance scores decline.

A Closer Look at Racism and Heterosexism in Medical Students' Clinical Decision-Making Related to HIV Pre-Exposure Prophylaxis (PrEP): Implications for PrEP Education.

PubMed

Calabrese, Sarah K; Earnshaw, Valerie A; Krakower, Douglas S; Underhill, Kristen; Vincent, Wilson; Magnus, Manya; Hansen, Nathan B; Kershaw, Trace S; Mayer, Kenneth H; Betancourt, Joseph R; Dovidio, John F

2018-04-01

Social biases among healthcare providers could limit PrEP access. In this survey study of 115 US medical students, we examined associations between biases (racism and heterosexism) and PrEP clinical decision-making and explored prior PrEP education as a potential buffer. After viewing a vignette about a PrEP-seeking MSM patient, participants reported anticipated patient behavior (condomless sex, extra-relational sex, and adherence), intention to prescribe PrEP to the patient, biases, and background characteristics. Minimal evidence for racism affecting clinical decision-making emerged. In unadjusted analyses, heterosexism indirectly affected prescribing intention via all anticipated behaviors, tested as parallel mediators. Participants expressing greater heterosexism more strongly anticipated increased risk behavior and adherence problems, which were associated with lower prescribing intention. The indirect effect via condomless sex remained significant adjusting for background characteristics. Prior PrEP education did not buffer any indirect effects. Heterosexism may compromise PrEP provision to MSM and should be addressed in PrEP-related medical education.

Does good critical thinking equal effective decision-making among critical care nurses? A cross-sectional survey.

PubMed

Ludin, Salizar Mohamed

2018-02-01

A critical thinker may not necessarily be a good decision-maker, but critical care nurses are expected to utilise outstanding critical thinking skills in making complex clinical judgements. Studies have shown that critical care nurses' decisions focus mainly on doing rather than reflecting. To date, the link between critical care nurses' critical thinking and decision-making has not been examined closely in Malaysia. To understand whether critical care nurses' critical thinking disposition affects their clinical decision-making skills. This was a cross-sectional study in which Malay and English translations of the Short Form-Critical Thinking Disposition Inventory-Chinese Version (SF-CTDI-CV) and the Clinical Decision-making Nursing Scale (CDMNS) were used to collect data from 113 nurses working in seven critical care units of a tertiary hospital on the east coast of Malaysia. Participants were recruited through purposive sampling in October 2015. Critical care nurses perceived both their critical thinking disposition and decision-making skills to be high, with a total score of 71.5 and a mean of 48.55 for the SF-CTDI-CV, and a total score of 161 and a mean of 119.77 for the CDMNS. One-way ANOVA test results showed that while age, gender, ethnicity, education level and working experience factors significantly impacted critical thinking (p<0.05), only age and working experience significantly impacted clinical decision-making (p<0.05). Pearson's correlation analysis showed a strong and positive relationship between critical care nurses' critical thinking and clinical decision-making (r=0.637, p=0.001). While this small-scale study has shown a relationship exists between critical care nurses' critical thinking disposition and clinical decision-making in one hospital, further investigation using the same measurement tools is needed into this relationship in diverse clinical contexts and with greater numbers of participants. Critical care nurses' perceived high level of critical thinking and decision-making also needs further investigation. Copyright © 2017 Elsevier Ltd. All rights reserved.

An approach to improve the care of mid-life women through the implementation of a Women’s Health Assessment Tool/Clinical Decision Support toolkit

PubMed Central

Silvestrin, Terry M; Steenrod, Anna W; Coyne, Karin S; Gross, David E; Esinduy, Canan B; Kodsi, Angela B; Slifka, Gayle J; Abraham, Lucy; Araiza, Anna L; Bushmakin, Andrew G; Luo, Xuemei

2016-01-01

The objectives of this study are to describe the implementation process of the Women’s Health Assessment Tool/Clinical Decision Support toolkit and summarize patients’ and clinicians’ perceptions of the toolkit. The Women’s Health Assessment Tool/Clinical Decision Support toolkit was piloted at three clinical sites over a 4-month period in Washington State to evaluate health outcomes among mid-life women. The implementation involved a multistep process and engagement of multiple stakeholders over 18 months. Two-thirds of patients (n = 76/110) and clinicians (n = 8/12) participating in pilot completed feedback surveys; five clinicians participated in qualitative interviews. Most patients felt more prepared for their annual visit (69.7%) and that quality of care improved (68.4%) while clinicians reported streamlined patient visits and improved communication with patients. The Women’s Health Assessment Tool/Clinical Decision Support toolkit offers a unique approach to introduce and address some of the key health issues that affect mid-life women. PMID:27558508

Are Physicians Likely to Adopt Emerging Mobile Technologies? Attitudes and Innovation Factors Affecting Smartphone Use in the Southeastern United States

PubMed Central

Putzer, Gavin J; Park, Yangil

2012-01-01

The smartphone has emerged as an important technological device to assist physicians with medical decision making, clinical tasks, and other computing functions. A smartphone is a device that combines mobile telecommunication with Internet accessibility as well as word processing. Moreover, smartphones have additional features such as applications pertinent to clinical medicine and practice management. The purpose of this study was to investigate the innovation factors that affect a physician's decision to adopt an emerging mobile technological device such as a smartphone. The study sample consisted of 103 physicians from community hospitals and academic medical centers in the southeastern United States. Innovation factors are elements that affect an individual's attitude toward using and adopting an emerging technology. In our model, the innovation characteristics of compatibility, job relevance, the internal environment, observability, personal experience, and the external environment were all significant predictors of attitude toward using a smartphone. These influential innovation factors presumably are salient predictors of a physician's attitude toward using a smartphone to assist with clinical tasks. Health information technology devices such as smartphones offer promise as a means to improve clinical efficiency, medical quality, and care coordination and possibly reduce healthcare costs. PMID:22737094

Construct validity of the Iowa Gambling Task.

PubMed

Buelow, Melissa T; Suhr, Julie A

2009-03-01

The Iowa Gambling Task (IGT) was created to assess real-world decision making in a laboratory setting and has been applied to various clinical populations (i.e., substance abuse, schizophrenia, pathological gamblers) outside those with orbitofrontal cortex damage, for whom it was originally developed. The current review provides a critical examination of lesion, functional neuroimaging, developmental, and clinical studies in order to examine the construct validity of the IGT. The preponderance of evidence provides support for the use of the IGT to detect decision making deficits in clinical populations, in the context of a more comprehensive evaluation. The review includes a discussion of three critical issues affecting the validity of the IGT, as it has recently become available as a clinical instrument: the lack of a concise definition as to what aspect of decision making the IGT measures, the lack of data regarding reliability of the IGT, and the influence of personality and state mood on IGT performance.

Orthopedic Implant Value Drivers: A Qualitative Survey Study of Hospital Purchasing Administrators.

PubMed

Li, Chuan Silvia; Vannabouathong, Christopher; Sprague, Sheila; Bhandari, Mohit

2015-01-01

Osteoarthritis (OA) is a chronic, degenerative disease that is highly prevalent in the population, yet the factors that affect purchasing decisions related to this condition are poorly understood. A questionnaire was developed and administered to hospital executives across North America to determine the factors that affect purchasing decisions related to OA. Thirty-four individuals participated in the survey. Clinical evidence and cost effectiveness were deemed to be the most important factors in the process of making purchasing decisions. The most important considerations for adopting new technology were whether there was sufficient evidence in the literature, followed by thoughts of key opinion leaders, and cost of intervention/device. Ongoing research is still needed, but the current study allowed us to identify some trends in the data, providing new insight on how hospital purchasing decisions are made, which could have an immediate impact on those currently involved with making these decisions.

Infant Feeding among Women Attending an Immunisation Clinic at a Tertiary Health Institution in Ibadan, Nigeria

ERIC Educational Resources Information Center

Fatiregun, A. A.; Abegunde, V. O.

2009-01-01

Maternal characteristics can affect a mother's decision to breastfeed. This study used a cross-sectional design to assess maternal variables and infant feeding patterns among nursing mothers attending an immunisation clinic in Ibadan, Nigeria. A total of 264 mothers who consecutively attended the immunisation clinic and met certain inclusion…

Feminist poststructuralism: a methodological paradigm for examining clinical decision-making.

PubMed

Arslanian-Engoren, Cynthia

2002-03-01

To present the philosophical framework of feminist poststructuralism, discuss its use as an innovative research approach and its implications for nursing knowledge development and practice. This perspective examines the construction of meaning, power relationships, and the importance of language as it affects contemporary healthcare decisions. It seeks to identify and expose biases that marginalize the healthcare needs of women and contribute to healthcare disparities for this population. Additionally, a feminist poststructuralist perspective seeks to develop new knowledge for understanding gender differences. A feminist poststructuralist perspective represents an alternative paradigm for studying the phenomenon of clinical decision-making. An empirical application example of a feminist poststructuralist perspective is provided. This exemplar investigated emergency department registered nurses' triage decisions for men and women with symptoms suggestive of coronary heart disease.

Trials, tricks and transparency: how disclosure rules affect clinical knowledge.

PubMed

Dahm, Matthias; González, Paula; Porteiro, Nicolás

2009-12-01

Scandals of selective reporting of clinical trial results by pharmaceutical firms have underlined the need for more transparency in clinical trials. We provide a theoretical framework which reproduces incentives for selective reporting and yields three key implications concerning regulation. First, a compulsory clinical trial registry complemented through a voluntary clinical trial results database can implement full transparency (the existence of all trials as well as their results is known). Second, full transparency comes at a price. It has a deterrence effect on the incentives to conduct clinical trials, as it reduces the firms' gains from trials. Third, in principle, a voluntary clinical trial results database without a compulsory registry is a superior regulatory tool; but we provide some qualified support for additional compulsory registries when medical decision-makers cannot anticipate correctly the drug companies' decisions whether to conduct trials.

Clinical evaluation of patients with patellofemoral disorders.

PubMed

Post, W R

1999-01-01

Accurate clinical evaluation of patients with patellofemoral disorders is the cornerstone of effective treatment. This article defines how a careful history and physical examination can direct strategies for nonoperative and operative management. A critical analysis of traditional methods of evaluation and a streamlined rational approach to clinical evaluation is presented. Key questions and important physical findings that affect treatment decisions are emphasized.

Decision-making impairment in anorexia nervosa: New insights into the role of age and decision-making style.

PubMed

Giannunzio, Valeria; Degortes, Daniela; Tenconi, Elena; Collantoni, Enrico; Solmi, Marco; Santonastaso, Paolo; Favaro, Angela

2018-07-01

Patients with anorexia nervosa (AN) often report difficulties in decision making, which may interfere with treatment. The aim of this study was to investigate decision making in a large sample of adolescent and adult patients with AN, by using the Iowa gambling task. Participants were 611 female individuals (310 patients and 301 controls) who underwent neuropsychological and clinical assessment. Significantly poorer decision-making performance was observed in adult patients, whereas no difference emerged between affected and nonaffected adolescents. Both adolescent and adult patients were characterized by trends for higher levels of attention to losses in comparison with healthy controls. Although healthy adult women exhibited better decision-making performance than healthy adolescents, in AN, there was no improvement of decision making with age. A cluster analysis identified 2 different styles of decision making in both patients and controls: a conservative style and an impulsive style. Our study provides evidence of dysfunctional decision making in adult patients with AN and reveals an association between poor decision making and excessive punishment sensitivity in AN. The clinical and scientific implications of these findings merit further exploration. Copyright © 2018 John Wiley & Sons, Ltd and Eating Disorders Association.

Shared decision making in chronic care in the context of evidence based practice in nursing.

PubMed

Friesen-Storms, Jolanda H H M; Bours, Gerrie J J W; van der Weijden, Trudy; Beurskens, Anna J H M

2015-01-01

In the decision-making environment of evidence-based practice, the following three sources of information must be integrated: research evidence of the intervention, clinical expertise, and the patient's values. In reality, evidence-based practice usually focuses on research evidence (which may be translated into clinical practice guidelines) and clinical expertise without considering the individual patient's values. The shared decision-making model seems to be helpful in the integration of the individual patient's values in evidence-based practice. We aim to discuss the relevance of shared decision making in chronic care and to suggest how it can be integrated with evidence-based practice in nursing. We start by describing the following three possible approaches to guide the decision-making process: the paternalistic approach, the informed approach, and the shared decision-making approach. Implementation of shared decision making has gained considerable interest in cases lacking a strong best-treatment recommendation, and when the available treatment options are equivalent to some extent. We discuss that in chronic care it is important to always invite the patient to participate in the decision-making process. We delineate the following six attributes of health care interventions in chronic care that influence the degree of shared decision making: the level of research evidence, the number of available intervention options, the burden of side effects, the impact on lifestyle, the patient group values, and the impact on resources. Furthermore, the patient's willingness to participate in shared decision making, the clinical expertise of the nurse, and the context in which the decision making takes place affect the shared decision-making process. A knowledgeable and skilled nurse with a positive attitude towards shared decision making—integrated with evidence-based practice—can facilitate the shared decision-making process. We conclude that nurses as well as other health care professionals in chronic care should integrate shared decision making with evidence-based practice to deliver patient-centred care. Copyright © 2014 Elsevier Ltd. All rights reserved.

How to improve vital sign data quality for use in clinical decision support systems? A qualitative study in nine Swedish emergency departments.

PubMed

Skyttberg, Niclas; Vicente, Joana; Chen, Rong; Blomqvist, Hans; Koch, Sabine

2016-06-04

Vital sign data are important for clinical decision making in emergency care. Clinical Decision Support Systems (CDSS) have been advocated to increase patient safety and quality of care. However, the efficiency of CDSS depends on the quality of the underlying vital sign data. Therefore, possible factors affecting vital sign data quality need to be understood. This study aims to explore the factors affecting vital sign data quality in Swedish emergency departments and to determine in how far clinicians perceive vital sign data to be fit for use in clinical decision support systems. A further aim of the study is to provide recommendations on how to improve vital sign data quality in emergency departments. Semi-structured interviews were conducted with sixteen physicians and nurses from nine hospitals and vital sign documentation templates were collected and analysed. Follow-up interviews and process observations were done at three of the hospitals to verify the results. Content analysis with constant comparison of the data was used to analyse and categorize the collected data. Factors related to care process and information technology were perceived to affect vital sign data quality. Despite electronic health records (EHRs) being available in all hospitals, these were not always used for vital sign documentation. Only four out of nine sites had a completely digitalized vital sign documentation flow and paper-based triage records were perceived to provide a better mobile workflow support than EHRs. Observed documentation practices resulted in low currency, completeness, and interoperability of the vital signs. To improve vital sign data quality, we propose to standardize the care process, improve the digital documentation support, provide workflow support, ensure interoperability and perform quality control. Vital sign data quality in Swedish emergency departments is currently not fit for use by CDSS. To address both technical and organisational challenges, we propose five steps for vital sign data quality improvement to be implemented in emergency care settings.

Gating the holes in the Swiss cheese (part I): Expanding professor Reason's model for patient safety.

PubMed

Seshia, Shashi S; Bryan Young, G; Makhinson, Michael; Smith, Preston A; Stobart, Kent; Croskerry, Pat

2018-02-01

Although patient safety has improved steadily, harm remains a substantial global challenge. Additionally, safety needs to be ensured not only in hospitals but also across the continuum of care. Better understanding of the complex cognitive factors influencing health care-related decisions and organizational cultures could lead to more rational approaches, and thereby to further improvement. A model integrating the concepts underlying Reason's Swiss cheese theory and the cognitive-affective biases plus cascade could advance the understanding of cognitive-affective processes that underlie decisions and organizational cultures across the continuum of care. Thematic analysis, qualitative information from several sources being used to support argumentation. Complex covert cognitive phenomena underlie decisions influencing health care. In the integrated model, the Swiss cheese slices represent dynamic cognitive-affective (mental) gates: Reason's successive layers of defence. Like firewalls and antivirus programs, cognitive-affective gates normally allow the passage of rational decisions but block or counter unsounds ones. Gates can be breached (ie, holes created) at one or more levels of organizations, teams, and individuals, by (1) any element of cognitive-affective biases plus (conflicts of interest and cognitive biases being the best studied) and (2) other potential error-provoking factors. Conversely, flawed decisions can be blocked and consequences minimized; for example, by addressing cognitive biases plus and error-provoking factors, and being constantly mindful. Informed shared decision making is a neglected but critical layer of defence (cognitive-affective gate). The integrated model can be custom tailored to specific situations, and the underlying principles applied to all methods for improving safety. The model may also provide a framework for developing and evaluating strategies to optimize organizational cultures and decisions. The concept is abstract, the model is virtual, and the best supportive evidence is qualitative and indirect. The proposed model may help enhance rational decision making across the continuum of care, thereby improving patient safety globally. © 2017 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.

Shared Decision Making Among Clinicians and Asian American and Pacific Islander Sexual and Gender Minorities: An Intersectional Approach to Address a Critical Care Gap.

PubMed

Tan, Judy Y; Xu, Lucy J; Lopez, Fanny Y; Jia, Justin L; Pho, Mai T; Kim, Karen E; Chin, Marshall H

2016-10-01

Shared decision making (SDM) is a model of patient-provider communication. Little is known about the role of SDM in health disparities among Asian American and Pacific Islander (AAPI) sexual and gender minorities (SGM). We illustrate how issues at the intersection of AAPI and SGM identities affect SDM processes and health outcomes. We discuss experiences of AAPI SGM that are affected by AAPI heterogeneity, SGM stigma, multiple minority group identities, and sources of discrimination. Recommendations for clinical practice, research, policy, community development, and education are offered.

The reciprocal dynamic model of career decision ambiguity tolerance with career indecision: A longitudinal three-wave investigation.

PubMed

Xu, Hui; Tracey, Terence J G

2017-10-01

The current study investigated the dynamic interplay of career decision ambiguity tolerance and career indecision over 3 assessment times in a sample of college students (n = 583). While the previous research has repeatedly shown an association of career decision ambiguity tolerance with career indecision, the direction of this association has not been adequately assessed with longitudinal investigation. It was hypothesized in this study that there is a reciprocal pattern of career decision ambiguity tolerance leading to subsequent career indecision and career indecision leading to subsequent career decision ambiguity tolerance. Using a cross-lagged panel design, this study found support for the reciprocal pattern that aversion to ambiguity led to increased negative affect and choice anxiety in career decision making, while negative affect and choice anxiety led to increased aversion to ambiguity. Additionally, this study revealed that aversion led to decreased readiness for career decision making and readiness for career decision making led to increased interests in new information. The key findings were discussed with respect to the theoretical and clinical implications for career counseling along with limitations and suggestions for future research. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

A survey of Internet utilization among patients with cancer.

PubMed

Castleton, Kimra; Fong, Thomas; Wang-Gillam, Andrea; Waqar, Muhammad A; Jeffe, Donna B; Kehlenbrink, Lisa; Gao, Feng; Govindan, Ramaswamy

2011-08-01

Recently published articles have established that a substantial number of cancer patients utilize the Internet to gather information about their respective diagnoses. The challenges for medical providers include understanding the prevalence and characteristics of patients using the Internet, reasons for Internet use, and the effectiveness of currently available websites in providing useful health-related information to patients. Adults with cancer were asked to complete a self-administered, anonymous, 21-item questionnaire upon registration at the Alvin J. Siteman Cancer Center at the Washington University School of Medicine. There were 500 respondents (mean age 58 years (range 18-90), 83% Caucasian and 15% African-American). Three hundred ninety-eight participants (80%) reported access to the Internet, and 315 (63%) reported searching for information about cancer on the Internet. Patients accessing the Internet for cancer information were younger than those who did not (median age 56 vs. 63 years; p < 0.001). Internet usage for cancer information also differed by race (p < 0.0001) and education (p < 0.0001). Among patients who searched the Internet for cancer information, 13.3% of patients had their decisions towards treatments affected or changed, and 11.4% of patients had their choice in physicians affected or changed because of Internet use; 23.5% of patients sought information on clinical trials, and 9.5% of patients were influenced or changed their decision regarding clinical trial enrollment due to Internet information. Approximately two thirds of patients with cancer used the Internet to obtain information about their disease. Factors affecting Internet use for cancer information included age, race, and education. Clinical decisions can be affected by Internet use.

Clinical Decision-Making in Community Children's Mental Health: Using Innovative Methods to Compare Clinicians With and Without Training in Evidence-Based Treatment.

PubMed

Baker-Ericzén, Mary J; Jenkins, Melissa M; Park, Soojin; Garland, Ann F

2015-02-01

Mental health professionals' decision-making practice is an area of increasing interest and importance, especially in the pediatric research and clinical communities. The present study explored the role of prior training in evidence-based treatments on clinicians' assessment and treatment formulations using case vignettes. Specifically, study aims included using the Naturalistic Decision Making (NDM) cognitive theory to 1) examine potential associations between EBT training and decision-making processes (novice versus expert type), and 2) explore how client and family contextual information affects clinical decision-making. Forty-eight clinicians across two groups (EBT trained=14, Not EBT trained=34) participated. Clinicians were comparable on professional experience, demographics, and discipline. The quasi-experimental design used an analog "think aloud" method where clinicians read case vignettes about a child with disruptive behavior problems and verbalized case conceptualization and treatment planning out-loud. Responses were coded according to NDM theory. MANOVA results were significant for EBT training status such that EBT trained clinicians' displayed cognitive processes more closely aligned with "expert" decision-makers and non-EBT trained clinicians' decision processes were more similar to "novice" decision-makers, following NDM theory. Non-EBT trained clinicians assigned significantly more diagnoses, provided less detailed treatment plans and discussed fewer EBTs. Parent/family contextual information also appeared to influence decision-making. This study offers a preliminary investigation of the possible broader impacts of EBT training and potential associations with development of expert decision-making skills. Targeting clinicians' decision-making may be an important avenue to pursue within dissemination-implementation efforts in mental health practice.

Effects of procurement practices on quality of medical device or service received: a qualitative study comparing countries.

PubMed

Lingg, Myriam; Wyss, Kaspar; Durán-Arenas, Luis

2016-08-08

We know little about how procurement of a high-risk medical device (HRMD) affects clinical practice and outcomes. In health systems in high-income countries, and specifically those that maintain a national arthroplasty registry, procurement decisions are frequently guided by long-term clinical results, with the goal of ensuring at least standard quality of HRMDs. But in countries like Mexico, decision-making is often dominated by lowest acquisition price. We set out to study the impact of procurement for orthopaedic HRMDs on clinical procedures and outcomes. We based our qualitative study on 59 in-depth interviews with stakeholders from Mexico, Switzerland, Germany, and UK: orthopaedic specialists, government officials, other experts, and social security system managers or administrators. We took a healthcare delivery approach to capturing and comparing factors that affected the regulations of HRMDs and procurement processes, and to understanding connections between procurement and clinical practice. Our findings demonstrate for procurement processes that the three European countries compared to Mexico don't have similar concerns with regards to their procurement processes. Deficiencies of procurement regulations and practices identified from representatives in Mexico were almost absent in European countries. We identified three areas of deficiency: 1) HRMD regulations based on insufficiently robust clinical evidence (mainly noted by European countries); 2) Follow-up on Health Technology Assessments is inadequate (noted by Mexico) and methodology not always good enough (noted by European countries); and, 3) Lowest-acquisition price often guides procurement decisions and thus may not align with needs of clinical procedures (noted by Mexico and some European countries). Procurement processes for orthopaedic HRMDs may have an impact on clinical procedures and outcomes. A favourable approach is one where orthopaedic specialists are parties to the procurement process, and post-market surveillance data informs decision-making. Actors in the procurement process can improve their impact on clinical procedures and outcomes by developing specific strategies that better align the needs of both, procurement and clinical procedures.

Responding to surrogate requests that seem inconsistent with a patient's living will.

PubMed

Vig, Elizabeth K; Sudore, Rebecca L; Berg, Karina M; Fromme, Erik K; Arnold, Robert M

2011-11-01

Clinicians may feel conflicted when a patient's legal decision maker is making decisions that seem inconsistent with a patient's living will. We provide evidence-based information to help clinicians consider whether a surrogate's inconsistent decisions are ethically appropriate. Surrogates are not flawless translators of their loved one's preferences; they are influenced by their own hopes and the current clinical context. Patients may be aware of this, are often concerned about burdening their loved ones, and often grant their surrogates leeway in interpreting their wishes. When appropriate, clinicians should respect surrogates' interpretations of patient values and take steps to decrease surrogate stress during the decision-making process. Finally, if clinicians are cognizant of their own values and preferences, they may recognize how these may affect their responses to certain clinical cases. Copyright © 2011 U.S. Cancer Pain Relief Committee. All rights reserved.

Gendered uncertainty and variation in physicians' decisions for coronary heart disease: the double-edged sword of "atypical symptoms".

PubMed

Welch, Lisa C; Lutfey, Karen E; Gerstenberger, Eric; Grace, Matthew

2012-09-01

Nonmedical factors and diagnostic certainty contribute to variation in clinical decision making, but the process by which this occurs remains unclear. We examine how physicians' interpretations of patient sex-gender affect diagnostic certainty and, in turn, decision making for coronary heart disease. Data are from a factorial experiment of 256 physicians who viewed 1 of 16 video vignettes with different patient-actors presenting the same symptoms of coronary heart disease. Physician participants completed a structured interview and provided a narrative about their decision-making processes. Quantitative analysis showed that diagnostic uncertainty reduces the likelihood that physicians will order tests and medications appropriate for an urgent cardiac condition in particular. Qualitative analysis revealed that a subset of physicians applied knowledge that women have "atypical symptoms" as a generalization, which engendered uncertainty for some. Findings are discussed in relation to social-psychological processes that underlie clinical decision making and the social framing of medical knowledge.

Gendered Uncertainty and Variation in Physicians’ Decisions for Coronary Heart Disease: The Double-Edged Sword of “Atypical Symptoms”*

PubMed Central

Welch, Lisa C.; Lutfey, Karen E.; Gerstenberger, Eric; Grace, Matthew

2013-01-01

Nonmedical factors and diagnostic certainty contribute to variation in clinical decision making, but the process by which this occurs remains unclear. We examine how physicians’ interpretations of patient sex/gender affect diagnostic certainty and, in turn, decision making for coronary heart disease (CHD). Data are from a factorial experiment of 256 physicians who viewed one of 16 video vignettes with different patient-actors presenting the same CHD symptoms. Physician participants completed a structured interview and provided a narrative about their decision-making processes. Quantitative analysis showed that diagnostic uncertainty reduces the likelihood that physicians will order tests and medications appropriate for an urgent cardiac condition in particular. Qualitative analysis revealed that a subset of physicians applied knowledge that women have “atypical symptoms” as a generalization, which engendered uncertainty for some. Findings are discussed in relation to social-psychological processes that underlie clinical decision making and the social framing of medical knowledge. PMID:22933590

Intraoperative Clinical Decision Support for Anesthesia: A Narrative Review of Available Systems.

PubMed

Nair, Bala G; Gabel, Eilon; Hofer, Ira; Schwid, Howard A; Cannesson, Maxime

2017-02-01

With increasing adoption of anesthesia information management systems (AIMS), there is growing interest in utilizing AIMS data for intraoperative clinical decision support (CDS). CDS for anesthesia has the potential for improving quality of care, patient safety, billing, and compliance. Intraoperative CDS can range from passive and post hoc systems to active real-time systems that can detect ongoing clinical issues and deviations from best practice care. Real-time CDS holds the most promise because real-time alerts and guidance can drive provider behavior toward evidence-based standardized care during the ongoing case. In this review, we describe the different types of intraoperative CDS systems with specific emphasis on real-time systems. The technical considerations in developing and implementing real-time CDS are systematically covered. This includes the functional modules of a CDS system, development and execution of decision rules, and modalities to alert anesthesia providers concerning clinical issues. We also describe the regulatory aspects that affect development, implementation, and use of intraoperative CDS. Methods and measures to assess the effectiveness of intraoperative CDS are discussed. Last, we outline areas of future development of intraoperative CDS, particularly the possibility of providing predictive and prescriptive decision support.

THE IMPACT OF RACISM ON CLINICIAN COGNITION, BEHAVIOR, AND CLINICAL DECISION MAKING

PubMed Central

van Ryn, Michelle; Burgess, Diana J.; Dovidio, John F.; Phelan, Sean M.; Saha, Somnath; Malat, Jennifer; Griffin, Joan M.; Fu, Steven S.; Perry, Sylvia

2014-01-01

Over the past two decades, thousands of studies have demonstrated that Blacks receive lower quality medical care than Whites, independent of disease status, setting, insurance, and other clinically relevant factors. Despite this, there has been little progress towards eradicating these inequities. Almost a decade ago we proposed a conceptual model identifying mechanisms through which clinicians’ behavior, cognition, and decision making might be influenced by implicit racial biases and explicit racial stereotypes, and thereby contribute to racial inequities in care. Empirical evidence has supported many of these hypothesized mechanisms, demonstrating that White medical care clinicians: (1) hold negative implicit racial biases and explicit racial stereotypes, (2) have implicit racial biases that persist independently of and in contrast to their explicit (conscious) racial attitudes, and (3) can be influenced by racial bias in their clinical decision making and behavior during encounters with Black patients. This paper applies evidence from several disciplines to further specify our original model and elaborate on the ways racism can interact with cognitive biases to affect clinicians’ behavior and decisions and in turn, patient behavior and decisions. We then highlight avenues for intervention and make specific recommendations to medical care and grant-making organizations. PMID:24761152

Factors affecting general practitioners' decisions about plain radiography for back pain: implications for classification of guideline barriers--a qualitative study.

PubMed

Espeland, Ansgar; Baerheim, Anders

2003-03-24

General practitioners often diverge from clinical guidelines regarding spine radiography. This study aimed to identify and describe A) factors general practitioners consider may affect their decisions about ordering plain radiography for back pain and B) barriers to guideline adherence suggested by such factors. Focus group interviews regarding factors affecting ordering decisions were carried out on a diverse sample of Norwegian general practitioners and were analysed qualitatively. Results of this study and two qualitative studies from the Netherlands and USA on use of spine radiography were interpreted for barriers to guideline adherence. These were compared with an existing barrier classification system described by Dr Cabana's group. The factors which Norwegian general practitioners considered might affect their decisions about ordering plain radiography for back pain concerned the following broader issues: clinical ordering criteria, patients' wishes for radiography and the general practitioner's response, uncertainty, professional dignity, access to radiology services, perception of whether the patient really was ill, sense of pressure from other health care providers/social security, and expectations about the consequences of ordering radiography. The three studies suggested several attitude-related and external barriers as classified in a previously reported system described by Dr Cabana in another study. Identified barriers not listed in this system were: lack of expectancy that guideline adherence will lead to desired health care process, emotional difficulty with adherence, improper access to actual/alternative health care services, and pressure from health care providers/organisations. Our findings may help implement spine radiography guidelines. They also indicate that Cabana et al.'s barrier classification system needs extending. A revised system is proposed.

Factors affecting general practitioners' decisions about plain radiography for back pain: implications for classification of guideline barriers – a qualitative study

PubMed Central

Espeland, Ansgar; Baerheim, Anders

2003-01-01

Background General practitioners often diverge from clinical guidelines regarding spine radiography. This study aimed to identify and describe A) factors general practitioners consider may affect their decisions about ordering plain radiography for back pain and B) barriers to guideline adherence suggested by such factors. Methods Focus group interviews regarding factors affecting ordering decisions were carried out on a diverse sample of Norwegian general practitioners and were analysed qualitatively. Results of this study and two qualitative studies from the Netherlands and USA on use of spine radiography were interpreted for barriers to guideline adherence. These were compared with an existing barrier classification system described by Dr Cabana's group. Results The factors which Norwegian general practitioners considered might affect their decisions about ordering plain radiography for back pain concerned the following broader issues: clinical ordering criteria, patients' wishes for radiography and the general practitioner's response, uncertainty, professional dignity, access to radiology services, perception of whether the patient really was ill, sense of pressure from other health care providers/social security, and expectations about the consequences of ordering radiography. The three studies suggested several attitude-related and external barriers as classified in a previously reported system described by Dr Cabana in another study. Identified barriers not listed in this system were: lack of expectancy that guideline adherence will lead to desired health care process, emotional difficulty with adherence, improper access to actual/alternative health care services, and pressure from health care providers/organisations. Conclusions Our findings may help implement spine radiography guidelines. They also indicate that Cabana et al.'s barrier classification system needs extending. A revised system is proposed. PMID:12659640

Physician styles of decision-making for a complex condition: Type 2 diabetes with co-morbid mental illness.

PubMed

Trachtenberg, Felicia L; Pober, David M; Welch, Lisa C; McKinlay, John B

Variation in physician decisions may reflect personal styles of decision-making, as opposed to singular clinical actions and these styles may be applied differently depending on patient complexity. The objective of this study is to examine clusters of physician decision-making for type 2 diabetes, overall and in the presence of a mental health co-morbidity. This randomized balanced factorial experiment presented video vignettes of a "patient" with diagnosed, but uncontrolled type 2 diabetes. "Patients" were systematically varied by age, sex, race and co-morbidity (depression, schizophrenia with normal or bizarre affect, eczema as control). Two hundred and fifty-six primary care physicians, balanced by gender and experience level, completed a structured interview about clinical management. Cluster analysis identified 3 styles of diabetes management. "Minimalists" (n=84) performed fewer exams or tests compared to "middle of the road" physicians (n=84). "Interventionists" (n=88) suggested more medications and referrals. A second cluster analysis, without control for co-morbidities, identified an additional cluster of "information seekers" (n=15) who requested more additional information and referrals. Physicians ranking schizophrenia higher than diabetes on their problem list were more likely "minimalists" and none were "interventionists" or "information seekers". Variations in clinical management encompass multiple clinical actions and physicians subtly shift these decision-making styles depending on patient co-morbidities. Physicians' practice styles may help explain persistent differences in patient care. Training and continuing education efforts to encourage physicians to implement evidence-based clinical practice should account for general styles of decision-making and for how physicians process complicating comorbidities.

Shared Decision Making Among Clinicians and Asian American and Pacific Islander Sexual and Gender Minorities: An Intersectional Approach to Address a Critical Care Gap

PubMed Central

Xu, Lucy J.; Lopez, Fanny Y.; Jia, Justin L.; Pho, Mai T.; Kim, Karen E.; Chin, Marshall H.

2016-01-01

Abstract Shared decision making (SDM) is a model of patient-provider communication. Little is known about the role of SDM in health disparities among Asian American and Pacific Islander (AAPI) sexual and gender minorities (SGM). We illustrate how issues at the intersection of AAPI and SGM identities affect SDM processes and health outcomes. We discuss experiences of AAPI SGM that are affected by AAPI heterogeneity, SGM stigma, multiple minority group identities, and sources of discrimination. Recommendations for clinical practice, research, policy, community development, and education are offered. PMID:27158858

Telephone triage by nurses in primary care out-of-hours services in Norway: an evaluation study based on written case scenarios

PubMed Central

Hunskaar, Steinar

2011-01-01

Background The use of nurses for telephone-based triage in out-of-hours services is increasing in several countries. No investigations have been carried out in Norway into the quality of decisions made by nurses regarding our priority degree system. There are three levels: acute, urgent and non-urgent. Methods Nurses working in seven casualty clinics in out-of-hours districts in Norway (The Watchtowers) were all invited to participate in a study to assess priority grade on 20 written medical scenarios validated by an expert group. 83 nurses (response rate 76%) participated in the study. A one-out-of-five sample of the nurses assessed the same written cases after 3 months (n=18, response rate 90%) as a test–retest assessment. Results Among the acute, urgent and non-urgent scenarios, 82%, 74% and 81% were correctly classified according to national guidelines. There were significant differences in the proportion of correct classifications among the casualty clinics, but neither employment percentage nor profession or work experience affected the triage decision. The mean intraobserver variability measured by the Cohen kappa was 0.61 (CI 0.52 to 0.70), and there were significant differences in kappa with employment percentage. Casualty clinics and work experience did not affect intrarater agreement. Conclusion Correct classification of acute and non-urgent cases among nurses was quite high. Work experience and employment percentage did not affect triage decision. The intrarater agreement was good and about the same as in previous studies performed in other countries. Kappa increased significantly with increasing employment percentage. PMID:21262792

Telephone triage by nurses in primary care out-of-hours services in Norway: an evaluation study based on written case scenarios.

PubMed

Hansen, Elisabeth Holm; Hunskaar, Steinar

2011-05-01

The use of nurses for telephone-based triage in out-of-hours services is increasing in several countries. No investigations have been carried out in Norway into the quality of decisions made by nurses regarding our priority degree system. There are three levels: acute, urgent and non-urgent. Nurses working in seven casualty clinics in out-of-hours districts in Norway (The Watchtowers) were all invited to participate in a study to assess priority grade on 20 written medical scenarios validated by an expert group. 83 nurses (response rate 76%) participated in the study. A one-out-of-five sample of the nurses assessed the same written cases after 3 months (n = 18, response rate 90%) as a test-retest assessment. Among the acute, urgent and non-urgent scenarios, 82%, 74% and 81% were correctly classified according to national guidelines. There were significant differences in the proportion of correct classifications among the casualty clinics, but neither employment percentage nor profession or work experience affected the triage decision. The mean intraobserver variability measured by the Cohen kappa was 0.61 (CI 0.52 to 0.70), and there were significant differences in kappa with employment percentage. Casualty clinics and work experience did not affect intrarater agreement. Correct classification of acute and non-urgent cases among nurses was quite high. Work experience and employment percentage did not affect triage decision. The intrarater agreement was good and about the same as in previous studies performed in other countries. Kappa increased significantly with increasing employment percentage.

Clinical decision making in cancer care: a review of current and future roles of patient age.

PubMed

Tranvåg, Eirik Joakim; Norheim, Ole Frithjof; Ottersen, Trygve

2018-05-09

Patient age is among the most controversial patient characteristics in clinical decision making. In personalized cancer medicine it is important to understand how individual characteristics do affect practice and how to appropriately incorporate such factors into decision making. Some argue that using age in decision making is unethical, and how patient age should guide cancer care is unsettled. This article provides an overview of the use of age in clinical decision making and discusses how age can be relevant in the context of personalized medicine. We conducted a scoping review, searching Pubmed for English references published between 1985 and May 2017. References concerning cancer, with patients above the age of 18 and that discussed age in relation to diagnostic or treatment decisions were included. References that were non-medical or concerning patients below the age of 18, and references that were case reports, ongoing studies or opinion pieces were excluded. Additional references were collected through snowballing and from selected reports, guidelines and articles. Three hundred and forty-seven relevant references were identified. Patient age can have many and diverse roles in clinical decision making: Contextual roles linked to access (age influences how fast patients are referred to specialized care) and incidence (association between increasing age and increasing incidence rates for cancer); patient-relevant roles linked to physiology (age-related changes in drug metabolism) and comorbidity (association between increasing age and increasing number of comorbidities); and roles related to interventions, such as treatment (older patients receive substandard care) and outcome (survival varies by age). Patient age is integrated into cancer care decision making in a range of ways that makes it difficult to claim age-neutrality. Acknowledging this and being more transparent about the use of age in decision making are likely to promote better clinical decisions, irrespective of one's normative viewpoint. This overview also provides a starting point for future discussions on the appropriate role of age in cancer care decision making, which we see as crucial for harnessing the full potential of personalized medicine.

Complex contexts and relationships affect clinical decisions in group therapy.

PubMed

Tasca, Giorgio A; Mcquaid, Nancy; Balfour, Louise

2016-09-01

Clinical errors tend to be underreported even though examining them can provide important training and professional development opportunities. The group therapy context may be prone to clinician errors because of the added complexity within which therapists work and patients receive treatment. We discuss clinical errors that occurred within a group therapy in which a patient for whom group was not appropriate was admitted to the treatment and then was not removed by the clinicians. This was countertherapeutic for both patient and group. Two clinicians were involved: a clinical supervisor who initially assessed and admitted the patient to the group, and a group therapist. To complicate matters, the group therapy occurred within the context of a clinical research trial. The errors, possible solutions, and recommendations are discussed within Reason's Organizational Accident Model (Reason, 2000). In particular, we discuss clinician errors in the context of countertransference and clinician heuristics, group therapy as a local work condition that complicates clinical decision-making, and the impact of the research context as a latent organizational factor. We also present clinical vignettes from the pregroup preparation, group therapy, and supervision. Group therapists are more likely to avoid errors in clinical decisions if they engage in reflective practice about their internal experiences and about the impact of the context in which they work. Therapists must keep in mind the various levels of group functioning, especially related to the group-as-a-whole (i.e., group composition, cohesion, group climate, and safety) when making complex clinical decisions in order to optimize patient outcomes. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Clinical Decision-Making in Community Children’s Mental Health: Using Innovative Methods to Compare Clinicians With and Without Training in Evidence-Based Treatment

PubMed Central

Baker-Ericzén, Mary J.; Jenkins, Melissa M.; Park, Soojin; Garland, Ann F.

2014-01-01

Background Mental health professionals’ decision-making practice is an area of increasing interest and importance, especially in the pediatric research and clinical communities. Objective The present study explored the role of prior training in evidence-based treatments on clinicians’ assessment and treatment formulations using case vignettes. Specifically, study aims included using the Naturalistic Decision Making (NDM) cognitive theory to 1) examine potential associations between EBT training and decision-making processes (novice versus expert type), and 2) explore how client and family contextual information affects clinical decision-making. Methods Forty-eight clinicians across two groups (EBT trained=14, Not EBT trained=34) participated. Clinicians were comparable on professional experience, demographics, and discipline. The quasi-experimental design used an analog “think aloud” method where clinicians read case vignettes about a child with disruptive behavior problems and verbalized case conceptualization and treatment planning out-loud. Responses were coded according to NDM theory. Results MANOVA results were significant for EBT training status such that EBT trained clinicians’ displayed cognitive processes more closely aligned with “expert” decision-makers and non-EBT trained clinicians’ decision processes were more similar to “novice” decision-makers, following NDM theory. Non-EBT trained clinicians assigned significantly more diagnoses, provided less detailed treatment plans and discussed fewer EBTs. Parent/family contextual information also appeared to influence decision-making. Conclusion This study offers a preliminary investigation of the possible broader impacts of EBT training and potential associations with development of expert decision-making skills. Targeting clinicians’ decision-making may be an important avenue to pursue within dissemination-implementation efforts in mental health practice. PMID:25892901

ASSESSMENT OF UPPER EXTREMITY IMPAIRMENT, FUNCTION, AND ACTIVITY FOLLOWING STROKE: FOUNDATIONS FOR CLINICAL DECISION MAKING

PubMed Central

Lang, Catherine E.; Bland, Marghuretta D.; Bailey, Ryan R.; Schaefer, Sydney Y.; Birkenmeier, Rebecca L.

2012-01-01

The purpose of this review is to provide a comprehensive approach for assessing the upper extremity (UE) after stroke. First, common upper extremity impairments and how to assess them are briefly discussed. While multiple UE impairments are typically present after stroke, the severity of one impairment, paresis, is the primary determinant of UE functional loss. Second, UE function is operationally defined and a number of clinical measures are discussed. It is important to consider how impairment and loss of function affect UE activity outside of the clinical environment. Thus, this review also identifies accelerometry as an objective method for assessing UE activity in daily life. Finally, the role that each of these levels of assessment should play in clinical decision making is discussed in order to optimize the provision of stroke rehabilitation services. PMID:22975740

Enrolling adolescents in asthma research: adolescent, parent, and physician influence in the decision-making process.

PubMed

Brody, Janet L; Annett, Robert D; Scherer, David G; Turner, Charles; Dalen, Jeanne

2009-06-01

The factors influencing family decisions to participate in adolescent asthma research are not well understood. Legal and ethical imperatives require adolescent research participation to be voluntary. While parents and adolescents often agree about research decisions, disagreements may also occur with relative frequency. Physician recommendations are also known to influence research participation decisions. Little attention has been given to how these dynamics may affect adolescents' involvement in decisions to participate in research. To examine the influence of family and physician-investigator relationships and recommendations on adolescent asthma clinical research participation decisions. A statewide community sample of 111 adolescents 11 to 17 years of age, with a diagnosis of asthma, and their parents participated in this study. Adolescents received a medical evaluation from an asthma specialist and then the family was offered participation in a hypothetical asthma clinical trial. By random assignment, the research study was presented by either the same or an unknown asthma specialist, and half the families in each group also received affirmative recommendations from the asthma specialist to participate in the hypothetical asthma clinical trial. Parents and adolescents made initial private decisions about participating in the trial. Then, following a family discussion of the clinical trial, a final research participation decision was made. Thirty-three percent of parents and adolescents initially disagreed about the research participation decision. When disagreements occurred, final decisions followed the parents' initial views except when the physician-investigator was known and a recommendation was made. Families with initial disagreement about participating were less likely to enroll when the investigator was unknown or when no recommendation was made. Adolescents who initially disagreed with parents' views were less likely to concur with the final research participation decision, felt less comfortable, and were less likely to feel they influenced the decision. Parents' views on research decisions take precedence over adolescents' views in most circumstances. Physician-investigator relationships may reduce parental resistance to participation and enhance adolescent decision-making autonomy when research participation is desired by the adolescent.

Enrolling adolescents in asthma research: Adolescent, parent, and physician influence in the decision-making process

PubMed Central

Brody, Janet L.; Annett, Robert D.; Scherer, David G.; Turner, Charles; Dalen, Jeanne

2009-01-01

Background The factors influencing family decisions to participate in adolescent asthma research are not well understood. Legal and ethical imperatives require adolescent research participation to be voluntary. While parents and adolescents often agree about research decisions, disagreements may also occur with relatively frequency. Physician recommendations are also known to influence research participation decisions. Little attention has been given to how these dynamics may affect adolescents’ involvement in decisions to participate in research. Objective To examine the influence of family and physician-investigator relationships and recommendations on adolescent asthma clinical research participation decisions. Methods A statewide community sample of 111 adolescents aged 11–17, with a diagnosis of asthma, and their parents participated in this study. Adolescents received a medical evaluation from an asthma specialist and then the family was offered participation in a hypothetical asthma clinical trial. By random assignment, the research study was presented by either the same or an unknown asthma specialist and half the families in each group also received affirmative recommendations from the asthma specialist to participate in the hypothetical asthma clinical trial. Parents and adolescent made initial private decisions about participating in the trial. Then, following a family discussion of the clinical trial, a final research participation decision was made. Results Thirty three percent of parents and adolescents initially disagreed about the research participation decision. When disagreements occurred, final decisions followed the parents’ initial views except when the physician-investigator was known and a recommendation was made. Families with initial disagreement about participating were less likely to enroll when the investigator was unknown or when no recommendation was made. Adolescents who initially disagreed with parents’ views were less likely to concur with the final research participation decision, felt less comfortable, and were less likely to feel they influenced the decision. Conclusions Parents’ views on research decisions take precedence over adolescents’ views in most circumstances. Physician-investigator relationships may reduce parental resistance to participation and enhance adolescent decision-making autonomy when research participation is desired by the adolescent. PMID:19544171

Distributed Cognition in Cancer Treatment Decision Making: An Application of the DECIDE Decision-Making Styles Typology.

PubMed

Krieger, Janice L; Krok-Schoen, Jessica L; Dailey, Phokeng M; Palmer-Wackerly, Angela L; Schoenberg, Nancy; Paskett, Electra D; Dignan, Mark

2017-07-01

Distributed cognition occurs when cognitive and affective schemas are shared between two or more people during interpersonal discussion. Although extant research focuses on distributed cognition in decision making between health care providers and patients, studies show that caregivers are also highly influential in the treatment decisions of patients. However, there are little empirical data describing how and when families exert influence. The current article addresses this gap by examining decisional support in the context of cancer randomized clinical trial (RCT) decision making. Data are drawn from in-depth interviews with rural, Appalachian cancer patients ( N = 46). Analysis of transcript data yielded empirical support for four distinct models of health decision making. The implications of these findings for developing interventions to improve the quality of treatment decision making and overall well-being are discussed.

The ambiguity of patient-centred practices: the case of a Dutch fertility clinic.

PubMed

Gerrits, Trudie

2014-01-01

When in-vitro fertilization (IVF) was introduced in the 1970s, doctors were criticized for not properly informing prospective users about its possible risks and limited success rates as well as for medicalizing fertility problems. Nowadays, many fertility clinics are seeking to improve their accountability to stakeholders through patient-centred practices. Based on an ethnographic study of a Dutch fertility clinic, outspoken in its aims to provide patient-centred medicine and to empower clients, this paper addresses how patient-centred medicine affects couples' decision-making to use IVF and related reproductive technologies. The author contends that while patient-centred practices facilitate informed decision-making and support couples emotionally, they may also have unintended disciplining and normalizing effects. The information and support provided, the trust couples have in clinic staff, the ongoing visualization of conception mediated by medical technology--all can be seen as practices that strengthen lay people's 'medical gaze' in how they come to view their bodies, fertility problems and possible solutions. These unintended effects are labelled 'the ambiguity of patient-centeredness' as they (may) interfere with processes of autonomous decision-making.

A Decision Tree to Identify Children Affected by Prenatal Alcohol Exposure

PubMed Central

Goh, Patrick K.; Doyle, Lauren R.; Glass, Leila; Jones, Kenneth L.; Riley, Edward P.; Coles, Claire D.; Hoyme, H. Eugene; Kable, Julie A.; May, Philip A.; Kalberg, Wendy O.; Elizabeth, R. Sowell; Wozniak, Jeffrey R.; Mattson, Sarah N.

2017-01-01

Objective To develop and validate a hierarchical decision tree model, combining neurobehavioral and physical measures, for identification of children affected by prenatal alcohol exposure even when facial dysmorphology is not present. Study design Data were collected as part of a multisite study across the United States. The model was developed after evaluating over 1000 neurobehavioral and dysmorphology variables collected from 434 children (8–16y) with prenatal alcohol exposure, with and without fetal alcohol syndrome (FAS), and non-exposed controls, with and without other clinically-relevant behavioral or cognitive concerns. The model was subsequently validated in an independent sample of 454 children in two age ranges (5–7y or 10–16y). In all analyses, the discriminatory ability of each model step was tested with logistic regression. Classification accuracies and positive and negative predictive values were calculated. Results The model consisted of variables from 4 measures (2 parent questionnaires, an IQ score, and a physical examination). Overall accuracy rates for both the development and validation samples met or exceeded our goal of 80% overall accuracy. Conclusions The decision tree model distinguished children affected by prenatal alcohol exposure from non-exposed controls, including those with other behavioral concerns or conditions. Improving identification of this population will streamline access to clinical services, including multidisciplinary evaluation and treatment. PMID:27476634

The Role of Health Care Provider and Partner Decisional Support in Patients' Cancer Treatment Decision-Making Satisfaction.

PubMed

Palmer-Wackerly, Angela L; Krieger, Janice L; Rhodes, Nancy D

2017-01-01

Cancer patients rely on multiple sources of support when making treatment decisions; however, most research studies examine the influence of health care provider support while the influence of family member support is understudied. The current study fills this gap by examining the influence of health care providers and partners on decision-making satisfaction. In a cross-sectional study via an online Qualtrics panel, we surveyed cancer patients who reported that they had a spouse or romantic partner when making cancer treatment decisions (n = 479). Decisional support was measured using 5-point, single-item scales for emotional support, informational support, informational-advice support, and appraisal support. Decision-making satisfaction was measured using Holmes-Rovner and colleagues' (1996) Satisfaction With Decision Scale. We conducted a mediated regression analysis to examine treatment decision-making satisfaction for all participants and a moderated mediation analysis to examine treatment satisfaction among those patients offered a clinical trial. Results indicated that partner support significantly and partially mediated the relationship between health care provider support and patients' decision-making satisfaction but that results did not vary by enrollment in a clinical trial. This study shows how and why decisional support from partners affects communication between health care providers and cancer patients.

Affective Biases in Humans and Animals.

PubMed

Robinson, E S J; Roiser, J P

Depression is one of the most common but poorly understood psychiatric conditions. Although drug treatments and psychological therapies are effective in some patients, many do not achieve full remission and some patients receive no apparent benefit. Developing new improved treatments requires a better understanding of the aetiology of symptoms and evaluation of novel therapeutic targets in pre-clinical studies. Recent developments in our understanding of the basic cognitive processes that may contribute to the development of depression and its treatment offer new opportunities for both clinical and pre-clinical research. This chapter discusses the clinical evidence supporting a cognitive neuropsychological model of depression and antidepressant efficacy, and how this information may be usefully translated to pre-clinical investigation. Studies using neuropsychological tests in depressed patients and at risk populations have revealed basic negative emotional biases and disrupted reward and punishment processing, which may also impact on non-affective cognition. These affective biases are sensitive to antidepressant treatments with early onset effects observed, suggesting an important role in recovery. This clinical work into affective biases has also facilitated back-translation to animals and the development of assays to study affective biases in rodents. These animal studies suggest that, similar to humans, rodents in putative negative affective states exhibit negative affective biases on decision-making and memory tasks. Antidepressant treatments also induce positive biases in these rodent tasks, supporting the translational validity of this approach. Although still in the early stages of development and validation, affective biases in depression have the potential to offer new insights into the clinical condition, as well as facilitating the development of more translational approaches for pre-clinical studies.

Interoceptive Awareness, Positive Affect, and Decision Making in Major Depressive Disorder

PubMed Central

Furman, Daniella J.; Waugh, Christian E.; Bhattacharjee, Kalpa; Thompson, Renee J.; Gotlib, Ian H.

2013-01-01

Background Little work has examined the relation between interoceptive awareness and symptoms of Major Depressive Disorder (MDD). Existing research suggests that depressed individuals exhibit impaired heartbeat perception, though the results of this research have been equivocal. Importantly, depressed participants in these studies have had comorbid anxiety disorders, making it difficult to draw inferences about interoceptive awareness in MDD. The current study addresses this issue by assessing heartbeat perception in depressed women without current anxiety disorders and exploring the relation between interoception and perturbations in both affective intensity and decision making, components of MDD postulated to be related to bodily awareness. Methods Depressed women without concurrent anxiety disorders (n=25) and never-disordered controls (n=36) performed a heartbeat perception task. Participants completed the self-report Affect Intensity Measure (AIM), and decision-making difficulty was assessed in MDD participants using the Structured Clinical Interview for DSM-IV. Results Depressed women exhibited poorer heartbeat perception accuracy than did control participants. Impaired accuracy in MDD participants was associated with reduced positive affectivity and difficulty in decision making. Limitations Our sample was composed exclusively of females and was heterogeneous with respect to treatment status, thereby limiting our ability to generalize results to depressed males and to exclude the contribution of exogenous factors to the observed group differences. Conclusions Results of this study suggest that for depressed individuals without anxiety comorbidities, disrupted perception of bodily responses reduces both the experience of positive arousal and the ability to use interoceptive feedback to inform decision making. PMID:23972662

Ethical responsibilities toward indirect and collateral participants in pragmatic clinical trials.

PubMed

Smalley, Jaye Bea; Merritt, Maria W; Al-Khatib, Sana M; McCall, Debbe; Staman, Karen L; Stepnowsky, Carl

2015-10-01

Pragmatic clinical trials are designed to inform decision makers about the benefits, burdens, and risks of health interventions in real-world settings. Pragmatic clinical trials often use for research purposes data collected in the course of clinical practice. The distinctive features of pragmatic clinical trials demand fresh thinking about what is required to act properly toward people affected by their conduct, in ways that go beyond ensuring the protection of rights and welfare for "human research subjects" under conventional research ethics regulations. To stimulate such work, we propose to distinguish among categories of research participants in pragmatic clinical trials as follows: Direct participants: (1) individuals being directly intervened upon and/or (2) individuals from whom personal identifiable data are being collected for the purposes of the pragmatic clinical trial. Indirect participants: individuals who are (1) not identified as direct participants and (2) whose rights and welfare may be affected by the intervention through their routine exposure to the environment in which the intervention is being deployed. Collateral participants: patient groups and other stakeholder communities who may be otherwise affected by the occurrence and findings of the pragmatic clinical trial. We illustrate these distinctions with case examples and discuss the distinctive responsibilities of researchers and pragmatic clinical trial leadership toward each type of participant. We suggest that pragmatic clinical trial investigators, institutional review boards, health systems leaders, and others engaged in the research enterprise work together to identify these participants. For indirect participants, risks and benefits to which they are exposed should be weighed to ensure that their rights and welfare are protected accordingly, and communication strategies should be considered to help them make well-informed decisions. Collateral participants could provide input on the design, planning, and conduct of a pragmatic clinical trial and offer insights regarding the best way to communicate the trial's results to their constituencies. © The Author(s) 2015.

Clinical utility of gene expression profiling data for clinical decision-making regarding adjuvant therapy in early stage, node-negative breast cancer: a case report.

PubMed

Schuster, Steven R; Pockaj, Barbara A; Bothe, Mary R; David, Paru S; Northfelt, Donald W

2012-09-10

Breast cancer is the most common malignancy among women in the United States with the second highest incidence of cancer-related death following lung cancer. The decision-making process regarding adjuvant therapy is a time intensive dialogue between the patient and her oncologist. There are multiple tools that help individualize the treatment options for a patient. Population-based analysis with Adjuvant! Online and genomic profiling with Oncotype DX are two commonly used tools in patients with early stage, node-negative breast cancer. This case report illustrates a situation in which the population-based prognostic and predictive information differed dramatically from that obtained from genomic profiling and affected the patient's decision. In light of this case, we discuss the benefits and limitations of these tools.

Bayesian Decision Support for Adaptive Lung Treatments

NASA Astrophysics Data System (ADS)

McShan, Daniel; Luo, Yi; Schipper, Matt; TenHaken, Randall

2014-03-01

Purpose: A Bayesian Decision Network will be demonstrated to provide clinical decision support for adaptive lung response-driven treatment management based on evidence that physiologic metrics may correlate better with individual patient response than traditional (population-based) dose and volume-based metrics. Further, there is evidence that information obtained during the course of radiation therapy may further improve response predictions. Methods: Clinical factors were gathered for 58 patients including planned mean lung dose, and the bio-markers IL-8 and TGF-β1 obtained prior to treatment and two weeks into treatment along with complication outcomes for these patients. A Bayesian Decision Network was constructed using Netica 5.0.2 from Norsys linking these clinical factors to obtain a prediction of radiation induced lung disese (RILD) complication. A decision node was added to the network to provide a plan adaption recommendation based on the trade-off between the RILD prediction and complexity of replanning. A utility node provides the weighting cost between the competing factors. Results: The decision node predictions were optimized against the data for the 58 cases. With this decision network solution, one can consider the decision result for a new patient with specific findings to obtain a recommendation to adaptively modify the originally planned treatment course. Conclusions: A Bayesian approach allows handling and propagating probabilistic data in a logical and principled manner. Decision networks provide the further ability to provide utility-based trade-offs, reflecting non-medical but practical cost/benefit analysis. The network demonstrated illustrates the basic concept, but many other factors may affect these decisions and work on building better models are being designed and tested. Acknowledgement: Supported by NIH-P01-CA59827

A Conceptual Framework for Decision-making Support in Uncertainty- and Risk-based Diagnosis of Rare Clinical Cases by Specialist Physicians.

PubMed

Santos, Adriano A; Moura, J Antão B; de Araújo, Joseana Macêdo Fechine Régis

2015-01-01

Mitigating uncertainty and risks faced by specialist physicians in analysis of rare clinical cases is something desired by anyone who needs health services. The number of clinical cases never seen by these experts, with little documentation, may introduce errors in decision-making. Such errors negatively affect well-being of patients, increase procedure costs, rework, health insurance premiums, and impair the reputation of specialists and medical systems involved. In this context, IT and Clinical Decision Support Systems (CDSS) play a fundamental role, supporting decision-making process, making it more efficient and effective, reducing a number of avoidable medical errors and enhancing quality of treatment given to patients. An investigation has been initiated to look into characteristics and solution requirements of this problem, model it, propose a general solution in terms of a conceptual risk-based, automated framework to support rare-case medical diagnostics and validate it by means of case studies. A preliminary validation study of the proposed framework has been carried out by interviews conducted with experts who are practicing professionals, academics, and researchers in health care. This paper summarizes the investigation and its positive results. These results motivate continuation of research towards development of the conceptual framework and of a software tool that implements the proposed model.

The role of emotion in clinical decision making: an integrative literature review.

PubMed

Kozlowski, Desirée; Hutchinson, Marie; Hurley, John; Rowley, Joanne; Sutherland, Joanna

2017-12-15

Traditionally, clinical decision making has been perceived as a purely rational and cognitive process. Recently, a number of authors have linked emotional intelligence (EI) to clinical decision making (CDM) and calls have been made for an increased focus on EI skills for clinicians. The objective of this integrative literature review was to identify and synthesise the empirical evidence for a role of emotion in CDM. A systematic search of the bibliographic databases PubMed, PsychINFO, and CINAHL (EBSCO) was conducted to identify empirical studies of clinician populations. Search terms were focused to identify studies reporting clinician emotion OR clinician emotional intelligence OR emotional competence AND clinical decision making OR clinical reasoning. Twenty three papers were retained for synthesis. These represented empirical work from qualitative, quantitative, and mixed-methods approaches and comprised work with a focus on experienced emotion and on skills associated with emotional intelligence. The studies examined nurses (10), physicians (7), occupational therapists (1), physiotherapists (1), mixed clinician samples (3), and unspecified infectious disease experts (1). We identified two main themes in the context of clinical decision making: the subjective experience of emotion; and, the application of emotion and cognition in CDM. Sub-themes under the subjective experience of emotion were: emotional response to contextual pressures; emotional responses to others; and, intentional exclusion of emotion from CDM. Under the application of emotion and cognition in CDM, sub-themes were: compassionate emotional labour - responsiveness to patient emotion within CDM; interdisciplinary tension regarding the significance and meaning of emotion in CDM; and, emotion and moral judgement. Clinicians' experienced emotions can and do affect clinical decision making, although acknowledgement of that is far from universal. Importantly, this occurs in the in the absence of a clear theoretical framework and educational preparation may not reflect the importance of emotional competence to effective CDM.

A prospective, longitudinal study to evaluate the clinical utility of a predictive algorithm that detects risk of opioid use disorder.

PubMed

Brenton, Ashley; Lee, Chee; Lewis, Katrina; Sharma, Maneesh; Kantorovich, Svetlana; Smith, Gregory A; Meshkin, Brian

2018-01-01

The purpose of this study was to determine the clinical utility of an algorithm-based decision tool designed to assess risk associated with opioid use. Specifically, we sought to assess how physicians were using the profile in patient care and how its use affected patient outcomes. A prospective, longitudinal study was conducted to assess the utility of precision medicine testing in 5,397 patients across 100 clinics in the USA. Using a patent-protected, validated algorithm combining specific genetic risk factors with phenotypic traits, patients were categorized into low-, moderate-, and high-risk patients for opioid abuse. Physicians who ordered precision medicine testing were asked to complete patient evaluations and document their actions, decisions, and perceptions regarding the utility of the precision medicine tests. The patient outcomes associated with each treatment action were carefully documented. Physicians used the profile to guide treatment decisions for over half of the patients. Of those, guided treatment decisions for 24.5% of the patients were opioid related, including changing the opioid prescribed, starting an opioid, or titrating a patient off the opioid. Treatment guidance was strongly influenced by profile-predicted opioid use disorder (OUD) risk. Most importantly, patients whose physicians used the profile to guide opioid-related treatment decisions had improved clinical outcomes, including better pain management by medication adjustments, with an average pain decrease of 3.4 points on a scale of 1-10. Patients whose physicians used the profile to guide opioid-related treatment decisions had improved clinical outcomes, as measured by decreased pain levels resulting from better pain management with prescribed medications. The clinical utility of the profile is twofold. It provides clinically actionable recommendations that can be used to 1) prevent OUD through limiting initial opioid prescriptions and 2) reduce pain in patients at low risk of developing OUD.

A prospective, longitudinal study to evaluate the clinical utility of a predictive algorithm that detects risk of opioid use disorder

PubMed Central

Brenton, Ashley; Lee, Chee; Lewis, Katrina; Sharma, Maneesh; Kantorovich, Svetlana; Smith, Gregory A; Meshkin, Brian

2018-01-01

Purpose The purpose of this study was to determine the clinical utility of an algorithm-based decision tool designed to assess risk associated with opioid use. Specifically, we sought to assess how physicians were using the profile in patient care and how its use affected patient outcomes. Patients and methods A prospective, longitudinal study was conducted to assess the utility of precision medicine testing in 5,397 patients across 100 clinics in the USA. Using a patent-protected, validated algorithm combining specific genetic risk factors with phenotypic traits, patients were categorized into low-, moderate-, and high-risk patients for opioid abuse. Physicians who ordered precision medicine testing were asked to complete patient evaluations and document their actions, decisions, and perceptions regarding the utility of the precision medicine tests. The patient outcomes associated with each treatment action were carefully documented. Results Physicians used the profile to guide treatment decisions for over half of the patients. Of those, guided treatment decisions for 24.5% of the patients were opioid related, including changing the opioid prescribed, starting an opioid, or titrating a patient off the opioid. Treatment guidance was strongly influenced by profile-predicted opioid use disorder (OUD) risk. Most importantly, patients whose physicians used the profile to guide opioid-related treatment decisions had improved clinical outcomes, including better pain management by medication adjustments, with an average pain decrease of 3.4 points on a scale of 1–10. Conclusion Patients whose physicians used the profile to guide opioid-related treatment decisions had improved clinical outcomes, as measured by decreased pain levels resulting from better pain management with prescribed medications. The clinical utility of the profile is twofold. It provides clinically actionable recommendations that can be used to 1) prevent OUD through limiting initial opioid prescriptions and 2) reduce pain in patients at low risk of developing OUD. PMID:29379313

Community Involvement in Developing Policies for Genetic Testing: Assessing the Interests and Experiences of Individuals Affected by Genetic Conditions

PubMed Central

Gollust, Sarah E.; Apse, Kira; Fuller, Barbara P.; Miller, Paul Steven; Biesecker, Barbara B.

2005-01-01

Because the introduction of genetic testing into clinical medicine and public health creates concerns for the welfare of individuals affected with genetic conditions, those individuals should have a role in policy decisions about testing. Mechanisms for promoting participation range from membership on advisory committees to community dialogues to surveys that provide evidence for supporting practice guidelines. Surveys can assess the attitudes and the experiences of members of an affected group and thus inform discussions about that community’s concerns regarding the appropriate use of a genetic test. Results of a survey of individuals affected with inherited dwarfism show how data can be used in policy and clinical-practice contexts. Future research of affected communities’ interests should be pursued so that underrepresented voices can be heard. PMID:15623855

A pathway to personalization of integrated treatment: informatics and decision science in psychiatric rehabilitation.

PubMed

Spaulding, William; Deogun, Jitender

2011-09-01

Personalization of treatment is a current strategic goal for improving health care. Integrated treatment approaches such as psychiatric rehabilitation benefit from personalization because they involve matching diverse arrays of treatment options to individually unique profiles of need. The need for personalization is evident in the heterogeneity of people with severe mental illness and in the findings of experimental psychopathology. One pathway to personalization lies in analysis of the judgments and decision making of human experts and other participants as they respond to complex circumstances in pursuit of treatment and rehabilitation goals. Such analysis is aided by computer simulation of human decision making, which in turn informs development of computerized clinical decision support systems. This inspires a research program involving concurrent development of databases, domain ontology, and problem-solving algorithms, toward the goal of personalizing psychiatric rehabilitation through human collaboration with intelligent cyber systems. The immediate hurdle is to demonstrate that clinical decisions beyond diagnosis really do affect outcome. This can be done by supporting the hypothesis that a human treatment team with access to a reasonably comprehensive clinical database that tracks patient status and treatment response over time achieves better outcome than a treatment team without such access, in a controlled experimental trial. Provided the hypothesis can be supported, the near future will see prototype systems that can construct an integrated assessment, formulation, and rehabilitation plan from clinical assessment data and contextual information. This will lead to advanced systems that collaborate with human decision makers to personalize psychiatric rehabilitation and optimize outcome.

Applying principles from the game theory to acute stroke care: Learning from the prisoner's dilemma, stag-hunt, and other strategies.

PubMed

Saposnik, Gustavo; Johnston, S Claiborne

2016-04-01

Acute stroke care represents a challenge for decision makers. Decisions based on erroneous assessments may generate false expectations of patients and their family members, and potentially inappropriate medical advice. Game theory is the analysis of interactions between individuals to study how conflict and cooperation affect our decisions. We reviewed principles of game theory that could be applied to medical decisions under uncertainty. Medical decisions in acute stroke care are usually made under constrains: short period of time, with imperfect clinical information, limit understanding about patients and families' values and beliefs. Game theory brings some strategies to help us manage complex medical situations under uncertainty. For example, it offers a different perspective by encouraging the consideration of different alternatives through the understanding of patients' preferences and the careful evaluation of cognitive distortions when applying 'real-world' data. The stag-hunt game teaches us the importance of trust to strength cooperation for a successful patient-physician interaction that is beyond a good or poor clinical outcome. The application of game theory to stroke care may improve our understanding of complex medical situations and help clinicians make practical decisions under uncertainty. © 2016 World Stroke Organization.

Patient and disease factors affecting the choice and adherence to active surveillance.

PubMed

Dall'Era, Marc A

2015-05-01

Treatment decisions for low-risk prostate cancer are arguably some of the most challenging in oncology. Active surveillance has emerged as an important option for many men with tumors estimated to have a low metastatic potential. Multiple complex patient and physician factors affect the recommendation, selection, and adherence to active surveillance. While baseline clinical criteria are used to identify candidates for this approach, it is important to identify and understand other forces that may influence the management of prostate cancer with active surveillance. Patient perceptions and acceptance of active surveillance have improved over time. Treatment decisions for prostate cancer are strongly associated with physician recommendations, and a high-quality relationship between the patient and his healthcare system is critical to successful active surveillance. Patient understanding of prostate cancer and consistency of information received from separate physicians can affect a decision to pursue active surveillance. Psychological symptoms, most notably regarding anxiety and distress, can affect adherence to active surveillance over time. In general, anxiety for men on active surveillance is low, and lifestyle interventions and self-management strategies may be helpful for increasing quality of life and limiting abandonment of active surveillance in the absence of disease progression. Multiple factors may affect the decision for and adherence to active surveillance for prostate cancer. It is important for both physicians and patients to be aware of these issues and work towards individualized approaches and interventions as needed to increase adoption of active surveillance in the future.

Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support?

PubMed

Lehnert, Bruce E; Bree, Robert L

2010-03-01

The aim of this study was to retrospectively analyze a large group of CT and MRI examinations for appropriateness using evidence-based guidelines. The authors reviewed medical records from 459 elective outpatient CT and MR examinations from primary care physicians. Evidence-based appropriateness criteria from a radiology benefit management company were used to determine if the examination would have met criteria for approval. Submitted clinical history at the time of interpretation and clinic notes and laboratory results preceding the date of the imaging study were examined to simulate a real-time consultation with the referring provider. The radiology reports and subsequent clinic visits were analyzed for outcomes. Of the 459 examinations reviewed, 284 (62%) were CT and 175 (38%) were MRI. Three hundred forty-one (74%) were considered appropriate, and 118 (26%) were not considered appropriate. Examples of inappropriate examinations included brain CT for chronic headache, lumbar spine MR for acute back pain, knee or shoulder MRI in patients with osteoarthritis, and CT for hematuria during a urinary tract infection. Fifty-eight percent of the appropriate studies had positive results and affected subsequent management, whereas only thirteen percent [corrected] of inappropriate studies had positive results and affected management. A high percentage of examinations not meeting appropriateness criteria and subsequently yielding negative results suggests a need for tools to help primary care physicians improve the quality of their imaging decision requests. In the current environment, which stresses cost containment and comparative effectiveness, traditional radiology benefit management tools are being challenged by clinical decision support, with an emphasis on provider education coupled with electronic order entry systems.

Advance care planning for patients with amyotrophic lateral sclerosis.

PubMed

Levi, Benjamin H; Simmons, Zachary; Hanna, Courtney; Brothers, Allyson; Lehman, Erik; Farace, Elana; Bain, Megan; Stewart, Renee; Green, Michael J

2017-08-01

To determine whether an advance care planning (ACP) decision-aid could improve communication about end-of-life treatment wishes between patients with amyotrophic lateral sclerosis (ALS) and their clinicians. Forty-four patients with ALS (>21, English-speaking, without dementia) engaged in ACP using an interactive computer based decision-aid. Before participants completed the intervention, and again three months later, their clinicians reviewed three clinical vignettes, and made treatment decisions (n = 18) for patients. After patients indicated their agreement with the team's decisions, concordance was calculated. The mean concordance between patient wishes and the clinical team decisions was significantly higher post-intervention (post = 91.9%, 95% CI = 87.8, 96.1, vs. pre = 52.4%, 95% CI = 41.9, 62.9; p <0.001). Clinical team members reported greater confidence that their decisions accurately represented each patient's wishes post-intervention (mean = 6.5) compared to pre-intervention (mean = 3.3, 1 = low, 10 = high, p <0.001). Patients reported high satisfaction (mean = 26.4, SD = 3.2; 6 = low, 30 = high) and low decisional conflict (mean = 28.8, SD = 8.2; 20 = low, 80 = high) with decisions about end-of-life care, and high satisfaction with the decision-aid (mean = 52.7, SD = 5.7, 20 = low, 60 = high). Patient knowledge regarding ACP increased post-intervention (pre = 47.8% correct responses vs. post = 66.3%; p <0.001) without adversely affecting patient anxiety or self-determination. A computer based ACP decision-aid can significantly improve clinicians' understanding of ALS patients' wishes with regard to end-of-life medical care.

From Narratives to Numbers: Data Work and Patient-Generated Health Data in Consultations.

PubMed

Lindroth, Tomas; Islind, Anna Sigridur; Steineck, Gunnar; Lundin, Johan

2018-01-01

This article presents preliminary findings on how the introduction of patient-generated health data (PGHD) triggers changes during patient-nurse consultations. This article builds on a two-year case study, examining the work practice at a cancer rehabilitation clinic at a Swedish Hospital using PGHD. The study focuses on how nurses' use data, gathered by patients with a mobile phone app, during consultations. The use of PGHD introduce a change in the translation work, the work of turning rich patient descriptions and transform them into data, during the consultation for documentation and clinical decision-making. This change affects precision, questions asked and the use of visualizations as well as the patient-nurse decision making.

Cost-Effectiveness Analysis of Family Planning Services Offered by Mobile Clinics versus Static Clinics in Assiut, Egypt.

PubMed

Al-Attar, Ghada S T; Bishai, David; El-Gibaly, Omaima

2017-03-01

Cost effectiveness studies of family planning (FP) services are very valuable in providing evidence-based data for decision makers in Egypt. Cost data came from record reviews for all 15 mobile clinics and a matched set of 15 static clinics and interviews with staff members of the selected clinics at Assiut Governorate. Effectiveness measures included couple years of protection (CYPs) and FP visits. Incremental cost-effectiveness ratios (ICER) and sensitivity analyses were calculated. Mobile clinics cost more per facility, produced more CYPs but had fewer FP visits. Sensitivity analysis was done using: total costs, CYP and FP visits of mobile and static clinics and showed that variations in CYP of mobile and static clinics altered the ICER for CYP from $2 -$6. Mobile clinics with their high emphasis on IUDs offer a reasonable cost effectiveness of $4.46 per additional CYP compared to static clinics. The ability of mobile clinics to reach more vulnerable women and to offer more long acting methods might affect a policy decision between these options. Static clinics should consider whether emphasizing IUDs may make their services more cost-effective.

Understanding cognitive processes behind acceptance or refusal of phase I trials.

PubMed

Pravettoni, Gabriella; Mazzocco, Ketti; Gorini, Alessandra; Curigliano, Giuseppe

2016-04-01

Participation in phase I trials gives patients the chance to obtain control over their disease by trying an experimental therapy. The patients' vulnerability, the informed consent process aiming at understanding the purpose and potential benefits of the phase I trial, and the complexity of the studies may impact the patient's final decision. Emotionally difficult health conditions may induce patients to succumb to cognitive biases, allocating attention only on a part of the provided information. Filling the gap in patients' information process can foster the implementation of strategies to help physicians tailor clinical trials' communication providing personalized support and tailored medical information around patients' need, so avoiding cognitive biases in patients and improving informed shared decision quality. The aim of the present review article focuses on the analysis of cognitive and psychological factors that affect patients' decision to participate or not to early phase clinical trials. Copyright © 2016. Published by Elsevier Ireland Ltd.

Enhancing nurse and physician collaboration in clinical decision making through high-fidelity interdisciplinary simulation training.

PubMed

Maxson, Pamela M; Dozois, Eric J; Holubar, Stefan D; Wrobleski, Diane M; Dube, Joyce A Overman; Klipfel, Janee M; Arnold, Jacqueline J

2011-01-01

To determine whether interdisciplinary simulation team training can positively affect registered nurse and/or physician perceptions of collaboration in clinical decision making. Between March 1 and April 21, 2009, a convenience sample of volunteer nurses and physicians was recruited to undergo simulation training consisting of a team response to 3 clinical scenarios. Participants completed the Collaboration and Satisfaction About Care Decisions (CSACD) survey before training and at 2 weeks and 2 months after training. Differences in CSACD summary scores between the time points were assessed with paired t tests. Twenty-eight health care professionals (19 nurses, 9 physicians) underwent simulation training. Nurses were of similar age to physicians (27.3 vs 34.5 years; p = .82), were more likely to be women (95.0% vs 12.5%; p < .001), and were less likely to have undergone prior simulation training (0% vs 37.5%; p = .02). The pretest showed that physicians were more likely to perceive that open communication exists between nurses and physicians (p = .04) and that both medical and nursing concerns influence the decision-making process (p = .02). Pretest CSACD analysis revealed that most participants were dissatisfied with the decision-making process. The CSACD summary score showed significant improvement from baseline to 2 weeks (4.2 to 5.1; p < .002), a trend that persisted at 2 months (p < .002). Team training using high-fidelity simulation scenarios promoted collaboration between nurses and physicians and enhanced the patient care decision-making process.

Financial capacity in older adults: a growing concern for clinicians.

PubMed

Gardiner, Paul A; Byrne, Gerard J; Mitchell, Leander K; Pachana, Nancy A

2015-02-02

Older people with cognitive impairment and/or dementia may be particularly vulnerable to diminished financial decision-making capacity. Financial capacity refers to the ability to satisfactorily manage one's financial affairs in a manner consistent with personal self-interest and values. Impairment of financial capacity makes the older individual vulnerable to financial exploitation, may negatively affect their family's financial situation and places strain on relationships within the family. Clinicians are often on the front line of responding to queries regarding decision-making capacity, and clinical evaluation options are often not well understood. Assessment of financial capacity should include formal objective assessment in addition to a clinical interview and gathering contextual data. Development of a flexible, empirically supported and clinically relevant assessment approach that spans all dimensions of financial capacity yet is simple enough to be used by non-specialist clinicians is needed.

[Affective and cognitive decision making in major depression: influence of the prefrontal cortex, serotonin transporter genotype and personality traits].

PubMed

Must, Anita; Horváth, Szatmár; Janka, Zoltán

2008-05-30

Patients with major depressive disorder (MDD) show neuropsychological impairments, including deficient executive functions and suboptimal decision-making strategies, which are mediated by several brain regions. In the development of these symptoms the pathology of the prefrontal cortex (PFC), including the dorsolateral, ventromedial and orbitofrontal regions, may also play an important role. Neuropsychological assessment is a useful tool in detecting and measuring these deficiencies, showing that patients with MDD exhibit altered sensitivity to reward and punishment. However, impairment of emotional decision-making strategies in MDD is influenced by genetic variations (5-HTTLPR polymorphism) and personality traits, which seem to have a higher predictive value on decision making performance than the clinical symptoms.

[The role of research-based evidence in health system policy decision-making].

PubMed

Patiño, Daniel; Lavis, John N; Moat, Kaelan

2013-01-01

Different models may be used for explaining how research-based evidence is used in healthcare system policy-making. It is argued that models arising from a clinical setting (i.e. evidence-based policy-making model) could be useful regarding some types of healthcare system decision-making. However, such models are "silent" concerning the influence of political contextual factors on healthcare policy-making and are thus inconsistent with decision-making regarding the modification of healthcare system arrangements. Other political science-based models would seem to be more useful for understanding that research is just one factor affecting decision-making and that different types of research-based evidence can be used instrumentally, conceptual or strategically during different policy-making stages.

The ambiguity of patient-centred practices: the case of a Dutch fertility clinic

PubMed Central

Gerrits, Trudie

2014-01-01

When in-vitro fertilization (IVF) was introduced in the 1970s, doctors were criticized for not properly informing prospective users about its possible risks and limited success rates as well as for medicalizing fertility problems. Nowadays, many fertility clinics are seeking to improve their accountability to stakeholders through patient-centred practices. Based on an ethnographic study of a Dutch fertility clinic, outspoken in its aims to provide patient-centred medicine and to empower clients, this paper addresses how patient-centred medicine affects couples’ decision-making to use IVF and related reproductive technologies. The author contends that while patient-centred practices facilitate informed decision-making and support couples emotionally, they may also have unintended disciplining and normalizing effects. The information and support provided, the trust couples have in clinic staff, the ongoing visualization of conception mediated by medical technology – all can be seen as practices that strengthen lay people's ‘medical gaze’ in how they come to view their bodies, fertility problems and possible solutions. These unintended effects are labelled ‘the ambiguity of patient-centeredness’ as they (may) interfere with processes of autonomous decision-making. PMID:24827743

Application of Bayes' to the prediction of referral decisions made by specialist optometrists in relation to chronic open angle glaucoma.

PubMed

Gurney, J C; Ansari, E; Harle, D; O'Kane, N; Sagar, R V; Dunne, M C M

2018-02-09

To determine the accuracy of a Bayesian learning scheme (Bayes') applied to the prediction of clinical decisions made by specialist optometrists in relation to the referral refinement of chronic open angle glaucoma. This cross-sectional observational study involved collection of data from the worst affected or right eyes of a consecutive sample of cases (n = 1,006) referred into the West Kent Clinical Commissioning Group Community Ophthalmology Team (COT) by high street optometrists. Multilevel classification of each case was based on race, sex, age, family history of chronic open angle glaucoma, reason for referral, Goldmann Applanation Tonometry (intraocular pressure and interocular asymmetry), optic nerve head assessment (vertical size, cup disc ratio and interocular asymmetry), central corneal thickness and visual field analysis (Hodapp-Parrish-Anderson classification). Randomised stratified tenfold cross-validation was applied to determine the accuracy of Bayes' by comparing its output to the clinical decisions of three COT specialist optometrists; namely, the decision to discharge, follow-up or refer each case. Outcomes of cross-validation, expressed as means and standard deviations, showed that the accuracy of Bayes' was high (95%, 2.0%) but that it falsely discharged (3.4%, 1.6%) or referred (3.1%, 1.5%) some cases. The results indicate that Bayes' has the potential to augment the decisions of specialist optometrists.

Reward-related decision making in older adults: relationship to clinical presentation of depression.

PubMed

McGovern, Amanda R; Alexopoulos, George S; Yuen, Genevieve S; Morimoto, Sarah Shizuko; Gunning-Dixon, Faith M

2014-11-01

Impairment in reward processes has been found in individuals with depression and in the aging population. The purpose of this study was twofold: (1) to use an affective neuroscience probe to identify abnormalities in reward-related decision making in late-life depression; and (2) to examine the relationship of reward-related decision making abnormalities in depressed, older adults to the clinical expression of apathy in depression. We hypothesized that relative to older, healthy subjects, depressed, older patients would exhibit impaired decision making and that apathetic, depressed patients would show greater impairment in decision making than non-apathetic, depressed patients. We used the Iowa Gambling Task to examine reward-related decision making in 60 non-demented, older patients with non-psychotic major depression and 36 older, psychiatrically healthy participants. Apathy was quantified using the Apathy Evaluation Scale. Of those with major depression, 18 individuals reported clinically significant apathy, whereas 42 participants did not have apathy. Older adults with depression and healthy comparison participants did not differ in their performance on the Iowa Gambling Task. However, apathetic, depressed older adults adopted an advantageous strategy and selected cards from the conservative decks compared with non-apathetic, depressed older adults. Non-apathetic, depressed patients showed a failure to adopt a conservative strategy and persisted in making risky decisions throughout the task. This study indicates that apathy in older, depressed adults is associated with a conservative response style on a behavioral probe of the systems involved in reward-related decision making. This conservative response style may be the result of reduced sensitivity to rewards in apathetic individuals. Copyright © 2014 John Wiley & Sons, Ltd.

Clinic-Based Mobile Health Decision Support to Enhance Adult Epilepsy Self-Management: An Intervention Mapping Approach.

PubMed

Shegog, Ross; Begley, Charles E

2017-01-01

Epilepsy is a neurological disorder involving recurrent seizures. It affects approximately 5 million people in the U.S. To optimize their quality of life people with epilepsy are encouraged to engage in self-management (S-M) behaviors. These include managing their treatment (e.g., adhering to anti-seizure medication and clinical visit schedules), managing their seizures (e.g., responding to seizure episodes), managing their safety (e.g., monitoring and avoiding environmental seizure triggers), and managing their co-morbid conditions (e.g., anxiety, depression). The clinic-based Management Information Decision Support Epilepsy Tool (MINDSET) is a decision-support system founded on theory and empirical evidence. It is designed to increase awareness by adult patients (≥18 years) and their health-care provider regarding the patient's epilepsy S-M behaviors, facilitate communication during the clinic visit to prioritize S-M goals and strategies commensurate with the patient's needs, and increase the patient's self-efficacy to achieve those goals. The purpose of this paper is to describe the application of intervention mapping (IM) to develop, implement, and formatively evaluate the clinic-based MINDSET prototype and in developing implementation and evaluation plans. Deliverables comprised a logic model of the problem (IM Step 1); matrices of program objectives (IM Step 2); a program planning document comprising scope, sequence, theory-based methods, and practical strategies (IM Step 3); a functional MINDSET program prototype (IM Step 4); plans for implementation (IM Step 5); and evaluation (IM Step 6). IM provided a logical and systematic approach to developing and evaluating clinic-based decision support toward epilepsy S-M.

Improving Breast Cancer Surgical Treatment Decision Making: The iCanDecide Randomized Clinical Trial.

PubMed

Hawley, Sarah T; Li, Yun; An, Lawrence C; Resnicow, Kenneth; Janz, Nancy K; Sabel, Michael S; Ward, Kevin C; Fagerlin, Angela; Morrow, Monica; Jagsi, Reshma; Hofer, Timothy P; Katz, Steven J

2018-03-01

Purpose This study was conducted to determine the effect of iCanDecide, an interactive and tailored breast cancer treatment decision tool, on the rate of high-quality patient decisions-both informed and values concordant-regarding locoregional breast cancer treatment and on patient appraisal of decision making. Methods We conducted a randomized clinical trial of newly diagnosed patients with early-stage breast cancer making locoregional treatment decisions. From 22 surgical practices, 537 patients were recruited and randomly assigned online to the iCanDecide interactive and tailored Web site (intervention) or the iCanDecide static Web site (control). Participants completed a baseline survey and were mailed a follow-up survey 4 to 5 weeks after enrollment to assess the primary outcome of a high-quality decision, which consisted of two components, high knowledge and values-concordant treatment, and secondary outcomes (decision preparation, deliberation, and subjective decision quality). Results Patients in the intervention arm had higher odds of making a high-quality decision than did those in the control arm (odds ratio, 2.00; 95% CI, 1.37 to 2.92; P = .0004), which was driven primarily by differences in the rates of high knowledge between groups. The majority of patients in both arms made values-concordant treatment decisions (78.6% in the intervention arm and 81.4% in the control arm). More patients in the intervention arm had high decision preparation (estimate, 0.18; 95% CI, 0.02 to 0.34; P = .027), but there were no significant differences in the other decision appraisal outcomes. The effect of the intervention was similar for women who were leaning strongly toward a treatment option at enrollment compared with those who were not. Conclusion The tailored and interactive iCanDecide Web site, which focused on knowledge building and values clarification, positively affected high-quality decisions largely by improving knowledge compared with static online information. To be effective, future patient-facing decision tools should be integrated into the clinical workflow to improve decision making.

Swallowing in Parkinson's disease: clinical issues and management.

PubMed

Miller, Nick

2017-06-01

Changes to swallowing affect most people with Parkinson's disease (PD). Changes may not initially exercise a decisive impact, but can later pose significant threats to nutritional, hydration and respiratory health and psychosocial quality of life. This review, from a largely clinical viewpoint, outlines the nature of changes in PD and considers the issue of how many people are affected and in what ways. It outlines main approaches to assessment and management, with an emphasis on aspects relevant to PD. Dysphagia contributes to drooling in PD. The review therefore also touches on the nature and management of this condition that has its own set of health and psychosocial quality-of-life issues.

Analysis on factors affecting consumers decision on purchasing simple-type houses

NASA Astrophysics Data System (ADS)

Rumintang, A.; Sholichin, I.

2018-01-01

In line with the increase of the population and the need of comfortable houses, as affected by modernization era, the house demand is getting higher. Hence, conducting a research on consumers need and want in buying a house should be seriously attempted to succeed marketing activity. Using an analysis consumers’ behavior, the researcher will know few affecting factors related to consumers’ satisfaction in buying a house. Among other, the factors in question include: house price, house condition, facilities, location and accessability. The sample of this research was drawn from the residents of Graha Asri Housing, Taman Bulang Permai, and Sukodono Permai. Based on the analysis and discussion, some conclusions are made as follow: the factors and variables affecting the consumers’ decision on each choice of house is different and also the same variables on three sources of data include housing atmosphere, cleaning service, ease of access to shopping center, health clinics or hospitals, tourism spot, schools, and the bus station.

Quality assessment of decision-making in colorectal cancer multidisciplinary meetings.

PubMed

Seretis, Charalampos; Mankotia, Rajnish; Goonetilleke, Kolitha; Rawstorne, Edward

2014-01-01

The quality of decision-making in the colorectal multidisciplinary team (MDT) meetings can significantly affect the quality of care delivered to patients with colorectal cancer. We performed a prospective study to assess the quality of the MDT meetings in a specialized colorectal unit using an externally observational validated tool. An externally validated observational tool, the Colorectal Multidisciplinary Team Metric for Observation of Decision-Making (cMDT-MODe), was used to assess the quality of clinical decision-making in 64 cases. Although case history information presented by the responsible surgeon was rated high (4.4/5), the quality of radiological and histopathological information regarding each patient's case which was available at the time was less adequate, scoring 3.9/5 and 3.8/5, respectively. Moreover, the precise knowledge of patients' personal views and circumstances was a field requiring further improvement. In a general overview however, the quality and extent of the available information enabled the MDT to provide a clear recommendation regarding the patients' treatment plans in 87.5% of the cases. The cMDT-MODe tool can be used to prospectively audit the quality of clinical decision-making in the colorectal MDT meetings and highlight the fields of potential improvement.

Justifying Clinical Nudges.

PubMed

Gorin, Moti; Joffe, Steven; Dickert, Neal; Halpern, Scott

2017-03-01

The shift away from paternalistic decision-making and toward patient-centered, shared decision-making has stemmed from the recognition that in order to practice medicine ethically, health care professionals must take seriously the values and preferences of their patients. At the same time, there is growing recognition that minor and seemingly irrelevant features of how choices are presented can substantially influence the decisions people make. Behavioral economists have identified striking ways in which trivial differences in the presentation of options can powerfully and predictably affect people's choices. Choice-affecting features of the decision environment that do not restrict the range of choices or significantly alter the incentives have come to be known as "nudges." Although some have criticized conscious efforts to influence choice, we believe that clinical nudges may often be morally justified. The most straightforward justification for nudge interventions is that they help people bypass their cognitive limitations-for example, the tendency to choose the first option presented even when that option is not the best for them-thereby allowing people to make choices that best align with their rational preferences or deeply held values. However, we argue that this justification is problematic. We argue that, if physicians wish to use nudges to shape their patients' choices, the justification for doing so must appeal to an ethical and professional standard, not to patients' preferences. We demonstrate how a standard with which clinicians and bioethicists already are quite familiar-the best-interest standard-offers a robust justification for the use of nudges. © 2017 The Hastings Center.

Acceptance of clinical decision support surveillance technology in the clinical pharmacy.

PubMed

English, Dan; Ankem, Kalyani; English, Kathleen

2017-03-01

There are clinical and economic benefits to incorporating clinical decision support systems (CDSSs) in patient care interventions in the clinical pharmacy setting. However, user dissatisfaction and resistance to HIT can prevent optimal use of such systems, particularly when users employ system workarounds and overrides. The present study applied a modified version of the unified theory of acceptance and use of technology (UTAUT) to evaluate the disposition and satisfaction with CDSS among clinical pharmacists who perform surveillance to identify potential medication therapy interventions on patients in the hospital setting. A survey of clinical pharmacists (N = 48) was conducted. Partial least squares (PLS) regression was used to analyze the influence of the UTAUT-related variables on behavioral intention and satisfaction with CDSS among clinical pharmacists. While behavioral intention did not predict actual use of HIT, facilitating conditions had a direct effect on pharmacists' use of CDSS. Likewise, satisfaction with CDSS was found to have a direct effect on use, with more satisfied users being less inclined to employ workarounds or overrides of the system. Based on the findings, organizational structures that facilitate CDSS use and user satisfaction affect the extent to which pharmacy and health care management maximize use in the clinical pharmacy setting.

Clearing the smoke around medical marijuana.

PubMed

Ware, M A

2011-12-01

The hazy world of "medical marijuana" continues to cry out for clear data on which to base medical decision making and rational policy design. In this issue of Clinical Pharmacology & Therapeutics, Abrams and colleagues report that vaporized cannabis does not meaningfully affect opioid plasma levels and may even augment the efficacy of oxycodone and morphine in patients with chronic non-cancer pain. This Commentary considers the implications of this work for clinical practice and further research initiatives.

Influence of patients' socioeconomic status on clinical management decisions: a qualitative study.

PubMed

Bernheim, Susannah M; Ross, Joseph S; Krumholz, Harlan M; Bradley, Elizabeth H

2008-01-01

Little is known about how patients' socioeconomic status (SES) influences physicians' clinical management decisions, although this information may have important implications for understanding inequities in health care quality. We investigated physician perspectives on how patients' SES influences care. The study consisted of in-depth semistructured interviews with primary care physicians in Connecticut. Investigators coded interviews line by line and refined the coding structure and interview guide based on successive interviews. Recurrent themes emerged through iterative analysis of codes and tagged quotations. We interviewed 18 physicians from varied practice settings, 6 female, 9 from minority racial backgrounds, and 3 of Hispanic ethnicity. Four themes emerged from our interviews: (1) physicians held conflicting views about the effect of patient SES on clinical management, (2) physicians believed that changes in clinical management based on the patient's SES were made in the patient's interest, (3) physicians varied in the degree to which they thought changes in clinical management influenced patient outcomes, and (4) physicians faced personal and financial strains when caring for patients of low SES. Physicians indicated that patient SES did affect their clinical management decisions. As a result, physicians commonly undertook changes to their management plan in an effort to enhance patient outcomes, but they experienced numerous strains when trying to balance what they believed was feasible for the patient with what they perceived as established standards of care.

Questioning context: a set of interdisciplinary questions for investigating contextual factors affecting health decision making

PubMed Central

Charise, Andrea; Witteman, Holly; Whyte, Sarah; Sutton, Erica J.; Bender, Jacqueline L.; Massimi, Michael; Stephens, Lindsay; Evans, Joshua; Logie, Carmen; Mirza, Raza M.; Elf, Marie

2011-01-01

Abstract Objective  To combine insights from multiple disciplines into a set of questions that can be used to investigate contextual factors affecting health decision making. Background  Decision‐making processes and outcomes may be shaped by a range of non‐medical or ‘contextual’ factors particular to an individual including social, economic, political, geographical and institutional conditions. Research concerning contextual factors occurs across many disciplines and theoretical domains, but few conceptual tools have attempted to integrate and translate this wide‐ranging research for health decision‐making purposes. Methods  To formulate this tool we employed an iterative, collaborative process of scenario development and question generation. Five hypothetical health decision‐making scenarios (preventative, screening, curative, supportive and palliative) were developed and used to generate a set of exploratory questions that aim to highlight potential contextual factors across a range of health decisions. Findings  We present an exploratory tool consisting of questions organized into four thematic domains – Bodies, Technologies, Place and Work (BTPW) – articulating wide‐ranging contextual factors relevant to health decision making. The BTPW tool encompasses health‐related scholarship and research from a range of disciplines pertinent to health decision making, and identifies concrete points of intersection between its four thematic domains. Examples of the practical application of the questions are also provided. Conclusions  These exploratory questions provide an interdisciplinary toolkit for identifying the complex contextual factors affecting decision making. The set of questions comprised by the BTPW tool may be applied wholly or partially in the context of clinical practice, policy development and health‐related research. PMID:21029277

Factors affecting Korean nursing student empowerment in clinical practice.

PubMed

Ahn, Yang-Heui; Choi, Jihea

2015-12-01

Understanding the phenomenon of nursing student empowerment in clinical practice is important. Investigating the cognition of empowerment and identifying predictors are necessary to enhance nursing student empowerment in clinical practice. To identify empowerment predictors for Korean nursing students in clinical practice based on studies by Bradbury-Jones et al. and Spreitzer. A cross-sectional design was used for this study. This study was performed in three nursing colleges in Korea, all of which had similar baccalaureate nursing curricula. Three hundred seven junior or senior nursing students completed a survey designed to measure factors that were hypothesized to influence nursing student empowerment in clinical practice. Data were collected from November to December 2011. Study variables included self-esteem, clinical decision making, being valued as a learner, satisfaction regarding practice with a team member, perception on professor/instructor/clinical preceptor attitude, and total number of clinical practice fields. Data were analyzed using stepwise multiple regression analyses. All of the hypothesized study variables were significantly correlated to nursing student empowerment. Stepwise multiple regression analysis revealed that clinical decision making in nursing (t=7.59, p<0.001), being valued as a learner (t=6.24, p<0.001), self-esteem (t=3.62, p<0.001), and total number of clinical practice fields (t=2.06, p=0.040). The explanatory power of these predictors was 35% (F=40.71, p<0.001). Enhancing nursing student empowerment in clinical practice will be possible by using educational strategies to improve nursing student clinical decision making. Simultaneously, attitudes of nurse educators are also important to ensure that nursing students are treated as valued learners and to increase student self-esteem in clinical practice. Finally, diverse clinical practice field environments should be considered to enhance experience. Copyright © 2015 Elsevier Ltd. All rights reserved.

Perceived Barriers and Facilitators of Using a Web-Based Interactive Decision Aid for Colorectal Cancer Screening in Community Practice Settings: Findings From Focus Groups With Primary Care Clinicians and Medical Office Staff

PubMed Central

2013-01-01

Background Information is lacking about the capacity of those working in community practice settings to utilize health information technology for colorectal cancer screening. Objective To address this gap we asked those working in community practice settings to share their perspectives about how the implementation of a Web-based patient-led decision aid might affect patient-clinician conversations about colorectal cancer screening and the day-to-day clinical workflow. Methods Five focus groups in five community practice settings were conducted with 8 physicians, 1 physician assistant, and 18 clinic staff. Focus groups were organized using a semistructured discussion guide designed to identify factors that mediate and impede the use of a Web-based decision aid intended to clarify patient preferences for colorectal cancer screening and to trigger shared decision making during the clinical encounter. Results All physicians, the physician assistant, and 8 of the 18 clinic staff were active participants in the focus groups. Clinician and staff participants from each setting reported a belief that the Web-based patient-led decision aid could be an informative and educational tool; in all but one setting participants reported a readiness to recommend the tool to patients. The exception related to clinicians from one clinic who described a preference for patients having fewer screening choices, noting that a colonoscopy was the preferred screening modality for patients in their clinic. Perceived barriers to utilizing the Web-based decision aid included patients’ lack of Internet access or low computer literacy, and potential impediments to the clinics’ daily workflow. Expanding patients’ use of an online decision aid that is both easy to access and understand and that is utilized by patients outside of the office visit was described as a potentially efficient means for soliciting patients’ screening preferences. Participants described that a system to link the online decision aid to a computerized reminder system could promote a better understanding of patients’ screening preferences, though some expressed concern that such a system could be difficult to keep up and running. Conclusions Community practice clinicians and staff perceived the Web-based decision aid technology as promising but raised questions as to how the technology and resultant information would be integrated into their daily practice workflow. Additional research investigating how to best implement online decision aids should be conducted prior to the widespread adoption of such technology so as to maximize the benefits of the technology while minimizing workflow disruptions. PMID:24351420

Costs can influence family planning decisions.

PubMed

Barnett, B

1998-01-01

This article discusses research in Cebu, Philippines, that examines the relationship between costs and income and family planning (FP) decisions. Clients weigh the costs and benefits of obtaining FP services. Costs may include the time to purchase supplies, travel to clinics, child care, and lost work time. Women should consider the costs of having more children. Family Health International's Women's Studies Project explored couple's FP decision-making. In Cebu, women play a decisive role in household expenditure decisions. 64% of women made sole decisions about children's shoes and clothing. 43% made decisions about taking children to the doctor. Women consulted husbands for larger expenditures, such as land purchases, hiring household help, and travel outside Cebu. If conflicts arose, 82% reported a mutual final decision, while 12% accepted the husband's judgment. Only 12% of women made sole decisions about FP. About 20% of the sample of women discussed FP with adult females. 25% of the women who consulted their husbands about FP made the final decision when there was conflict. Only 7% reported that the husband's decision was final. A recent follow-up study to a 1983 study finds that price is only one among many factors that affect contraceptive decision-making. Rural women in Cebu reported that the time needed to obtain contraceptives was an important factor in determining their use. A study of 64 women in rural southern India finds that contraceptive prevalence was influenced by women's autonomy rather than income. Women's and children's ages, family size, and birth order affected women's autonomy and access to money. In another related study, Pakistani women had lower fertility rates when wives' unearned income was high. An increase by 25% in unearned income among rural women decreased fertility by one child.

Future perspectives toward the early definition of a multivariate decision-support scheme employed in clinical decision making for senior citizens.

PubMed

Frantzidis, Christos A; Gilou, Sotiria; Billis, Antonis; Karagianni, Maria; Bratsas, Charalampos D; Bamidis, Panagiotis

2016-03-01

Recent neuroscientific studies focused on the identification of pathological neurophysiological patterns (emotions, geriatric depression, memory impairment and sleep disturbances) through computerised clinical decision-support systems. Almost all these research attempts employed either resting-state condition (e.g. eyes-closed) or event-related potentials extracted during a cognitive task known to be affected by the disease under consideration. This Letter reviews existing data mining techniques and aims to enhance their robustness by proposing a holistic decision framework dealing with comorbidities and early symptoms' identification, while it could be applied in realistic occasions. Multivariate features are elicited and fused in order to be compared with average activities characteristic of each neuropathology group. A proposed model of the specific cognitive function which may be based on previous findings (a priori information) and/or validated by current experimental data should be then formed. So, the proposed scheme facilitates the early identification and prevention of neurodegenerative phenomena. Neurophysiological semantic annotation is hypothesised to enhance the importance of the proposed framework in facilitating the personalised healthcare of the information society and medical informatics research community.

Using the Situated Clinical Decision-Making framework to guide analysis of nurses' clinical decision-making.

PubMed

Gillespie, Mary

2010-11-01

Nurses' clinical decision-making is a complex process that holds potential to influence the quality of care provided and patient outcomes. The evolution of nurses' decision-making that occurs with experience has been well documented. In addition, literature includes numerous strategies and approaches purported to support development of nurses' clinical decision-making. There has been, however, significantly less attention given to the process of assessing nurses' clinical decision-making and novice clinical educators are often challenged with knowing how to best support nurses and nursing students in developing their clinical decision-making capacity. The Situated Clinical Decision-Making framework is presented for use by clinical educators: it provides a structured approach to analyzing nursing students' and novice nurses' decision-making in clinical nursing practice, assists educators in identifying specific issues within nurses' clinical decision-making, and guides selection of relevant strategies to support development of clinical decision-making. A series of questions is offered as a guide for clinical educators when assessing nurses' clinical decision-making. The discussion presents key considerations related to analysis of various decision-making components, including common sources of challenge and errors that may occur within nurses' clinical decision-making. An exemplar illustrates use of the framework and guiding questions. Implications of this approach for selection of strategies that support development of clinical decision-making are highlighted. Copyright © 2010 Elsevier Ltd. All rights reserved.

Use of Decision Aids with Minority Patients: a Systematic Review.

PubMed

Nathan, Aviva G; Marshall, Imani M; Cooper, Jennifer M; Huang, Elbert S

2016-06-01

One potential approach to reducing health disparities among minorities is through the promotion of shared decision making (SDM). The most commonly studied SDM intervention is the decision aid (DA). While DAs have been extensively studied, we know relatively little about their use in minority populations. We conducted a systematic review to characterize the application and effectiveness of DAs in racial, ethnic, sexual, and gender minorities. We searched PubMed for randomized controlled trials (RCTs) evaluating DAs between 2004 and 2013. We included trials that enrolled adults (> 18 years of age) with > 50 % representation by minority patients. Four reviewers independently assessed 597 initially identified articles, and those with inconclusive results were discussed to consensus. We abstracted decision quality, patient-doctor communication, and clinical treatment decision outcomes. Results were considered significantly modified by the DA if the study reported p < 0.05. We reviewed 18 RCTs of DA interventions in minority populations. The majority of interventions (78 %) addressed cancer screening. The most common mode of delivery for the DAs was personal counseling (46 %), followed by multi-media (29 %), and print materials (25 %). Most of the trials studied racial (78 %) or ethnic (17 %) minorities with only one trial focused on sexual minorities and none on gender minorities. Ten studies tailored their interventions for their minority populations. Comparing intervention vs. control, decision quality outcomes improved in six out of eight studies and patient-doctor communication improved in six out of seven studies. Of the 15 studies that reported on clinical decisions, eight demonstrated significant changes in decisions with DAs. DAs have been effective in improving patient-doctor communication and decision quality outcomes in minority populations and could help address health disparities. However, the existing literature is almost non-existent for sexual and gender minorities and has not included the full breadth of clinical decisions that affect minority populations.

Measuring outcomes in children's rehabilitation: a decision protocol.

PubMed

Law, M; King, G; Russell, D; MacKinnon, E; Hurley, P; Murphy, C

1999-06-01

To develop and test the feasibility and clinical utility of a computerized self-directed software program designed to enable service providers in children's rehabilitation to make decisions about the most appropriate outcome measures to use in client and program evaluation. A before-and-after design was used to test the feasibility and initial impact of the decision-making outcome software in improving knowledge and use of clinical outcome measures. A children's rehabilitation center in a city of 50,000. All service providers in the children's rehabilitation center. Disciplines represented included early childhood education, occupational therapy, physical therapy, speech and language pathology, audiology, social work, and psychology. Using a conceptual framework based on the International Classification of Impairment, Disability, and Handicap (ICIDH), an outcome measurement decision-making protocol was developed. The decision-making protocol was computerized in an educational software program with an attached database of critically appraised measures. Participants learned about outcome measures through the program and selected outcome measures that met their specifications. The computer software was tested for feasibility in the children's rehabilitation center for 6 months. Knowledge and use of clinical outcome measures were determined before and after the feasibility testing using a survey of all service providers currently at the centre and audits of 30 randomly selected rehabilitation records (at pretest, posttest, and follow-up). Service providers indicated that the outcomes software was easy to follow and believed that the use of the ICIDH framework helped them in making decisions about selecting outcome measures. Results of the survey indicated that there were significant changes in the service providers' level of comfort with selecting measures and knowing what measures were available. Use of outcome measures as identified through the audit did not change. The "All About Outcomes" software is clinically useful. Further research should evaluate whether using the software affects the use of outcome measures in clinical practice.

End-of-life decisions in Malaysia: Adequacies of ethical codes and developing legal standards.

PubMed

Kassim, Puteri Nemie Jahn; Alias, Fadhlina

2015-06-01

End-of-life decision-making is an area of medical practice in which ethical dilemmas and legal interventions have become increasingly prevalent. Decisions are no longer confined to clinical assessments; rather, they involve wider considerations such as a patient's religious and cultural beliefs, financial constraints, and the wishes and needs of family members. These decisions affect everyone concerned, including members of the community as a whole. Therefore it is imperative that clear ethical codes and legal standards are developed to help guide the medical profession on the best possible course of action for patients. This article considers the relevant ethical, codes and legal provisions in Malaysia governing certain aspects of end-of-life decision-making. It highlights the lack of judicial decisions in this area as well as the limitations with the Malaysian regulatory system. The article recommends the development of comprehensive ethical codes and legal standards to guide end-of-life decision-making in Malaysia.

A patient decision aid regarding antithrombotic therapy for stroke prevention in atrial fibrillation: a randomized controlled trial.

PubMed

Man-Son-Hing, M; Laupacis, A; O'Connor, A M; Biggs, J; Drake, E; Yetisir, E; Hart, R G

1999-08-25

Decision aids are tools designed to help patients participate in the clinical decision-making process. To determine whether use of an audiobooklet (AB) decision aid explaining the results of a clinical trial affected the decision-making process of study participants. Randomized controlled trial conducted from May 1997 to April 1998. Fourteen centers that participated in the Stroke Prevention in Atrial Fibrillation (SPAF) III trial. A total of 287 patients from the SPAF III aspirin cohort study, in which patients with atrial fibrillation and a relatively low risk of stroke received 325 mg/d of aspirin and were followed up for a mean of 2 years. At the end of SPAF III, participants were randomized to be informed of the study results with usual care plus use of an AB (AB group) vs usual care alone (control group). The AB included pertinent information to help patients decide whether to continue taking aspirin or switch to warfarin. Patients' ability to make choices regarding antithrombotic therapy, and 6-month adherence to these decisions. Their knowledge, expectations, decisional conflict (the amount of uncertainty about the course of action to take), and satisfaction with the decision-making process were also measured. More patients in the AB group made a choice about antithrombotic therapy than in the control group (99% vs 94%; P = .02). Patients in the AB group were more knowledgeable and had more realistic expectations about the risk of stroke and hemorrhage (in the AB group, 53%-80% correctly estimated different risks; in the control group, 16%-28% gave correct estimates). Decisional conflict and satisfaction were similar for the 2 groups. After 6 months, a similar percentage of patients were still taking their initial choice of antithrombotic therapy (95% vs 93%; P = .44). For patients with atrial fibrillation who had participated in a major clinical trial, the use of an AB decision aid improved their understanding of the benefits and risks associated with different treatment options and helped them make definitive choices about which therapy to take. Further studies are necessary to evaluate the acceptability and impact of decision aids in other clinical settings.

A Primer on Receiver Operating Characteristic Analysis and Diagnostic Efficiency Statistics for Pediatric Psychology: We Are Ready to ROC

PubMed Central

2014-01-01

Objective To offer a practical demonstration of receiver operating characteristic (ROC) analyses, diagnostic efficiency statistics, and their application to clinical decision making using a popular parent checklist to assess for potential mood disorder. Method Secondary analyses of data from 589 families seeking outpatient mental health services, completing the Child Behavior Checklist and semi-structured diagnostic interviews. Results Internalizing Problems raw scores discriminated mood disorders significantly better than did age- and gender-normed T scores, or an Affective Problems score. Internalizing scores <8 had a diagnostic likelihood ratio <0.3, and scores >30 had a diagnostic likelihood ratio of 7.4. Conclusions This study illustrates a series of steps in defining a clinical problem, operationalizing it, selecting a valid study design, and using ROC analyses to generate statistics that support clinical decisions. The ROC framework offers important advantages for clinical interpretation. Appendices include sample scripts using SPSS and R to check assumptions and conduct ROC analyses. PMID:23965298

A primer on receiver operating characteristic analysis and diagnostic efficiency statistics for pediatric psychology: we are ready to ROC.

PubMed

Youngstrom, Eric A

2014-03-01

To offer a practical demonstration of receiver operating characteristic (ROC) analyses, diagnostic efficiency statistics, and their application to clinical decision making using a popular parent checklist to assess for potential mood disorder. Secondary analyses of data from 589 families seeking outpatient mental health services, completing the Child Behavior Checklist and semi-structured diagnostic interviews. Internalizing Problems raw scores discriminated mood disorders significantly better than did age- and gender-normed T scores, or an Affective Problems score. Internalizing scores <8 had a diagnostic likelihood ratio <0.3, and scores >30 had a diagnostic likelihood ratio of 7.4. This study illustrates a series of steps in defining a clinical problem, operationalizing it, selecting a valid study design, and using ROC analyses to generate statistics that support clinical decisions. The ROC framework offers important advantages for clinical interpretation. Appendices include sample scripts using SPSS and R to check assumptions and conduct ROC analyses.

Determination of the anaerobic threshold in the pre-operative assessment clinic: inter-observer measurement error.

PubMed

Sinclair, R C F; Danjoux, G R; Goodridge, V; Batterham, A M

2009-11-01

The variability between observers in the interpretation of cardiopulmonary exercise tests may impact upon clinical decision making and affect the risk stratification and peri-operative management of a patient. The purpose of this study was to quantify the inter-reader variability in the determination of the anaerobic threshold (V-slope method). A series of 21 cardiopulmonary exercise tests from patients attending a surgical pre-operative assessment clinic were read independently by nine experienced clinicians regularly involved in clinical decision making. The grand mean for the anaerobic threshold was 10.5 ml O(2).kg body mass(-1).min(-1). The technical error of measurement was 8.1% (circa 0.9 ml.kg(-1).min(-1); 90% confidence interval, 7.4-8.9%). The mean absolute difference between readers was 4.5% with a typical random error of 6.5% (6.0-7.2%). We conclude that the inter-observer variability for experienced clinicians determining the anaerobic threshold from cardiopulmonary exercise tests is acceptable.

Unintended adverse consequences of a clinical decision support system: two cases.

PubMed

Stone, Erin G

2018-05-01

Many institutions have implemented clinical decision support systems (CDSSs). While CDSS research papers have focused on benefits of these systems, there is a smaller body of literature showing that CDSSs may also produce unintended adverse consequences (UACs). Detailed here are 2 cases of UACs resulting from a CDSS. Both of these cases were related to external systems that fed data into the CDSS. In the first case, lack of knowledge of data categorization in an external pharmacy system produced a UAC; in the second case, the change of a clinical laboratory instrument produced the UAC. CDSSs rely on data from many external systems. These systems are dynamic and may have changes in hardware, software, vendors, or processes. Such changes can affect the accuracy of CDSSs. These cases point to the need for the CDSS team to be familiar with these external systems. This team (manager and alert builders) should include members in specific clinical specialties with deep knowledge of these external systems.

Family factors affect clinician attitudes in pediatric end-of-life decision making: a randomized vignette study.

PubMed

Ruppe, Michael D; Feudtner, Chris; Hexem, Kari R; Morrison, Wynne E

2013-05-01

Conflicts between families and clinicians in pediatric end-of-life (EOL) care cause distress for providers, dissatisfaction for patients' families, and potential suffering for terminally ill children. We hypothesized that family factors might influence clinician decision making in these circumstances. We presented vignettes concerning difficult EOL decision making, randomized for religious objection to therapy withdrawal and perceived level of family involvement, to clinicians working in three Children's Hospital intensive care units. Additionally, attitudes about EOL care were assessed. Three hundred sixty-four respondents completed the questionnaire, for an overall response rate of 54%. Respondents receiving the "involved family" vignette were more likely to agree to continue medical care indefinitely (P<0.0005). Respondents were marginally more likely to pursue a court-appointed guardian for those patients whose families had nonreligious objections to withdrawal (P=0.05). Respondents who thought that a fear of being sued affected decisions were less likely to pursue unilateral withdrawal (odds ratio 0.8, 95% CI=0.6-0.9). Those who felt personal distress as a result of difficult EOL decision making, thought they often provided "futile" care, or those who felt EOL care was effectively addressed at the institution were less likely to want to defer to the parents' wishes (range of odds ratios 0.7-1). In this randomized vignette study, we have shown that family factors, particularly how involved a family seems to be in a child's life, affect what clinicians think is ethically appropriate in challenging EOL cases. Knowledge of how a family's degree of involvement may affect clinicians should be helpful to the clinical ethics consultants and offer some degree of insight to the clinicians themselves. Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Operating room managerial decision-making on the day of surgery with and without computer recommendations and status displays.

PubMed

Dexter, Franklin; Willemsen-Dunlap, Ann; Lee, John D

2007-08-01

There are three basic types of decision aids to facilitate operating room (OR) management decision-making on the day of surgery. Decision makers can rely on passive status displays (e.g., big screens or whiteboards), active status displays (e.g., text pager notification), and/or command displays (e.g., text recommendations about what to do). Anesthesiologists, OR nurses, and housekeepers were given nine simulated scenarios (vignettes) involving multiple ORs to study their decision-making. Participants were randomized to one of four groups, all with an updated paper OR schedule: with/without command display and with/without passive status display. Participants making decisions without command displays performed no better than random chance in terms of increasing the predictability of work hours, reducing over-utilized OR time, and increasing OR efficiency. Status displays had no effect on these end-points, whereas command displays improved the quality of decisions. In the scenarios for which the command displays provided recommendations that adversely affected safety, participants appropriately ignored advice. Anesthesia providers and nursing staff made decisions that increased clinical work per unit time in each OR, even when doing so resulted in an increase in over-utilized OR time, higher staffing costs, unpredictable work hours, and/or mandatory overtime. Organizational culture and socialization during clinical training may be a cause. Command displays showed promise in mitigating this tendency. Additional investigations are in our companion paper.

Enhancing Nurse and Physician Collaboration in Clinical Decision Making Through High-fidelity Interdisciplinary Simulation Training

PubMed Central

Maxson, Pamela M.; Dozois, Eric J.; Holubar, Stefan D.; Wrobleski, Diane M.; Dube, Joyce A. Overman; Klipfel, Janee M.; Arnold, Jacqueline J.

2011-01-01

OBJECTIVE: To determine whether interdisciplinary simulation team training can positively affect registered nurse and/or physician perceptions of collaboration in clinical decision making. PARTICIPANTS AND METHODS: Between March 1 and April 21, 2009, a convenience sample of volunteer nurses and physicians was recruited to undergo simulation training consisting of a team response to 3 clinical scenarios. Participants completed the Collaboration and Satisfaction About Care Decisions (CSACD) survey before training and at 2 weeks and 2 months after training. Differences in CSACD summary scores between the time points were assessed with paired t tests. RESULTS: Twenty-eight health care professionals (19 nurses, 9 physicians) underwent simulation training. Nurses were of similar age to physicians (27.3 vs 34.5 years; p=.82), were more likely to be women (95.0% vs 12.5%; p<.001), and were less likely to have undergone prior simulation training (0% vs 37.5%; p=.02). The pretest showed that physicians were more likely to perceive that open communication exists between nurses and physicians (p=.04) and that both medical and nursing concerns influence the decision-making process (p=.02). Pretest CSACD analysis revealed that most participants were dissatisfied with the decision-making process. The CSACD summary score showed significant improvement from baseline to 2 weeks (4.2 to 5.1; p<.002), a trend that persisted at 2 months (p<.002). CONCLUSION: Team training using high-fidelity simulation scenarios promoted collaboration between nurses and physicians and enhanced the patient care decision-making process. PMID:21193653

Prostate cancer decision-making, health services, and the family physician workforce.

PubMed

Bowman, Marjorie A; Neale, Anne Victoria

2012-01-01

Does untreated cancer equal death? Does having a registered nurse versus a licensed practical nurse versus a medical assistant affect diabetes quality outcomes? Do physicians caring for stressed patients experience vicarious traumatic stress? Oregon presents an operationalized definition of a patient-centered medical home for their state. Lots of important clinical topics in family medicine--adult attention deficit disorder office questionnaire; Bell palsy; cancer screening and treatment decisions; lubrication during Papanicolaou testing; changes in maternity care training by residencies; changing prescribing patterns for thiazide diuretics; and night sweats remain a mystery.

Impact of Childbearing Decisions on Family Size of Korean Women with Systemic Lupus Erythematosus

PubMed Central

2016-01-01

Systemic lupus erythematosus (SLE) predominantly affects women in their reproductive years and has a significant impact on childbearing. We investigated the influence of personal decision on family size among Korean women with SLE and factors that affect the decisions. A case-control study comparing childbearing history and decisions of 112 SLE patients and 135 controls was performed. Women with SLE participating in the Network for Lupus Clinical Research in South Korea and matching controls between ages of 18-45, who are/were married or living with a partner were included. Data regarding socio-demographics, reproductive history, and childbearing decisions were collected through a survey using a standardized questionnaire and medical record review. More women with SLE reported at least one pregnancy (85.7% vs. 71.9%, P = 0.009) or at least one live birth (85.7% vs. 71.9%, P = 0.003) compared with controls. Mean number of pregnancies was significantly higher (2.4 ± 1.6 vs. 1.4 ± 1.3, P < 0.001), and mean number of live births was significantly lower in women with SLE (1.2 ± 0.8 vs. 1.6 ± 0.8, P < 0.001). Significantly more women with SLE made the decision not to have children compared with controls (54.5% vs. 40.7%, P = 0.031), and health-related concerns were the major cause of the decision. Other socio-demographic factors did not influence the decision to limit childbearing in SLE women. The disease-related concerns had significant impact on family size and childbearing decisions among Korean women with SLE. PMID:27134494

Impact of Childbearing Decisions on Family Size of Korean Women with Systemic Lupus Erythematosus.

PubMed

Kim, In Je; Kim, Hyoun-Ah; Suh, Chang-Hee; Park, Yong-Wook; Lee, Hye-Soon; Bang, So-Young; Bae, Sang-Cheol; Kang, Young Mo; Lee, Won Kyung; Park, Hyesook; Lee, Jisoo

2016-05-01

Systemic lupus erythematosus (SLE) predominantly affects women in their reproductive years and has a significant impact on childbearing. We investigated the influence of personal decision on family size among Korean women with SLE and factors that affect the decisions. A case-control study comparing childbearing history and decisions of 112 SLE patients and 135 controls was performed. Women with SLE participating in the Network for Lupus Clinical Research in South Korea and matching controls between ages of 18-45, who are/were married or living with a partner were included. Data regarding socio-demographics, reproductive history, and childbearing decisions were collected through a survey using a standardized questionnaire and medical record review. More women with SLE reported at least one pregnancy (85.7% vs. 71.9%, P = 0.009) or at least one live birth (85.7% vs. 71.9%, P = 0.003) compared with controls. Mean number of pregnancies was significantly higher (2.4 ± 1.6 vs. 1.4 ± 1.3, P < 0.001), and mean number of live births was significantly lower in women with SLE (1.2 ± 0.8 vs. 1.6 ± 0.8, P < 0.001). Significantly more women with SLE made the decision not to have children compared with controls (54.5% vs. 40.7%, P = 0.031), and health-related concerns were the major cause of the decision. Other socio-demographic factors did not influence the decision to limit childbearing in SLE women. The disease-related concerns had significant impact on family size and childbearing decisions among Korean women with SLE.

Clinician perspectives on decision-making capacity after acquired brain injury.

PubMed

Mukherjee, Debjani; McDonough, Carol

2006-01-01

Acquired brain injury frequently alters an individual's ability to make health care decisions based on a clear understanding of the situation and options. This exploratory study investigated the ways health care providers address issues of decisionmaking capacity (DMC) on a daily, functional basis. 33 clinicians providing rehabilitation services to persons with acquired brain injury participated in 1 of 5 semi-structured focus groups. All 33 participants, representing 8 different occupations, agreed that DMC determinations affected their practice every day. Participants underscored a multidimensional rather than a unitary definition of DMC, with an emphasis on fluctuating capacities due to the injury. Important concerns were for the safety of the person with brain injury, the health care provider, and community members. Other themes included rehabilitation team involvement, family context, and professional socialization. Clinical determinations of DMC are context dependent and are affected by the abilities of the individual and the substance and consequences of the decision being made and include the concepts of regaining trust and reclaiming capacity.

Fear and decision-making in narcissistic personality disorder-a link between psychoanalysis and neuroscience.

PubMed

Ronningstam, Elsa; Baskin-Sommers, Arielle R

2013-06-01

Linking psychoanalytic studies with neuroscience has proven increasingly productive for identifying and understanding personality functioning. This article focuses on pathological narcissism and narcissistic personality disorder (NPD), with the aim of exploring two clinically relevant aspects of narcissistic functioning also recognized in psychoanalysis: fear and decision-making. Evidence from neuroscientific studies of related conditions, such as psychopathy, suggests links between affective and cognitive functioning that can influence the sense of self-agency and narcissistic self-regulation. Attention can play a crucial role in moderating fear and self-regulatory deficits, and the interaction between experience and emotion can be central for decision-making. In this review we will explore fear as a motivating factor in narcissistic personality functioning, and the impact fear may have on decision-making in people with pathological narcissism and NPD. Understanding the processes and neurological underpinnings of fear and decision-making can potentially influence both the diagnosis and treatment of NPD.

Evidence-based medicine, the research-practice gap, and biases in medical and surgical decision making in dermatology.

PubMed

Eaglstein, William H

2010-10-01

The objectives of this article are to promote a better understanding of a group of biases that influence therapeutic decision making by physicians/dermatologists and to raise the awareness that these biases contribute to a research-practice gap that has an impact on physicians and treatment solutions. The literature included a wide range of peer-reviewed articles dealing with biases in decision making, evidence-based medicine, randomized controlled clinical trials, and the research-practice gap. Bias against new therapies, bias in favor of indirect harm or omission, and bias against change when multiple new choices are offered may unconsciously affect therapeutic decision making. Although there is no comprehensive understanding or theory as to how choices are made by physicians, recognition of certain cognition patterns and their associated biases will help narrow the research-practice gap and optimize decision making regarding therapeutic choices.

Putting the value into biosimilar decision making: the judgment value criteria.

PubMed

Mendes de Abreu, Mirhelen; Strand, Vibeke; Levy, Roger Abramino; Araujo, Denizar Vianna

2014-06-01

Uncertainties remain the key issue surrounding biosimilars, although decisions regarding their use must be made. The challenges for policymakers, doctors, patients and others seeking to navigate in the uncharted waters of biosimilars must be clarified. At the most basic level, scientific understanding of the issue remains limited and when making decisions, policymakers must consider all those affected by health policy decisions, particularly the ultimate recipients of these medicines: the patients. The biosimilar-value chain relies on measurement of comparabilities. The goal is to demonstrate how, from a molecular perspective, closely similar they are or are not and how potential small differences may be relevant to clinical outcomes. To critically understand these points, this conceptual paper will present a knowledge-value chain and discuss each dimension assigning value in the decision making process re-utilization of biosimilars. Copyright © 2014 Elsevier B.V. All rights reserved.

Constructing diagnostic likelihood: clinical decisions using subjective versus statistical probability.

PubMed

Kinnear, John; Jackson, Ruth

2017-07-01

Although physicians are highly trained in the application of evidence-based medicine, and are assumed to make rational decisions, there is evidence that their decision making is prone to biases. One of the biases that has been shown to affect accuracy of judgements is that of representativeness and base-rate neglect, where the saliency of a person's features leads to overestimation of their likelihood of belonging to a group. This results in the substitution of 'subjective' probability for statistical probability. This study examines clinicians' propensity to make estimations of subjective probability when presented with clinical information that is considered typical of a medical condition. The strength of the representativeness bias is tested by presenting choices in textual and graphic form. Understanding of statistical probability is also tested by omitting all clinical information. For the questions that included clinical information, 46.7% and 45.5% of clinicians made judgements of statistical probability, respectively. Where the question omitted clinical information, 79.9% of clinicians made a judgement consistent with statistical probability. There was a statistically significant difference in responses to the questions with and without representativeness information (χ2 (1, n=254)=54.45, p<0.0001). Physicians are strongly influenced by a representativeness bias, leading to base-rate neglect, even though they understand the application of statistical probability. One of the causes for this representativeness bias may be the way clinical medicine is taught where stereotypic presentations are emphasised in diagnostic decision making. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Behavioral and Psychological Symptoms Impact Clinical Competence in Alzheimer’s Disease

PubMed Central

Bertrand, Elodie; van Duinkerken, Eelco; Landeira-Fernandez, J.; Dourado, Marcia C. N.; Santos, Raquel L.; Laks, Jerson; Mograbi, Daniel C.

2017-01-01

Decision-making is considered a fundamental aspect of personal autonomy and can be affected in psychiatric and neurologic diseases. It has been shown that cognitive deficits in dementia impact negatively on decision-making. Moreover, studies highlighted impaired clinical competence in neuropsychiatric disorders, such as schizophrenia and bipolar disorder. In this context, the current study explored the relationship between behavioral and psychological symptoms of dementia (BPSD) and clinical competence, especially the capacity to consent to treatment, in Alzheimer’s disease (AD). Seventy-one patients with mild to moderate AD participated, completing assessments for capacity to consent to treatment, general cognition and neuropsychiatric disturbances. For each neuropsychiatric symptom, patients with and without the particular disturbance were compared on the different subscales of the MacArthur Competence Tool for Treatment (MacCAT-T; Understanding, Appreciation, Reasoning and Expression). The results showed that patients presenting delusions, as well as apathetic patients, had a lower ability to express a clear treatment choice compared to patients without these symptoms. By contrast, patients with dysphoria/depression had higher scores on this variable. Additionally, AD patients with euphoria had more difficulties discussing consequences of treatment alternatives compared to patients without this disturbance. None of the differences were confounded by global cognition. There were no between-group differences in clinical decision-making for patients with hallucinations, agitation/aggression, anxiety, irritability, disinhibition and aberrant motor behavior. These findings highlight the importance of taking BPSD into account when assessing decision-making capacity, especially clinical competence, in AD. Furthermore, reducing BPSD may lead to better clinical competence in patients with AD, as well as to improvements in patients and caregivers’ quality of life. PMID:28670272

Buried Versus Exposed Kirschner Wires Following Fixation of Hand Fractures: l Clinician and Patient Surveys.

PubMed

2018-04-01

Fractures of the metacarpals and phalanges are common. Placement of Kirschner wires (K-wires) is the most common form of surgical fixation. After placement, a key decision is whether to bury the end of a K-wire or leave it protruding from the skin (exposed). A recent systematic review found no evidence to support either approach. The aim of study was to investigate current clinical practice, understand the key factors influencing clinician decision-making, and explore patient preferences to inform the design of a randomized clinical trial. The steering group developed surveys for hand surgeons, hand therapists, and patients. Following piloting, they were distributed across the United Kingdom hand surgery units using the Reconstructive Surgery Trials Network. A total of 423 hand surgeons, 187 hand therapists, and 187 patients completed the surveys. Plastic surgeons and junior surgical trainees preferred to leave K-wires not buried. Ease of removal correlated with a decision to leave wires exposed, whereas perceived risk of infection correlated with burying wires. Cost did not affect the decision. Hand therapists were primarily concerned about infection and patient-related outcomes. Patients were most concerned about wire-related problems and pain. This national survey provides a new understanding of the use of K-wires to manage hand fractures in the United Kingdom. A number of nonevidence-based factors seem to influence the decision to bury or leave K-wires exposed. The choice has important clinical and health economic implications that justify a randomized controlled trial.

Quantitative Analysis of Variables Affecting Nursing Program Completion at Arizona State University

ERIC Educational Resources Information Center

Herrera, Cheryl

2013-01-01

This study is designed to understand the patterns of selection, preparation, retention and graduation of undergraduate pre-licensure clinical nursing students in the College of Nursing and Health Innovation at Arizona State University enrolled in 2007 and 2008. The resulting patterns may guide policy decision making regarding future cohorts in…

Improving the Quality of Nursing Documentation in Home Health Care Setting

ERIC Educational Resources Information Center

Obioma, Chidiadi

2017-01-01

Poor nursing documentation of patient care was identified in daily nurse visit notes in a health care setting. This problem affects effective communication of patient status with other clinicians, thereby jeopardizing clinical decision-making. The purpose of this evidence-based project was to determine the impact of a retraining program on the…

Beyond individualism: Is there a place for relational autonomy in clinical practice and research?

PubMed

Dove, Edward S; Kelly, Susan E; Lucivero, Federica; Machirori, Mavis; Dheensa, Sandi; Prainsack, Barbara

2017-09-01

The dominant, individualistic understanding of autonomy that features in clinical practice and research is underpinned by the idea that people are, in their ideal form, independent, self-interested and rational gain-maximising decision-makers. In recent decades, this paradigm has been challenged from various disciplinary and intellectual directions. Proponents of 'relational autonomy' in particular have argued that people's identities, needs, interests - and indeed autonomy - are always also shaped by their relations to others. Yet, despite the pronounced and nuanced critique directed at an individualistic understanding of autonomy, this critique has had very little effect on ethical and legal instruments in clinical practice and research so far. In this article, we use four case studies to explore to what extent, if at all, relational autonomy can provide solutions to ethical and practical problems in clinical practice and research. We conclude that certain forms of relational autonomy can have a tangible and positive impact on clinical practice and research. These solutions leave the ultimate decision to the person most affected, but encourage and facilitate the consideration of this person's care and responsibility for connected others.

Return to play after infectious mononucleosis.

PubMed

Becker, Jonathan A; Smith, Julie Anne

2014-05-01

Infectious mononucleosis is a disease primarily of adolescence and early adulthood. The risk of splenic injury and chronic fatigue make return-to-play decisions a challenge for the clinician caring for athletes with infectious mononucleosis. Data were obtained from the PubMed and MEDLINE databases through December 2012 by searching for epidemiology, diagnosis, clinical manifestations, management, and the role of the spleen in infectious mononucleosis. Clinical review. Level 4. Infectious mononucleosis is commonly encountered in young athletes. Its disease pattern is variable and can affect multiple organ systems. Supportive care is the cornerstone, with little role for medications such as corticosteroids. Physical examination is unreliable for the spleen, and ultrasound imaging has limitations in its ability to guide return-to-play decisions. Exercise does not appear to place the young athlete at risk for chronic fatigue, but determining who is at risk for persistent symptoms is a challenge. Return-to-play decisions for the athlete with infectious mononucleosis need to be individualized because of the variable disease course and lack of evidence-based guidelines.

Cost-effectiveness modelling in diagnostic imaging: a stepwise approach.

PubMed

Sailer, Anna M; van Zwam, Wim H; Wildberger, Joachim E; Grutters, Janneke P C

2015-12-01

Diagnostic imaging (DI) is the fastest growing sector in medical expenditures and takes a central role in medical decision-making. The increasing number of various and new imaging technologies induces a growing demand for cost-effectiveness analysis (CEA) in imaging technology assessment. In this article we provide a comprehensive framework of direct and indirect effects that should be considered for CEA in DI, suitable for all imaging modalities. We describe and explain the methodology of decision analytic modelling in six steps aiming to transfer theory of CEA to clinical research by demonstrating key principles of CEA in a practical approach. We thereby provide radiologists with an introduction to the tools necessary to perform and interpret CEA as part of their research and clinical practice. • DI influences medical decision making, affecting both costs and health outcome. • This article provides a comprehensive framework for CEA in DI. • A six-step methodology for conducting and interpreting cost-effectiveness modelling is proposed.

Understanding critical care nurses' autonomy in Jordan.

PubMed

Maharmeh, Mahmoud

2017-10-02

Purpose The aim of this study was to describe Jordanian critical care nurses' experiences of autonomy in their clinical practice. Design/methodology/approach A descriptive correlational design was applied using a self-reported cross-sectional survey. A total of 110 registered nurses who met the eligibility criteria participated in this study. The data were collected by a structured questionnaire. Findings A majority of critical care nurses were autonomous in their decision-making and participation in decisions to take action in their clinical settings. Also, they were independent to develop their own knowledge. The study identified that their autonomy in action and acquired knowledge were influenced by a number of factors such as gender and area of practice. Practical implications Nurse's autonomy could be increased if nurses are made aware of the current level of autonomy and explore new ways to increase empowerment. This could be offered through classroom lectures that concentrate on the concept of autonomy and its implication in practice. Nurses should demonstrate autonomous nursing care at the same time in the clinical practice. This could be done through collaboration between educators and clinical practice to help merge theory to practice. Originality/value Critical care nurses were more autonomous in action and knowledge base. This may negatively affect the quality of patient care and nurses' job satisfaction. Therefore, improving nurses' clinical decision-making autonomy could be done by the support of both hospital administrators and nurses themselves.

Management of advanced colon cancer in a community hospital--impact of age on clinical management and survival.

PubMed

Mogili, Sujatha; Yousaf, Mobeen; Nadaraja, Nagendra; Woodlock, Timothy

2012-09-01

Colon cancer is more common in the elderly than in younger and middle-aged people. Cancer clinical trials focus more on younger patients and the management of elderly patients with advanced disease is still unclear. We studied all patients presenting with colon adenocarcinoma metastasis to liver at a community teaching hospital from Dec 2000 through Dec 2007 by a retrospective review of Tumor Registry data and patient chart review with focus on age, clinical management, decision making, and survival. Sixty-seven patients with a median age of 69 and a male to female ratio of 31:36 were identified. The patients with obstructive symptoms and Eastern Cooperative Oncology Group performance status on presentation though varied little by age, smaller proportion of elderly patients underwent resection of the primary bowel tumor in the presence of liver metastases with ten of 16 (63%) aged 80 or greater being managed without surgery. The percentage of patient's preference to physician's preference for patients not undergoing the primary bowel resection increased for older age group. Median survival decreased significantly with age (p < 0.05). Age-related clinical management, decision-making autonomy, and survival are apparent in this study, and there was an increasing trend of patient's involvement in decision making as the age increases and, thus, affecting the age-related clinical management.

Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety.

PubMed

Murji, Ally; Luketic, Lea; Sobel, Mara L; Kulasegaram, Kulamakan Mahan; Leyland, Nicholas; Posner, Glenn

2016-10-01

Answering telephone calls and pagers is common distraction in the operating room. We sought to evaluate the impact of distractions on patient care by (1) assessing the accuracy and safety of responses to clinical questions posed to a surgeon while operating and (2) determining whether pager distractions affect simulation-based surgical performance. We conducted a randomized crossover study of obstetrics and gynecology residents. After studying a patient sign-out list, subjects performed a virtual salpingectomy. They were randomized to a distraction phase followed by quiet phase or vice versa. In the distraction phase, a pager beeped and subjects were asked questions based on the sign-out list. Accuracy of responses and the number of unsafe responses were recorded. In the quiet phase, trainees performed the task uninterrupted. Measures of surgical performance were successful task completion, time to task completion and operative blood loss. The mean score for correct responses to clinical questions during the distracted phase was 80 % (SD ±14 %). Nineteen residents (63 %) made at least 1 unsafe clinical decision while operating on the simulator (range 0-3). Subjects were more likely to successfully complete the surgical task in the allotted time under the quiet compared to distraction condition (OR 11.3, p = 0.03). There was no difference between the conditions in paired analysis for mean time (seconds) to task completion [426 (SD 133) vs. 440 (SD 186), p = 0.61] and mean operative blood loss (mL) [73.14 (SD 106) vs. 112.70 (SD 358), p = 0.47]. Distractions in the operating room may have a profound impact on patient safety on the wards. While multitasking in a simulated setting, the majority of residents made at least one unsafe clinical decision. Pager distractions also hindered surgical residents' ability to complete a simulated laparoscopic task in the allotted time without affecting other variables of surgical performance.

Investigating Miranda waiver decisions: An examination of the rational consequences.

PubMed

Blackwood, Hayley L; Rogers, Richard; Steadham, Jennifer A; Fiduccia, Chelsea E

2015-01-01

Millions of custodial suspects waive their Miranda rights each year without the benefit of legal counsel. Miranda understanding, appreciation, and reasoning abilities are essential to courts' acceptance of Miranda waivers (Grisso, 2003; Rogers & Shuman, 2005). The question posed to forensic psychologists and psychiatrists in the disputed Miranda waivers is whether a particular waiver decision was knowing, intelligent, and voluntary. Despite the remarkable development of Miranda research in recent decades, studies have generally focused on understanding and appreciation of Miranda rights, but with comparatively minimal emphasis on Miranda reasoning and attendant waiver decisions. Research on defendants' decisional capacities constitutes a critical step in further developing theoretical and clinical models for Miranda waiver decisions. The current study evaluated Miranda waiver decisions for 80 pretrial defendants from two Oklahoma jails to study systematically how rational decision abilities affect defendants' personal waiver decisions. In stark contrast to what was expected, many defendants were able to identify a rational decisional process in their own legal cases, yet cast such reasoning aside and chose a completely contradictory Miranda waiver decision. Published by Elsevier Ltd.

Decision Making for Healthcare Resource Allocation: Joint v. Separate Decisions on Interacting Interventions.

PubMed

Dakin, Helen; Gray, Alastair

2018-05-01

Standard guidance for allocating healthcare resources based on cost-effectiveness recommends using different decision rules for independent and mutually exclusive alternatives, although there is some confusion around the definition of "mutually exclusive." This paper reviews the definitions used in the literature and shows that interactions (i.e., non-additive effects, whereby the effect of giving 2 interventions simultaneously does not equal the sum of their individual effects) are the defining feature of mutually exclusive alternatives: treatments cannot be considered independent if the costs and/or benefits of one treatment are affected by the other treatment. The paper then identifies and categorizes the situations in which interventions are likely to have non-additive effects, including interventions targeting the same goal or clinical event, or life-saving interventions given to overlapping populations. We demonstrate that making separate decisions on interventions that have non-additive effects can prevent us from maximizing health gained from the healthcare budget. In contrast, treating combinations of independent options as though they were "mutually exclusive" makes the analysis more complicated but does not affect the conclusions. Although interactions are considered by the World Health Organization, other decision makers, such as the National Institute for Health and Care Excellence (NICE), currently make independent decisions on treatments likely to have non-additive effects. We propose a framework by which interactions could be considered when selecting, prioritizing, and appraising healthcare technologies to ensure efficient, evidence-based decision making.

Decision Making for Healthcare Resource Allocation: Joint v. Separate Decisions on Interacting Interventions

PubMed Central

Dakin, Helen; Gray, Alastair

2018-01-01

Standard guidance for allocating healthcare resources based on cost-effectiveness recommends using different decision rules for independent and mutually exclusive alternatives, although there is some confusion around the definition of “mutually exclusive.” This paper reviews the definitions used in the literature and shows that interactions (i.e., non-additive effects, whereby the effect of giving 2 interventions simultaneously does not equal the sum of their individual effects) are the defining feature of mutually exclusive alternatives: treatments cannot be considered independent if the costs and/or benefits of one treatment are affected by the other treatment. The paper then identifies and categorizes the situations in which interventions are likely to have non-additive effects, including interventions targeting the same goal or clinical event, or life-saving interventions given to overlapping populations. We demonstrate that making separate decisions on interventions that have non-additive effects can prevent us from maximizing health gained from the healthcare budget. In contrast, treating combinations of independent options as though they were “mutually exclusive” makes the analysis more complicated but does not affect the conclusions. Although interactions are considered by the World Health Organization, other decision makers, such as the National Institute for Health and Care Excellence (NICE), currently make independent decisions on treatments likely to have non-additive effects. We propose a framework by which interactions could be considered when selecting, prioritizing, and appraising healthcare technologies to ensure efficient, evidence-based decision making. PMID:29683792

Comprehensive process model of clinical information interaction in primary care: results of a "best-fit" framework synthesis.

PubMed

Veinot, Tiffany C; Senteio, Charles R; Hanauer, David; Lowery, Julie C

2018-06-01

To describe a new, comprehensive process model of clinical information interaction in primary care (Clinical Information Interaction Model, or CIIM) based on a systematic synthesis of published research. We used the "best fit" framework synthesis approach. Searches were performed in PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Library and Information Science Abstracts, Library, Information Science and Technology Abstracts, and Engineering Village. Two authors reviewed articles according to inclusion and exclusion criteria. Data abstraction and content analysis of 443 published papers were used to create a model in which every element was supported by empirical research. The CIIM documents how primary care clinicians interact with information as they make point-of-care clinical decisions. The model highlights 3 major process components: (1) context, (2) activity (usual and contingent), and (3) influence. Usual activities include information processing, source-user interaction, information evaluation, selection of information, information use, clinical reasoning, and clinical decisions. Clinician characteristics, patient behaviors, and other professionals influence the process. The CIIM depicts the complete process of information interaction, enabling a grasp of relationships previously difficult to discern. The CIIM suggests potentially helpful functionality for clinical decision support systems (CDSSs) to support primary care, including a greater focus on information processing and use. The CIIM also documents the role of influence in clinical information interaction; influencers may affect the success of CDSS implementations. The CIIM offers a new framework for achieving CDSS workflow integration and new directions for CDSS design that can support the work of diverse primary care clinicians.

Integrative clinical genomics of advanced prostate cancer.

PubMed

Robinson, Dan; Van Allen, Eliezer M; Wu, Yi-Mi; Schultz, Nikolaus; Lonigro, Robert J; Mosquera, Juan-Miguel; Montgomery, Bruce; Taplin, Mary-Ellen; Pritchard, Colin C; Attard, Gerhardt; Beltran, Himisha; Abida, Wassim; Bradley, Robert K; Vinson, Jake; Cao, Xuhong; Vats, Pankaj; Kunju, Lakshmi P; Hussain, Maha; Feng, Felix Y; Tomlins, Scott A; Cooney, Kathleen A; Smith, David C; Brennan, Christine; Siddiqui, Javed; Mehra, Rohit; Chen, Yu; Rathkopf, Dana E; Morris, Michael J; Solomon, Stephen B; Durack, Jeremy C; Reuter, Victor E; Gopalan, Anuradha; Gao, Jianjiong; Loda, Massimo; Lis, Rosina T; Bowden, Michaela; Balk, Stephen P; Gaviola, Glenn; Sougnez, Carrie; Gupta, Manaswi; Yu, Evan Y; Mostaghel, Elahe A; Cheng, Heather H; Mulcahy, Hyojeong; True, Lawrence D; Plymate, Stephen R; Dvinge, Heidi; Ferraldeschi, Roberta; Flohr, Penny; Miranda, Susana; Zafeiriou, Zafeiris; Tunariu, Nina; Mateo, Joaquin; Perez-Lopez, Raquel; Demichelis, Francesca; Robinson, Brian D; Schiffman, Marc; Nanus, David M; Tagawa, Scott T; Sigaras, Alexandros; Eng, Kenneth W; Elemento, Olivier; Sboner, Andrea; Heath, Elisabeth I; Scher, Howard I; Pienta, Kenneth J; Kantoff, Philip; de Bono, Johann S; Rubin, Mark A; Nelson, Peter S; Garraway, Levi A; Sawyers, Charles L; Chinnaiyan, Arul M

2015-05-21

Toward development of a precision medicine framework for metastatic, castration-resistant prostate cancer (mCRPC), we established a multi-institutional clinical sequencing infrastructure to conduct prospective whole-exome and transcriptome sequencing of bone or soft tissue tumor biopsies from a cohort of 150 mCRPC affected individuals. Aberrations of AR, ETS genes, TP53, and PTEN were frequent (40%-60% of cases), with TP53 and AR alterations enriched in mCRPC compared to primary prostate cancer. We identified new genomic alterations in PIK3CA/B, R-spondin, BRAF/RAF1, APC, β-catenin, and ZBTB16/PLZF. Moreover, aberrations of BRCA2, BRCA1, and ATM were observed at substantially higher frequencies (19.3% overall) compared to those in primary prostate cancers. 89% of affected individuals harbored a clinically actionable aberration, including 62.7% with aberrations in AR, 65% in other cancer-related genes, and 8% with actionable pathogenic germline alterations. This cohort study provides clinically actionable information that could impact treatment decisions for these affected individuals. Copyright © 2015 Elsevier Inc. All rights reserved.

Integrative clinical genomics of advanced prostate cancer

PubMed Central

Dan, Robinson; Van Allen, Eliezer M.; Wu, Yi-Mi; Schultz, Nikolaus; Lonigro, Robert J.; Mosquera, Juan-Miguel; Montgomery, Bruce; Taplin, Mary-Ellen; Pritchard, Colin C; Attard, Gerhardt; Beltran, Himisha; Abida, Wassim M.; Bradley, Robert K.; Vinson, Jake; Cao, Xuhong; Vats, Pankaj; Kunju, Lakshmi P.; Hussain, Maha; Feng, Felix Y.; Tomlins, Scott A.; Cooney, Kathleen A.; Smith, David C.; Brennan, Christine; Siddiqui, Javed; Mehra, Rohit; Chen, Yu; Rathkopf, Dana E.; Morris, Michael J.; Solomon, Stephen B.; Durack, Jeremy C.; Reuter, Victor E.; Gopalan, Anuradha; Gao, Jianjiong; Loda, Massimo; Lis, Rosina T.; Bowden, Michaela; Balk, Stephen P.; Gaviola, Glenn; Sougnez, Carrie; Gupta, Manaswi; Yu, Evan Y.; Mostaghel, Elahe A.; Cheng, Heather H.; Mulcahy, Hyojeong; True, Lawrence D.; Plymate, Stephen R.; Dvinge, Heidi; Ferraldeschi, Roberta; Flohr, Penny; Miranda, Susana; Zafeiriou, Zafeiris; Tunariu, Nina; Mateo, Joaquin; Lopez, Raquel Perez; Demichelis, Francesca; Robinson, Brian D.; Schiffman, Marc A.; Nanus, David M.; Tagawa, Scott T.; Sigaras, Alexandros; Eng, Kenneth W.; Elemento, Olivier; Sboner, Andrea; Heath, Elisabeth I.; Scher, Howard I.; Pienta, Kenneth J.; Kantoff, Philip; de Bono, Johann S.; Rubin, Mark A.; Nelson, Peter S.; Garraway, Levi A.; Sawyers, Charles L.; Chinnaiyan, Arul M.

2015-01-01

SUMMARY Toward development of a precision medicine framework for metastatic, castration resistant prostate cancer (mCRPC), we established a multi-institutional clinical sequencing infrastructure to conduct prospective whole exome and transcriptome sequencing of bone or soft tissue tumor biopsies from a cohort of 150 mCRPC affected individuals. Aberrations of AR, ETS genes, TP53 and PTEN were frequent (40–60% of cases), with TP53 and AR alterations enriched in mCRPC compared to primary prostate cancer. We identified novel genomic alterations in PIK3CA/B, R-spondin, BRAF/RAF1, APC, β-catenin and ZBTB16/PLZF. Aberrations of BRCA2, BRCA1 and ATM were observed at substantially higher frequencies (19.3% overall) than seen in primary prostate cancers. 89% of affected individuals harbored a clinically actionable aberration including 62.7% with aberrations in AR, 65% in other cancer-related genes, and 8% with actionable pathogenic germline alterations. This cohort study provides evidence that clinical sequencing in mCRPC is feasible and could impact treatment decisions in significant numbers of affected individuals. PMID:26000489

Skin-deep diagnosis: affective bias and zebra retreat complicating the diagnosis of systemic sclerosis.

PubMed

Miller, Chad S

2013-01-01

Nearly half of medical errors can be attributed to an error of clinical reasoning or decision making. It is estimated that the correct diagnosis is missed or delayed in between 5% and 14% of acute hospital admissions. Through understanding why and how physicians make these errors, it is hoped that strategies can be developed to decrease the number of these errors. In the present case, a patient presented with dyspnea, gastrointestinal symptoms and weight loss; the diagnosis was initially missed when the treating physicians took mental short cuts and used heuristics as in this case. Heuristics have an inherent bias that can lead to faulty reasoning or conclusions, especially in complex or difficult cases. Affective bias, which is the overinvolvement of emotion in clinical decision making, limited the available information for diagnosis because of the hesitancy to acquire a full history and perform a complete physical examination in this patient. Zebra retreat, another type of bias, is when a rare diagnosis figures prominently on the differential diagnosis but the physician retreats for various reasons. Zebra retreat also factored in the delayed diagnosis. Through the description of these clinical reasoning errors in an actual case, it is hoped that future errors can be prevented or inspiration for additional research in this area will develop.

Does a Physician's Attitude toward a Patient with Mental Illness Affect Clinical Management of Diabetes? Results from a Mixed-Method Study.

PubMed

Welch, Lisa C; Litman, Heather J; Borba, Christina P C; Vincenzi, Brenda; Henderson, David C

2015-08-01

To determine whether physician's attitudes toward patients with comorbid mental illness affect management of a chronic disease. A total of 256 primary care physicians interviewed in 2010. This randomized factorial experiment entailed physicians observing video vignettes of patient-actors with poorly controlled diabetes. Patients were balanced across age, gender, race, and comorbidity (schizophrenia with bizarre or normal affect, depression, eczema). Physicians completed structured and semistructured interviews plus chart notes about clinical management and attitudes. Physicians reported more negative attitudes for patients with schizophrenia with bizarre affect (SBA). There were few differences in clinical decisions measured quantitatively or in charting, but qualitative data revealed less trust of patients with SBA as reporters, with more reliance on sources other than engaging the patient in care. Physicians often alerted colleagues about SBA, thereby shaping expectations before interactions occurred. Results are consistent with common stereotypes about people with serious mental illness. Vignettes did not include intentional indication of unreliable reporting or danger. Reducing health care disparities requires attention to subtle aspects of managing patients--particularly those with atypical affect--as seemingly slight differences could engender disparate patient experiences over time. © Health Research and Educational Trust.

The laboratory diagnosis of testosterone deficiency.

PubMed

Paduch, Darius A; Brannigan, Robert E; Fuchs, Eugene F; Kim, Edward D; Marmar, Joel L; Sandlow, Jay I

2014-05-01

The evaluation and treatment of hypogonadal men has become an important part of urologic practice. Fatigue, loss of libido, and erectile dysfunction are commonly reported, but nonspecific symptoms and laboratory verification of low testosterone (T) are an important part of evaluation in addition to a detailed history and physical examination. Significant intraindividual fluctuations in serum T levels, biologic variation of T action on end organs, the wide range of T levels in human serum samples, and technical limitations of currently available assays have led to poor reliability of T measurements in the clinical laboratory setting. There is no universally accepted threshold of T concentration that distinguishes eugonadal from hypogonadal men; thus, laboratory results have to be interpreted in the appropriate clinical setting. This review focuses on clinical, biological, and technological challenges that affect serum T measurements to educate clinicians regarding technological advances and limitations of the currently available laboratory methods to diagnose hypogonadism. A collaborative effort led by the American Urological Association between practicing clinicians, patient advocacy groups, government regulatory agencies, industry, and professional societies is underway to provide optimized assay platforms and evidence-based normal assay ranges to guide clinical decision making. Until such standardization is commonplace in clinical laboratories, the decision to treat should be based on the presence of signs and symptoms in addition to serum T measurements. Rigid interpretation of T ranges should not dictate clinical decision making or define coverage of treatment by third party payers. Copyright © 2014 Elsevier Inc. All rights reserved.

Comparing data accuracy between structured abstracts and full-text journal articles: implications in their use for informing clinical decisions.

PubMed

Fontelo, Paul; Gavino, Alex; Sarmiento, Raymond Francis

2013-12-01

The abstract is the most frequently read section of a research article. The use of 'Consensus Abstracts', a clinician-oriented web application formatted for mobile devices to search MEDLINE/PubMed, for informing clinical decisions was proposed recently; however, inaccuracies between abstracts and the full-text article have been shown. Efforts have been made to improve quality. We compared data in 60 recent-structured abstracts and full-text articles from six highly read medical journals. Data inaccuracies were identified and then classified as either clinically significant or not significant. Data inaccuracies were observed in 53.33% of articles ranging from 3.33% to 45% based on the IMRAD format sections. The Results section showed the highest discrepancies (45%) although these were deemed to be mostly not significant clinically except in one. The two most common discrepancies were mismatched numbers or percentages (11.67%) and numerical data or calculations found in structured abstracts but not mentioned in the full text (40%). There was no significant relationship between journals and the presence of discrepancies (Fisher's exact p value =0.3405). Although we found a high percentage of inaccuracy between structured abstracts and full-text articles, these were not significant clinically. The inaccuracies do not seem to affect the conclusion and interpretation overall. Structured abstracts appear to be informative and may be useful to practitioners as a resource for guiding clinical decisions.

Patient Perceptions of Illness Identity in Cancer Clinical Trial Decision-Making.

PubMed

Palmer-Wackerly, Angela L; Dailey, Phokeng M; Krok-Schoen, Jessica L; Rhodes, Nancy D; Krieger, Janice L

2018-08-01

When patients are diagnosed with cancer, they begin to negotiate their illness identity in relation to their past and future selves, their relationships, and their group memberships. Thus, how patients view their cancer in relation to their other identities may affect how and why they make particular decisions about treatment options. Using the Communication Theory of Identity (CTI), the current study explores: (1) how and why illness identity is framed across identity layers in relation to one particular cancer treatment: participation in a cancer clinical trial (CT); and (2) how and why patients experience identity conflicts while making their treatment decisions. Semi-structured, in-depth interviews were analyzed for 46 cancer patients who were offered a CT. Results of a grounded theory analysis indicated that patients expressed separate identity frames (e.g., personal, relational, and communal), aligned identity frames (e.g., personal and communal), and identity conflicts (e.g., personal-personal). This study theoretically shows how and why patient illness identity relates to cancer treatment decision-making as well as how and why patients relate (and conflict) with the cancer communal identity frame. Practical implications include how healthcare providers and family members can support patient decision-making through awareness of and accommodating to identity shifts.

Exploring Factors Affecting Voluntary Adoption of Electronic Medical Records Among Physicians and Clinical Assistants of Small or Solo Private General Practice Clinics.

PubMed

Or, Calvin; Tong, Ellen; Tan, Joseph; Chan, Summer

2018-05-29

The health care reform initiative led by the Hong Kong government's Food and Health Bureau has started the implementation of an electronic sharing platform to provide an information infrastructure that enables public hospitals and private clinics to share their electronic medical records (EMRs) for improved access to patients' health care information. However, previous attempts to convince the private clinics to adopt EMRs to document health information have faced challenges, as the EMR adoption has been voluntary. The lack of electronic data shared by private clinics carries direct impacts to the efficacy of electronic record sharing between public and private healthcare providers. To increase the likelihood of buy-in, it is essential to proactively identify the users' and organizations' needs and capabilities before large-scale implementation. As part of the reform initiative, this study examined factors affecting the adoption of EMRs in small or solo private general practice clinics, by analyzing the experiences and opinions of the physicians and clinical assistants during the pilot implementation of the technology, with the purpose to learn from it before full-scale rollout. In-depth, semistructured interviews were conducted with 23 physicians and clinical assistants from seven small or solo private general practice clinics to evaluate their experiences, expectations, and opinions regarding the deployment of EMRs. Interview transcripts were content analyzed to identify key factors. Factors affecting the adoption of EMRs to record and manage health care information were identified as follows: system interface design; system functions; stability and reliability of hardware, software, and computing networks; financial and time costs; task and outcome performance, work practice, and clinical workflow; physical space in clinics; trust in technology; users' information technology literacy; training and technical support; and social and organizational influences. The factors are interrelated with the others. The adoption factors identified are multifaceted, ranging from technological characteristics, clinician-technology interactions, skills and knowledge, and the user-workflow-technology fit. Other findings, which have been relatively underrepresented in previous studies, contribute unique insights about the influence of work and social environment on the adoption of EMRs, including limited clinic space and the effects of physicians' decision to use the technology on clinical staffs' adoption decisions. Potential strategies to address the concerns, overcome adoption barriers, and define relevant policies are discussed.

Psychopathological and personality traits underlie decision making in recent onset medication naïve anorexia nervosa: a pilot study.

PubMed

Fornasari, Livia; Gregoraci, Giorgia; Isola, Miriam; Laura Negri, Gioia Anna; Rambaldelli, Gianluca; Cremaschi, Silvana; Faleschini, Laura; Canalaz, Francesca; Perini, Laura; Balestrieri, Matteo; Fabbro, Franco; Brambilla, Paolo

2014-04-30

The Iowa Gambling Task (IGT) analyzes the ability of participants to sacrifice immediate rewards in view of a long term gain. Anorexia Nervosa (AN) in addition to weight loss and body image disturbances is also characterized by the tendency to make decisions that may result in long-term negative outcomes. Studies that analyzed IGT performance in patients with AN were not consistent with each other. Fifteen adolescents with AN and 15 matched controls carried out IGT after being clinically and neuropsychologically evaluated. An interesting generalized estimating equation approach showed that four independent clinical variables, and not the group, explained IGT performances, such as blocks repetition, anxiety, psychogenic eating disorders and self transcendence. The impairment of decision making is not related to the diagnosis of AN, but it is driven by high levels of anxiety and self transcendence. Instead, some psychogenic eating disorders traits, related to illness severity, positively affected IGT performance in the whole sample. IGT impairment in AN found by prior studies could be related to these clinical features which are not always taken into account. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Analyzing the effectiveness of teaching and factors in clinical decision-making.

PubMed

Hsieh, Ming-Chen; Lee, Ming-Shinn; Chen, Tsung-Ying; Tsai, Tsuen-Chiuan; Pai, Yi-Fong; Sheu, Min-Muh

2017-01-01

The aim of this study is to prepare junior physicians, clinical education should focus on the teaching of clinical decision-making. This research is designed to explore teaching of clinical decision-making and to analyze the benefits of an "Analogy guide clinical decision-making" as a learning intervention for junior doctors. This study had a "quasi-experimental design" and was conducted in a medical center in eastern Taiwan. Participants and Program Description: Thirty junior doctors and three clinical teachers were involved in the study. The experimental group (15) received 1 h of instruction from the "Analogy guide for teaching clinical decision-making" every day for 3 months. Program Evaluation: A "Clinical decision-making self-evaluation form" was used as the assessment tool to evaluate participant learning efficiency before and after the teaching program. Semi-structured qualitative research interviews were also conducted. We found using the analogy guide for teaching clinical decision-making could help enhance junior doctors' self-confidence. Important factors influencing clinical decision-making included workload, decision-making, and past experience. Clinical teaching using the analogy guide for clinical decision-making may be a helpful tool for training and can contribute to a more comprehensive understanding of decision-making.

Asymmetric effects of positive and negative affect on decision making.

PubMed

Cahir, Caitriona; Thomas, Kevin

2010-02-01

Although affect is a fundamental element of decision making, there are different theoretical accounts and conflicting empirical evidence of its influence. This experiment was done to begin a more coherent account of the influence of affect by using standardised images to induce affect and a betting task to measure decision making. Eighty-five participants were assigned to a positive, a negative, or a neutral affect condition before making decisions on two hypothetical horse races. Analysis indicated that those in the positive and negative conditions made lower-risk decisions than those in the neutral condition; however, this did not differ between the races, suggesting that task familiarity did not moderate the influence of affect. Contrary to previous research, these results indicate that positive and negative affect do not necessarily exert symmetrical effects on decision making. Implications for the major accounts of the influence of affect on decision making are discussed in relation to the findings.

Dual Processing Model for Medical Decision-Making: An Extension to Diagnostic Testing

PubMed Central

Tsalatsanis, Athanasios; Hozo, Iztok; Kumar, Ambuj; Djulbegovic, Benjamin

2015-01-01

Dual Processing Theories (DPT) assume that human cognition is governed by two distinct types of processes typically referred to as type 1 (intuitive) and type 2 (deliberative). Based on DPT we have derived a Dual Processing Model (DPM) to describe and explain therapeutic medical decision-making. The DPM model indicates that doctors decide to treat when treatment benefits outweigh its harms, which occurs when the probability of the disease is greater than the so called “threshold probability” at which treatment benefits are equal to treatment harms. Here we extend our work to include a wider class of decision problems that involve diagnostic testing. We illustrate applicability of the proposed model in a typical clinical scenario considering the management of a patient with prostate cancer. To that end, we calculate and compare two types of decision-thresholds: one that adheres to expected utility theory (EUT) and the second according to DPM. Our results showed that the decisions to administer a diagnostic test could be better explained using the DPM threshold. This is because such decisions depend on objective evidence of test/treatment benefits and harms as well as type 1 cognition of benefits and harms, which are not considered under EUT. Given that type 1 processes are unique to each decision-maker, this means that the DPM threshold will vary among different individuals. We also showed that when type 1 processes exclusively dominate decisions, ordering a diagnostic test does not affect a decision; the decision is based on the assessment of benefits and harms of treatment. These findings could explain variations in the treatment and diagnostic patterns documented in today’s clinical practice. PMID:26244571

Dual Processing Model for Medical Decision-Making: An Extension to Diagnostic Testing.

PubMed

Tsalatsanis, Athanasios; Hozo, Iztok; Kumar, Ambuj; Djulbegovic, Benjamin

2015-01-01

Dual Processing Theories (DPT) assume that human cognition is governed by two distinct types of processes typically referred to as type 1 (intuitive) and type 2 (deliberative). Based on DPT we have derived a Dual Processing Model (DPM) to describe and explain therapeutic medical decision-making. The DPM model indicates that doctors decide to treat when treatment benefits outweigh its harms, which occurs when the probability of the disease is greater than the so called "threshold probability" at which treatment benefits are equal to treatment harms. Here we extend our work to include a wider class of decision problems that involve diagnostic testing. We illustrate applicability of the proposed model in a typical clinical scenario considering the management of a patient with prostate cancer. To that end, we calculate and compare two types of decision-thresholds: one that adheres to expected utility theory (EUT) and the second according to DPM. Our results showed that the decisions to administer a diagnostic test could be better explained using the DPM threshold. This is because such decisions depend on objective evidence of test/treatment benefits and harms as well as type 1 cognition of benefits and harms, which are not considered under EUT. Given that type 1 processes are unique to each decision-maker, this means that the DPM threshold will vary among different individuals. We also showed that when type 1 processes exclusively dominate decisions, ordering a diagnostic test does not affect a decision; the decision is based on the assessment of benefits and harms of treatment. These findings could explain variations in the treatment and diagnostic patterns documented in today's clinical practice.

Ethical safety of deep brain stimulation: A study on moral decision-making in Parkinson's disease.

PubMed

Fumagalli, Manuela; Marceglia, Sara; Cogiamanian, Filippo; Ardolino, Gianluca; Picascia, Marta; Barbieri, Sergio; Pravettoni, Gabriella; Pacchetti, Claudio; Priori, Alberto

2015-07-01

The possibility that deep brain stimulation (DBS) in Parkinson's disease (PD) alters patients' decisions and actions, even temporarily, raises important clinical, ethical and legal questions. Abnormal moral decision-making can lead to ethical rules violations. Previous experiments demonstrated the subthalamic (STN) activation during moral decision-making. Here we aim to study whether STN DBS can affect moral decision-making in PD patients. Eleven patients with PD and bilateral STN DBS implant performed a computerized moral task in ON and OFF stimulation conditions. A control group of PD patients without DBS implant performed the same experimental protocol. All patients underwent motor, cognitive and psychological assessments. STN stimulation was not able to modify neither reaction times nor responses to moral task both when we compared the ON and the OFF state in the same patient (reaction times, p = .416) and when we compared DBS patients with those treated only with the best medical treatment (reaction times: p = .408, responses: p = .776). Moral judgment is the result of a complex process, requiring cognitive executive functions, problem-solving, anticipations of consequences of an action, conflict processing, emotional evaluation of context and of possible outcomes, and involving different brain areas and neural circuits. Our data show that STN DBS leaves unaffected moral decisions thus implying relevant clinical and ethical implications for DBS consequences on patients' behavior, on decision-making and on judgment ability. In conclusion, the technique can be considered safe on moral behavior. Copyright © 2015 Elsevier Ltd. All rights reserved.

Balancing certainty and uncertainty in clinical medicine.

PubMed

Hayward, Richard

2006-01-01

Nothing in clinical medicine is one hundred per cent certain. Part of a doctor's education involves learning how to cope with the anxiety that uncertainty in decisions affecting life and death inevitably produces. This paper examines: (1) the role of anxiety -- both rational and irrational -- in the provision of health care; (2) the effects of uncertainty upon the doctor-patient relationship; (3) the threat uncertainty poses to medical authority (and the assumption of infallibility that props it up); (4) the contribution of clinical uncertainty to the rising popularity of alternative therapies; and (5) the clash between the medical and the legal understanding of how certainty should be defined, particularly as it affects the paediatric community. It concludes by suggesting some strategies that might facilitate successful navigation between the opposing and ever-present forces of certainty and uncertainty.

Custom software development for use in a clinical laboratory

PubMed Central

Sinard, John H.; Gershkovich, Peter

2012-01-01

In-house software development for use in a clinical laboratory is a controversial issue. Many of the objections raised are based on outdated software development practices, an exaggeration of the risks involved, and an underestimation of the benefits that can be realized. Buy versus build analyses typically do not consider total costs of ownership, and unfortunately decisions are often made by people who are not directly affected by the workflow obstacles or benefits that result from those decisions. We have been developing custom software for clinical use for over a decade, and this article presents our perspective on this practice. A complete analysis of the decision to develop or purchase must ultimately examine how the end result will mesh with the departmental workflow, and custom-developed solutions typically can have the greater positive impact on efficiency and productivity, substantially altering the decision balance sheet. Involving the end-users in preparation of the functional specifications is crucial to the success of the process. A large development team is not needed, and even a single programmer can develop significant solutions. Many of the risks associated with custom development can be mitigated by a well-structured development process, use of open-source tools, and embracing an agile development philosophy. In-house solutions have the significant advantage of being adaptable to changing departmental needs, contributing to efficient and higher quality patient care. PMID:23372985

Custom software development for use in a clinical laboratory.

PubMed

Sinard, John H; Gershkovich, Peter

2012-01-01

In-house software development for use in a clinical laboratory is a controversial issue. Many of the objections raised are based on outdated software development practices, an exaggeration of the risks involved, and an underestimation of the benefits that can be realized. Buy versus build analyses typically do not consider total costs of ownership, and unfortunately decisions are often made by people who are not directly affected by the workflow obstacles or benefits that result from those decisions. We have been developing custom software for clinical use for over a decade, and this article presents our perspective on this practice. A complete analysis of the decision to develop or purchase must ultimately examine how the end result will mesh with the departmental workflow, and custom-developed solutions typically can have the greater positive impact on efficiency and productivity, substantially altering the decision balance sheet. Involving the end-users in preparation of the functional specifications is crucial to the success of the process. A large development team is not needed, and even a single programmer can develop significant solutions. Many of the risks associated with custom development can be mitigated by a well-structured development process, use of open-source tools, and embracing an agile development philosophy. In-house solutions have the significant advantage of being adaptable to changing departmental needs, contributing to efficient and higher quality patient care.

Building clinical networks: a developmental evaluation framework.

PubMed

Carswell, Peter; Manning, Benjamin; Long, Janet; Braithwaite, Jeffrey

2014-05-01

Clinical networks have been designed as a cross-organisational mechanism to plan and deliver health services. With recent concerns about the effectiveness of these structures, it is timely to consider an evidence-informed approach for how they can be developed and evaluated. To document an evaluation framework for clinical networks by drawing on the network evaluation literature and a 5-year study of clinical networks. We searched literature in three domains: network evaluation, factors that aid or inhibit network development, and on robust methods to measure network characteristics. This material was used to build a framework required for effective developmental evaluation. The framework's architecture identifies three stages of clinical network development; partner selection, network design and network management. Within each stage is evidence about factors that act as facilitators and barriers to network growth. These factors can be used to measure progress via appropriate methods and tools. The framework can provide for network growth and support informed decisions about progress. For the first time in one place a framework incorporating rigorous methods and tools can identify factors known to affect the development of clinical networks. The target user group is internal stakeholders who need to conduct developmental evaluation to inform key decisions along their network's developmental pathway.

Factors Affecting Dermatologists' Use of a 31-Gene Expression Profiling Test as an Adjunct for Predicting Metastatic Risk in Cutaneous Melanoma.

PubMed

Svoboda, Ryan M; Glazer, Alex M; Farberg, Aaron S; Rigel, Darrell S

2018-05-01

A 31-gene expression profile (31-GEP) test to predict metastatic risk in patients with cutaneous malignant melanoma has previously been validated and is available for clinical use. The impact of the availability of such a test on clinical decision-making has previously been studied. However, little is known about which factors play a role in clinicians' decision to utilize the test. To determine factors affecting clinicians' decisions to utilize the 31-GEP test for metastatic risk stratification in patients with cutaneous malignant melanoma. Dermatologists attending a national conference completed a series of questions based around four clinical vignettes using an audience response system. The vignettes and associated questions were designed to determine the impact of three factors-Breslow thickness, ulceration, and sentinel lymph node biopsy status-on the decision to order the 31-GEP test. Main Outcomes and Measures: The percentage of respondents who would order the 31-GEP test in the various clinical scenarios was quantified. Differences between groups were assessed using the chi-squared test. A total of 181/187 individuals completed the survey (96.8% response rate). For tumors with a Breslow thickness ≥0.5 mm, a majority of respondents reported that they would recommend the 31-GEP test. Ulceration was associated with a statistically significant increase in the percentage of clinicians who would recommend the assay for all but the thickest (2.1 mm) tumors. A negative SLN was only associated with a statistically significant increase in the percentage of clinicians who would recommend the test for the thinnest (0.26 mm) tumors (22% to 34%, P=0.033). Ulceration appears to be the most important factor impacting clinicians when deciding to order the 31-GEP test to assess risk for melanoma metastasis. J Drugs Dermatol. 2018;17(5):544-547.

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[Subjectivity, decision and neurodegenerative diseases: reflexions on the role of the clinical psychologist in medical decision making].

PubMed

Brocq, H; Liarte, A; Soriani, M-H; Desnuelle, C

2013-01-01

Should a patient be forced to accept a treatment, especially when suffering from a neurodegenerative disease? We argue that physicians, nurses and care givers should instead accept his or her choice in accordance with the principle that every patient is an autonomous person able to make a choice, even in case of declined cognition. Beside the legal obligation, we suggest a theoretical approach and focus on the practical impacts of the patient's decision. Our objective is to promote the value of ethical doubt and attentive listening to individual opinions, so as to improve the quality of the medical staff's work and reduce patients' distress when affected by fatal diseases. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Ethical aspects of clinical chemistry.

PubMed Central

BenGershôm, E

1983-01-01

The work performed by the clinical chemist may deeply affect the decisions of the doctor and the well-being of the patient. Yet in contrast to the doctor and to the nurse the clinical chemist usually has no personal relationship with the patient. Being encumbered by much technology and anonymity is itself a reason for scrutinising his involvement in issues of health care ethics. This is an attempt at clarifying some major aspects: the relationship of his professional ethics to medical ethics as a whole, his ethical obligations to the patient and to society, and other aspects. PMID:6199500

Common decisions made and actions taken during small-animal consultations at eight first-opinion practices in the United Kingdom.

PubMed

Robinson, N J; Brennan, M L; Cobb, M; Dean, R S

2017-04-01

In order for veterinary surgeons to undertake an evidence-based approach to making decisions about their patients, it is important that new evidence is generated to support the clinical decision-making process. Many of the decisions are likely to be around the actions taken to treat or manage health problems discussed during the consultation, and little is currently known about the factors which affect the type of action taken. The aim of this study was to determine the decisions made and actions taken for health problems discussed during first-opinion small-animal consultations, as well as identifying factors which may affect the decision-making process. Data were gathered during direct observation of small-animal consultations conducted by 62 veterinary surgeons in eight first-opinion practices in the United Kingdom. For each patient presented, data were gathered on all health problems discussed during the consultation. The decision made (whether an action was taken or not) and the action taken where applicable (e.g. therapeutic treatment with antibiotics) was also recorded. A three-level multivariable logistic-regression model was developed, with problem (Level 1) nested within patient (Level 2) nested within consulting veterinary surgeon (Level 3), and a binary outcome variable of action versus no action. At least one action was taken for 69% (n=2203/3192) of all problems discussed. Therapeutic treatment was the most common action taken (n=1286/3192 problems; 40.3%), followed by management advice (n=1040/3192; 32.6%) and diagnostic work-up (n=323/3192; 10.1%). The most common therapeutic treatment was antibiotics (n=386/1286; 30%), while the most common management advice given was dietary advice (n=509/1040; 48.9%). The three explanatory variables remaining in the final model were whether the problem was a presenting or non-presenting problem, the type of diagnosis made, and the body system affected. Explanatory variables which did not remain in the final model were patient signalment, problem history, consultation type, clinical examination type, and who raised the problem (veterinary surgeon or owner). For over two-thirds of problems discussed, an action was taken which suggests these problems may be seen as important by the veterinary surgeon and/or pet owner. No action was taken for almost a third of cases which could represent 'watchful waiting', which has been highlighted as important in human healthcare. Future research should focus on the common actions taken, further exploring the complex decision-making process, and examining the effect of the decisions made on long-term patient outcomes. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.

Factors affecting decision-making of patients choosing acupuncture in a public hospital.

PubMed

Sayampanathan, Andrew Arjun; Koh, Thean Howe Bryan; Kong, Keng He; Low, Yin Peng

2015-11-01

With increasing evidence to support its practice, acupuncture has been integrated within many hospitals around the world. The purpose of this study is to understand the factors affecting decision making of patients as they select acupuncture treatment for their medical conditions and symptoms within a public hospital. A qualitative study consisting of in depth interviews with 14 patients was conducted. All patients attended an acupuncture clinic within a public hospital. Data collected was analysed via thematic analysis. Four main factor groups affecting decision making of patients were identified- factors affecting the level and value of patient-centric care, the confidence and trust patients place within the acupuncture service, the presence of collaborative efforts between acupuncturists and Western medicine practitioners, and the knowledge, culture and belief society has regarding the role of acupuncture and Western medicine. All participants interviewed had more than one factor group present as enablers toward their eventual selection of acupuncture for ailment management. It was also noted that although the majority of participants had sufficient knowledge regarding acupuncture, there were a select few who had misperceptions or no knowledge regarding certain aspects of acupuncture. There may be certain patterns in the way patients choose to utilise acupuncture services in public hospitals. Further studies should also be carried out in other public hospitals to analyse the factor groups identified further.

Barriers and decisions when answering clinical questions at the point of care: a grounded theory study.

PubMed

Cook, David A; Sorensen, Kristi J; Wilkinson, John M; Berger, Richard A

2013-11-25

Answering clinical questions affects patient-care decisions and is important to continuous professional development. The process of point-of-care learning is incompletely understood. To understand what barriers and enabling factors influence physician point-of-care learning and what decisions physicians face during this process. Focus groups with grounded theory analysis. Focus group discussions were transcribed and then analyzed using a constant comparative approach to identify barriers, enabling factors, and key decisions related to physician information-seeking activities. Academic medical center and outlying community sites. Purposive sample of 50 primary care and subspecialist internal medicine and family medicine physicians, interviewed in 11 focus groups. Insufficient time was the main barrier to point-of-care learning. Other barriers included the patient comorbidities and contexts, the volume of available information, not knowing which resource to search, doubt that the search would yield an answer, difficulty remembering questions for later study, and inconvenient access to computers. Key decisions were whether to search (reasons to search included infrequently seen conditions, practice updates, complex questions, and patient education), when to search (before, during, or after the clinical encounter), where to search (with the patient present or in a separate room), what type of resource to use (colleague or computer), what specific resource to use (influenced first by efficiency and second by credibility), and when to stop. Participants noted that key features of efficiency (completeness, brevity, and searchability) are often in conflict. Physicians perceive that insufficient time is the greatest barrier to point-of-care learning, and efficiency is the most important determinant in selecting an information source. Designing knowledge resources and systems to target key decisions may improve learning and patient care.

Company stock prices before and after public announcements related to oncology drugs.

PubMed

Rothenstein, Jeffrey M; Tomlinson, George; Tannock, Ian F; Detsky, Allan S

2011-10-19

Phase III clinical trials and Food and Drug Administration (FDA) regulatory decisions are critical for success of new drugs and can influence a company's market valuation. Knowledge of trial results before they are made public (ie, "inside information") can affect the price of a drug company's stock. We examined the stock prices of companies before and after public announcements regarding experimental anticancer drugs owned by the companies. We identified drugs that were undergoing evaluation in phase III trials or for regulatory approval by the US FDA from January 2000 to January 2009. Stock prices of companies that owned such drugs were analyzed for 120 trading days before and after the first public announcement of 1) results of clinical trials with positive and negative outcomes and 2) positive and negative regulatory decisions. All statistical tests were two-sided. We identified public announcements from 23 positive trials and 36 negative trials and from 41 positive and nine negative FDA regulatory decisions. The mean stock price for the 120 trading days before a phase III clinical trial announcement increased by 13.7% (95% confidence interval = -2.2% to 29.6%) for companies that reported positive trials and decreased by 0.7% (95% confidence interval = -13.8% to 12.3%) for companies that reported negative trials (P = .09). In a post hoc analysis comparing the stock price averaged over 60 trading days before and after day -60 relative to the clinical trial announcement, the mean stock price increased by 9.4% for companies that reported positive trials and decreased by 4.5% for companies that reported negative trials (P = .03). Changes in company stock prices before FDA regulatory decisions did not differ statistically between companies with positive decision and companies with negative decisions. Trends in company stock prices before the first public announcement differ for companies that report positive vs negative trials. This finding has important legal and ethical implications for investigators, drug companies, and the investment industry.

Reliability and criterion-related validity testing (construct) of the Endotracheal Suction Assessment Tool (ESAT©).

PubMed

Davies, Kylie; Bulsara, Max K; Ramelet, Anne-Sylvie; Monterosso, Leanne

2018-05-01

To establish criterion-related construct validity and test-retest reliability for the Endotracheal Suction Assessment Tool© (ESAT©). Endotracheal tube suction performed in children can significantly affect clinical stability. Previously identified clinical indicators for endotracheal tube suction were used as criteria when designing the ESAT©. Content validity was reported previously. The final stages of psychometric testing are presented. Observational testing was used to measure construct validity and determine whether the ESAT© could guide "inexperienced" paediatric intensive care nurses' decision-making regarding endotracheal tube suction. Test-retest reliability of the ESAT© was performed at two time points. The researchers and paediatric intensive care nurse "experts" developed 10 hypothetical clinical scenarios with predetermined endotracheal tube suction outcomes. "Experienced" (n = 12) and "inexperienced" (n = 14) paediatric intensive care nurses were presented with the scenarios and the ESAT© guiding decision-making about whether to perform endotracheal tube suction for each scenario. Outcomes were compared with those predetermined by the "experts" (n = 9). Test-retest reliability of the ESAT© was measured at two consecutive time points (4 weeks apart) with "experienced" and "inexperienced" paediatric intensive care nurses using the same scenarios and tool to guide decision-making. No differences were observed between endotracheal tube suction decisions made by "experts" (n = 9), "inexperienced" (n = 14) and "experienced" (n = 12) nurses confirming the tool's construct validity. No differences were observed between groups for endotracheal tube suction decisions at T1 and T2. Criterion-related construct validity and test-retest reliability of the ESAT© were demonstrated. Further testing is recommended to confirm reliability in the clinical setting with the "inexperienced" nurse to guide decision-making related to endotracheal tube suction. The ESAT© is the first validated tool to systematically guide endotracheal nursing practice for the "inexperienced" nurse. © 2018 John Wiley & Sons Ltd.

Safer Conception for Couples Affected by HIV: Structural and Cultural Considerations in the Delivery of Safer Conception Care in Uganda.

PubMed

Mindry, Deborah; Wanyenze, Rhoda K; Beyeza-Kashesya, Jolly; Woldetsadik, Mahlet A; Finocchario-Kessler, Sarah; Goggin, Kathy; Wagner, Glenn

2017-08-01

In countries with high HIV prevalence and high fertility desires, the rights of HIV-affected couples to have children are a pressing issue. Conception among people living with HIV carries risks for both horizontal and vertical HIV transmission. In Uganda ~100,000 HIV-infected women become pregnant annually. Providers face a number of challenges to preventing HIV transmission, reducing unplanned pregnancies, and ensuring safer conception. We report findings from interviews with 27 HIV-affected couples (54 individuals) in Uganda. We explored key cultural and structural factors shaping couples' childbearing decisions. Our data reveal a complex intersection of gender norms, familial expectations, relationship dynamics, and HIV stigma influencing their decisions. Participants provided insights regarding provider bias, stigma, and the gendering of reproductive healthcare. To reduce horizontal transmission HIV and family planning clinics must address men's and women's concerns regarding childbearing with specific attention to cultural and structural challenges.

Evidence Based-Practice and Affect: The Impact of Physician Attitudes on Outcomes Associated with Clinical Reasoning and Decision-Making

ERIC Educational Resources Information Center

Dunphy, Bruce; Dunphy, Stacey; Cantwell, Robert; Bourke, Sid; Fleming, Mark

2010-01-01

The relationship between obstetrician attitudes and patient outcomes from intrapartum care was examined. Obstetrician attitudes were assessed utilizing a newly-designed pilot 35-item obstetrician attitude questionnaire (OAQ). Twelve obstetricians completed the OAQ, who provided intra-partum care to 4,149 women. Outcome measures included delivery…

"I'd Been Like Freaking out the Whole Night": Exploring Emotion Regulation Based on Junior Doctors' Narratives

ERIC Educational Resources Information Center

Lundin, Robert M.; Bashir, Kiran; Bullock, Alison; Kostov, Camille E.; Mattick, Karen L.; Rees, Charlotte E.; Monrouxe, Lynn V.

2018-01-01

The importance of emotions within medical practice is well documented. Research suggests that how clinicians deal with negative emotions can affect clinical decision-making, health service delivery, clinician well-being, attentiveness to patient care and patient satisfaction. Previous research has identified the transition from student to junior…

Clinical decision making in hypotonia and gross motor delay: a case report of type 1 spinal muscular atrophy in an infant.

PubMed

Malerba, Kirsten Hawkins; Tecklin, Jan Stephen

2013-06-01

Children often are referred for physical therapy with the diagnosis of hypotonia when the definitive cause of hypotonia is unknown. The purpose of this case report is to describe the clinical decision-making process using the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II) for an infant with hypotonia and gross motor delay. The patient was a 5-month-old infant who had been evaluated by a neurologist and then referred for physical therapy by his pediatrician. Physical therapist evaluation results and clinical observations of marked hypotonia, significant gross motor delay, tongue fasciculations, feeding difficulties, and respiratory abnormalities prompted necessary referral to specialists. Recognition of developmental, neurologic, and respiratory abnormalities facilitated clinical decision making for determining the appropriate physical therapy plan of care. During the brief episode of physical therapy care, the patient was referred to a feeding specialist and diagnosed with pharyngeal-phase dysphasia and mild aspiration. Continued global weakness, signs and symptoms of type 1 spinal muscular atrophy (SMA), and concerns about increased work of breathing and respiratory compromise were discussed with the referring physician. After inconclusive laboratory testing for metabolic etiologies of hypotonia, a genetics consult was recommended and confirmed the diagnosis of type 1 SMA at 9 months of age. Physical therapists use clinical decision making to determine whether to treat patients or to refer them to other medical professionals. Accurate and timely referral to appropriate specialists may assist families in obtaining a diagnosis for their child and guide necessary interventions. In the case of type 1 SMA, early diagnosis may affect outcomes and survival rate in this pediatric population.

Incorporating affective bias in models of human decision making

NASA Technical Reports Server (NTRS)

Nygren, Thomas E.

1991-01-01

Research on human decision making has traditionally focused on how people actually make decisions, how good their decisions are, and how their decisions can be improved. Recent research suggests that this model is inadequate. Affective as well as cognitive components drive the way information about relevant outcomes and events is perceived, integrated, and used in the decision making process. The affective components include how the individual frames outcomes as good or bad, whether the individual anticipates regret in a decision situation, the affective mood state of the individual, and the psychological stress level anticipated or experienced in the decision situation. A focus of the current work has been to propose empirical studies that will attempt to examine in more detail the relationships between the latter two critical affective influences (mood state and stress) on decision making behavior.

Anxiety Evokes Hypofrontality and Disrupts Rule-Relevant Encoding by Dorsomedial Prefrontal Cortex Neurons.

PubMed

Park, Junchol; Wood, Jesse; Bondi, Corina; Del Arco, Alberto; Moghaddam, Bita

2016-03-16

Anxiety is a debilitating symptom of most psychiatric disorders, including major depression, post-traumatic stress disorder, schizophrenia, and addiction. A detrimental aspect of anxiety is disruption of prefrontal cortex (PFC)-mediated executive functions, such as flexible decision making. Here we sought to understand how anxiety modulates PFC neuronal encoding of flexible shifting between behavioral strategies. We used a clinically substantiated anxiogenic treatment to induce sustained anxiety in rats and recorded from dorsomedial PFC (dmPFC) and orbitofrontal cortex (OFC) neurons while they were freely moving in a home cage and while they performed a PFC-dependent task that required flexible switches between rules in two distinct perceptual dimensions. Anxiety elicited a sustained background "hypofrontality" in dmPFC and OFC by reducing the firing rate of spontaneously active neuronal subpopulations. During task performance, the impact of anxiety was subtle, but, consistent with human data, behavior was selectively impaired when previously correct conditions were presented as conflicting choices. This impairment was associated with reduced recruitment of dmPFC neurons that selectively represented task rules at the time of action. OFC rule representation was not affected by anxiety. These data indicate that a neural substrate of the decision-making deficits in anxiety is diminished dmPFC neuronal encoding of task rules during conflict-related actions. Given the translational relevance of the model used here, the data provide a neuronal encoding mechanism for how anxiety biases decision making when the choice involves overcoming a conflict. They also demonstrate that PFC encoding of actions, as opposed to cues or outcome, is especially vulnerable to anxiety. A debilitating aspect of anxiety is its impact on decision making and flexible control of behavior. These cognitive constructs depend on proper functioning of the prefrontal cortex (PFC). Understanding how anxiety affects PFC encoding of cognitive events is of great clinical and evolutionary significance. Using a clinically valid experimental model, we find that, under anxiety, decision making may be skewed by salient and conflicting environmental stimuli at the expense of flexible top-down guided choices. We also find that anxiety suppresses spontaneous activity of PFC neurons, and weakens encoding of task rules by dorsomedial PFC neurons. These data provide a neuronal encoding scheme for how anxiety disengages PFC during decision making. Copyright © 2016 the authors 0270-6474/16/363322-14$15.00/0.

Service providers' perception of affective influences on decision-making about treatments for chronic pain.

PubMed

Brown, Cary A

2004-01-07

Service providers working with people who have complex health problems like chronic pain are considered at particular risk from the heavy emotional content of these interactions (frustration, guilt, hostility). For the good of service users and in the interests of healthcare workers' own health it is important for them to employ reflective practice acknowledging these issues. Service providers are inculcated to negate the affective domain of their practice despite the growing awareness that wellbeing can no longer be envisioned as a linear (cause and effect) process divorced from socio-cultural influences and attendant values and beliefs. The aim of this report is to examine to what degree service users (SU) and service providers (SP) believe their decisions about treatment importance are influenced by self-image and emotion. These results are extrapolated from a larger study based on a postal questionnaire that went to members of the Pain Society (UK Chapter of IASP) and service users belonging to chronic pain support groups in the North-West of England. The question of interest in this report asked participants to identify their level of agreement with statements about how four themes influence their decision-making about whether a treatment is important. The themes (coherence, purposiveness, self-image and affect) arise from Chapman's model of consciousness and pain. Only 20.5% of service providers rated the influence of self-image (what someone like me would think) as 3 (mostly) or 4 (completely). Service provider rating for the influence of affect (how this treatment makes me feel) were similarly low with only 19.4% of respondents selecting a rating of 3 or 4. In marked contrast, 73.3% of the service users selected self-image and 92.9% selected affect as a strong influence. Service providers felt that affect and self-image had little influence on their decision-making. However, there is growing evidence in the literature to suggest that it is not possible, nor preferable, to divorce emotion from the clinical encounter.

Added Value of Contrast-Enhanced Ultrasound on Biopsies of Focal Hepatic Lesions Invisible on Fusion Imaging Guidance.

PubMed

Kang, Tae Wook; Lee, Min Woo; Song, Kyoung Doo; Kim, Mimi; Kim, Seung Soo; Kim, Seong Hyun; Ha, Sang Yun

2017-01-01

To assess whether contrast-enhanced ultrasonography (CEUS) with Sonazoid can improve the lesion conspicuity and feasibility of percutaneous biopsies for focal hepatic lesions invisible on fusion imaging of real-time ultrasonography (US) with computed tomography/magnetic resonance images, and evaluate its impact on clinical decision making. The Institutional Review Board approved this retrospective study. Between June 2013 and January 2015, 711 US-guided percutaneous biopsies were performed for focal hepatic lesions. Biopsies were performed using CEUS for guidance if lesions were invisible on fusion imaging. We retrospectively evaluated the number of target lesions initially invisible on fusion imaging that became visible after applying CEUS, using a 4-point scale. Technical success rates of biopsies were evaluated based on histopathological results. In addition, the occurrence of changes in clinical decision making was assessed. Among 711 patients, 16 patients (2.3%) were included in the study. The median size of target lesions was 1.1 cm (range, 0.5-1.9 cm) in pre-procedural imaging. After CEUS, 15 of 16 (93.8%) focal hepatic lesions were visualized. The conspicuity score was significantly increased after adding CEUS, as compared to that on fusion imaging (p < 0.001). The technical success rate of biopsy was 87.6% (14/16). After biopsy, there were changes in clinical decision making for 11 of 16 patients (68.8%). The addition of CEUS could improve the conspicuity of focal hepatic lesions invisible on fusion imaging. This dual guidance using CEUS and fusion imaging may affect patient management via changes in clinical decision-making.

Finding and applying evidence during clinical rounds: the "evidence cart".

PubMed

Sackett, D L; Straus, S E

1998-10-21

Physicians need easy access to evidence for clinical decisions while they care for patients but, to our knowledge, no investigators have assessed use of evidence during rounds with house staff. To determine if it was feasible to find and apply evidence during clinical rounds, using an "evidence cart" that contains multiple sources of evidence and the means for projecting and printing them. Descriptive feasibility study of use of evidence during 1 month (April 1997) and anonymous questionnaire (May 1997). General medicine inpatient service. Medical students, house staff, fellows, and attending consultant. Evidence cart that included 2 secondary sources developed by the department (critically appraised topics [CATs] and Redbook), Best Evidence, JAMA Rational Clinical Examination series, the Cochrane Library, MEDLINE, a physical examination textbook, a radiology anatomy textbook, and a Simulscope, which allows several people to listen simultaneously to the same signs on physical examination. Number of times sources were used, type of sources searched and success of searches, time needed to search, and whether the search affected patient care. The evidence cart was used 98 times, but could not be taken on bedside rounds because of its bulk; hard copies of several sources were taken instead. When the evidence cart was used during team rounds and student rounds, some sources could be accessed quickly enough (10.2-25.4 seconds) to be practical on our service. Of 98 searches, 79 (81%) sought evidence that could affect diagnostic and/or treatment decisions. Seventy-one (90%) of 79 searches regarding patient management were successful, and when assessed from the perspective of the most junior team members responsible for each patient's evaluation and management, 37 (52%) of the 71 successful searches confirmed their current or tentative diagnostic or treatment plans, 18 (25%) led to a new diagnostic skill, an additional test, or a new management decision, and 16 (23%) corrected a previous clinical skill, diagnostic test, or treatment. When the cart was removed, the perceived need for evidence rose sharply, but a search for it was carried out only 12% of the time (5 searches performed out of the 41 times evidence was needed). Making evidence quickly available to clinicians on a busy medical inpatient service using an evidence cart increased the extent to which evidence was sought and incorporated into patient care decisions.

Losing a dime with a satisfied mind: positive affect predicts less search in sequential decision making.

PubMed

von Helversen, Bettina; Mata, Rui

2012-12-01

We investigated the contribution of cognitive ability and affect to age differences in sequential decision making by asking younger and older adults to shop for items in a computerized sequential decision-making task. Older adults performed poorly compared to younger adults partly due to searching too few options. An analysis of the decision process with a formal model suggested that older adults set lower thresholds for accepting an option than younger participants. Further analyses suggested that positive affect, but not fluid abilities, was related to search in the sequential decision task. A second study that manipulated affect in younger adults supported the causal role of affect: Increased positive affect lowered the initial threshold for accepting an attractive option. In sum, our results suggest that positive affect is a key factor determining search in sequential decision making. Consequently, increased positive affect in older age may contribute to poorer sequential decisions by leading to insufficient search. 2013 APA, all rights reserved

[A study on participation in clinical decision making by home healthcare nurses].

PubMed

Kim, Se Young

2010-12-01

This study was done to identify participation by home healthcare nurses in clinical decision making and factors influencing clinical decision making. A descriptive survey was used to collect data from 68 home healthcare nurses in 22 hospital-based home healthcare services in Korea. To investigate participation, the researcher developed 3 scenarios through interviews with 5 home healthcare nurses. A self-report questionnaire composed of tools for characteristics, factors of clinical decision making, and participation was used. Participation was relatively high, but significantly lower in the design phase (F=3.51, p=.032). Competency in clinical decision making (r=.45, p<.001), perception of the decision maker role (r=.47, p<.001), and perception of the utility of clinical practice guidelines (r=.25, p=.043) were significantly correlated with participation. Competency in clinical decision making (Odds ratio [OR]=41.79, p=.007) and perception of the decision maker role (OR=15.09, p=.007) were significant factors predicting participation in clinical decision making by home healthcare nurses. In order to encourage participation in clinical decision making, education programs should be provided to home healthcare nurses. Official clinical practice guidelines should be used to support home healthcare nurses' participation in clinical decision making in cases where they can identify and solve the patient health problems.

Women's views of two interventions designed to assist in the prophylactic oophorectomy decision: a qualitative pilot evaluation

PubMed Central

Bhavnani, Vanita; Clarke, Aileen; Dowie, Jack; Kennedy, Andrew; Pell, Ian

2002-01-01

Abstract Introduction  A qualitative pilot evaluation of two different decision interventions for the prophylactic oophorectomy (PO) decision: a Decision Chart and a computerized clinical guidance programme (CGP) was undertaken. The Decision Chart, representing current practice in decision interventions, presents population‐based information. The CGP elicits individual values to allow for quality‐adjusted life years to be calculated and an explicit guidance statement is given. Prophylactic oophorectomy involves removal of the ovaries as an adjunct to hysterectomy to prevent ovarian cancer. The decision is complex because the operation can affect a number of long‐term outcomes including breast cancer, coronary heart disease and osteoporosis. Methods  Both interventions were based on the evidence and were administered by a facilitator. The Decision Chart is a file, which progressively reveals information in the form of bar charts. The CGP is a decision‐analysis based program integrating the results from a cluster of Markov cycle trees. The research evidence is incorporated with woman's individual risk factors, values and preferences. A purposive sample of 19 women awaiting hysterectomy used the decision interventions (10 CGP, nine Decision Chart). In‐depth semi‐structured interviews were undertaken. Interviews were transcribed and analysed to derive themes. Results  Reactions to the different decision interventions were mixed. Both were seen as clarifying the decision. Some women found some of the tasks difficult (e.g. rating health status). Some were surprised by the ‘individualized’ guidance, which the CGP offered. The Decision Chart provided some with a sense of empowerment, although some found that it provided too much information. Conclusions  Women were able to use both decision interventions. Both provided decision clarification. Problems were evident with both interventions, which give useful pointers for future development. These included the possibility for women to see how their individual risks of different outcomes are affected in the Decision Chart and enhanced explanation of the CGP tasks. Future design and evaluation of decision aids, will need to accommodate differences between patients in the desire for amount and type of information and level of involvement in the decision‐making process. PMID:12031056

Reaching beyond the review of research evidence: a qualitative study of decision making during the development of clinical practice guidelines for disease prevention in healthcare.

PubMed

Richter Sundberg, Linda; Garvare, Rickard; Nyström, Monica Elisabeth

2017-05-11

The judgment and decision making process during guideline development is central for producing high-quality clinical practice guidelines, but the topic is relatively underexplored in the guideline research literature. We have studied the development process of national guidelines with a disease-prevention scope produced by the National board of Health and Welfare (NBHW) in Sweden. The NBHW formal guideline development model states that guideline recommendations should be based on five decision-criteria: research evidence; curative/preventive effect size, severity of the condition; cost-effectiveness; and ethical considerations. A group of health profession representatives (i.e. a prioritization group) was assigned the task of ranking condition-intervention pairs for guideline recommendations, taking into consideration the multiple decision criteria. The aim of this study was to investigate the decision making process during the two-year development of national guidelines for methods of preventing disease. A qualitative inductive longitudinal case study approach was used to investigate the decision making process. Questionnaires, non-participant observations of nine two-day group meetings, and documents provided data for the analysis. Conventional and summative qualitative content analysis was used to analyse data. The guideline development model was modified ad-hoc as the group encountered three main types of dilemmas: high quality evidence vs. low adoptability of recommendation; insufficient evidence vs. high urgency to act; and incoherence in assessment and prioritization within and between four different lifestyle areas. The formal guideline development model guided the decision-criteria used, but three new or revised criteria were added by the group: 'clinical knowledge and experience', 'potential guideline consequences' and 'needs of vulnerable groups'. The frequency of the use of various criteria in discussions varied over time. Gender, professional status, and interpersonal skills were perceived to affect individuals' relative influence on group discussions. The study shows that guideline development groups make compromises between rigour and pragmatism. The formal guideline development model incorporated multiple aspects, but offered few details on how the different criteria should be handled. The guideline development model devoted little attention to the role of the decision-model and group-related factors. Guideline development models could benefit from clarifying the role of the group-related factors and non-research evidence, such as clinical experience and ethical considerations, in decision-processes during guideline development.

The Role of Documentation Quality in Anesthesia-Related Closed Claims: A Descriptive Qualitative Study.

PubMed

Wilbanks, Bryan A; Geisz-Everson, Marjorie; Boust, Rebecca R

2016-09-01

Clinical documentation is a critical tool in supporting care provided to patients. Sound documentation provides a picture of clinical events that can be used to improve patient care. However, many other uses for clinical documentation are equally important. Such documentation informs clinical decision support tools, creates a legal record of patient care, assists in financial reimbursement of services, and serves as a repository for secondary data analysis. Conversely, poor documentation can impair patient safety and increase malpractice risk exposure by reflecting poor or inaccurate information that ultimately may guide patient care decisions.Through an examination of anesthesia-related closed claims, a descriptive qualitative study emerged, which explored the antecedents and consequences of documentation quality in the claims reviewed. A secondary data analysis utilized a database generated by the American Association of Nurse Anesthetists Foundation closed claim review team. Four major themes emerged from the analysis. Themes 1, 2, and 4 primarily describe how poor documentation quality can have negative consequences for clinicians. The third theme primarily describes how poor documentation quality that can negatively affect patient safety.

Impaired decision making and delayed memory are related with anxiety and depressive symptoms in acromegaly.

PubMed

Crespo, Iris; Santos, Alicia; Valassi, Elena; Pires, Patricia; Webb, Susan M; Resmini, Eugenia

2015-12-01

Evaluation of cognitive function in acromegaly has revealed contradictory findings; some studies report normal cognition in patients with long-term cured acromegaly, while others show attention and memory deficits. Moreover, the presence of affective disorders in these patients is common. Our aim was to evaluate memory and decision making in acromegalic patients and explore their relationship with affective disorders like anxiety and depressive symptoms. Thirty-one patients with acromegaly (mean age 49.5 ± 8.5 years, 14 females and 17 males) and thirty-one healthy controls participated in this study. The Iowa Gambling Task (IGT), Rey Auditory Verbal Learning Test, State-Trait Anxiety Inventory, and Beck Depression Inventory-II (BDI-II) were used to evaluate decision making, verbal memory, anxiety, and depressive symptoms, respectively. Acromegalic patients showed impairments in delayed verbal memory (p < 0.05) and more anxiety and depressive symptoms (p < 0.05) than controls. In the IGT, acromegalic patients presented an altered decision-making strategy compared to controls, choosing a lower number of the safer cards (p < 0.05) and higher number of the riskier cards (p < 0.05). Moreover, multiple correlations between anxiety and depressive symptoms and performance in memory and decision making were found. Impaired delayed memory and decision making observed in acromegalic patients are related to anxiety and depressive symptoms. Providing emotional support to the patients could improve their cognitive function. A key clinical application of this research is the finding that depressive symptoms and anxiety are essentially modifiable factors.

Robust parameter extraction for decision support using multimodal intensive care data

PubMed Central

Clifford, G.D.; Long, W.J.; Moody, G.B.; Szolovits, P.

2008-01-01

Digital information flow within the intensive care unit (ICU) continues to grow, with advances in technology and computational biology. Recent developments in the integration and archiving of these data have resulted in new opportunities for data analysis and clinical feedback. New problems associated with ICU databases have also arisen. ICU data are high-dimensional, often sparse, asynchronous and irregularly sampled, as well as being non-stationary, noisy and subject to frequent exogenous perturbations by clinical staff. Relationships between different physiological parameters are usually nonlinear (except within restricted ranges), and the equipment used to measure the observables is often inherently error-prone and biased. The prior probabilities associated with an individual's genetics, pre-existing conditions, lifestyle and ongoing medical treatment all affect prediction and classification accuracy. In this paper, we describe some of the key problems and associated methods that hold promise for robust parameter extraction and data fusion for use in clinical decision support in the ICU. PMID:18936019

Heuristics in Managing Complex Clinical Decision Tasks in Experts’ Decision Making

PubMed Central

Islam, Roosan; Weir, Charlene; Del Fiol, Guilherme

2016-01-01

Background Clinical decision support is a tool to help experts make optimal and efficient decisions. However, little is known about the high level of abstractions in the thinking process for the experts. Objective The objective of the study is to understand how clinicians manage complexity while dealing with complex clinical decision tasks. Method After approval from the Institutional Review Board (IRB), three clinical experts were interviewed the transcripts from these interviews were analyzed. Results We found five broad categories of strategies by experts for managing complex clinical decision tasks: decision conflict, mental projection, decision trade-offs, managing uncertainty and generating rule of thumb. Conclusion Complexity is created by decision conflicts, mental projection, limited options and treatment uncertainty. Experts cope with complexity in a variety of ways, including using efficient and fast decision strategies to simplify complex decision tasks, mentally simulating outcomes and focusing on only the most relevant information. Application Understanding complex decision making processes can help design allocation based on the complexity of task for clinical decision support design. PMID:27275019

Heuristics in Managing Complex Clinical Decision Tasks in Experts' Decision Making.

PubMed

Islam, Roosan; Weir, Charlene; Del Fiol, Guilherme

2014-09-01

Clinical decision support is a tool to help experts make optimal and efficient decisions. However, little is known about the high level of abstractions in the thinking process for the experts. The objective of the study is to understand how clinicians manage complexity while dealing with complex clinical decision tasks. After approval from the Institutional Review Board (IRB), three clinical experts were interviewed the transcripts from these interviews were analyzed. We found five broad categories of strategies by experts for managing complex clinical decision tasks: decision conflict, mental projection, decision trade-offs, managing uncertainty and generating rule of thumb. Complexity is created by decision conflicts, mental projection, limited options and treatment uncertainty. Experts cope with complexity in a variety of ways, including using efficient and fast decision strategies to simplify complex decision tasks, mentally simulating outcomes and focusing on only the most relevant information. Understanding complex decision making processes can help design allocation based on the complexity of task for clinical decision support design.

A review of clinical decision making: models and current research.

PubMed

Banning, Maggi

2008-01-01

The aim of this paper was to review the current literature clinical decision-making models and the educational application of models to clinical practice. This was achieved by exploring the function and related research of the three available models of clinical decision making: information-processing model, the intuitive-humanist model and the clinical decision-making model. Clinical decision making is a unique process that involves the interplay between knowledge of pre-existing pathological conditions, explicit patient information, nursing care and experiential learning. Historically, two models of clinical decision making are recognized from the literature; the information-processing model and the intuitive-humanist model. The usefulness and application of both models has been examined in relation the provision of nursing care and care related outcomes. More recently a third model of clinical decision making has been proposed. This new multidimensional model contains elements of the information-processing model but also examines patient specific elements that are necessary for cue and pattern recognition. Literature review. Evaluation of the literature generated from MEDLINE, CINAHL, OVID, PUBMED and EBESCO systems and the Internet from 1980 to November 2005. The characteristics of the three models of decision making were identified and the related research discussed. Three approaches to clinical decision making were identified, each having its own attributes and uses. The most recent addition to the clinical decision making is a theoretical, multidimensional model which was developed through an evaluation of current literature and the assessment of a limited number of research studies that focused on the clinical decision-making skills of inexperienced nurses in pseudoclinical settings. The components of this model and the relative merits to clinical practice are discussed. It is proposed that clinical decision making improves as the nurse gains experience of nursing patients within a specific speciality and with experience, nurses gain a sense of saliency in relation to decision making. Experienced nurses may use all three forms of clinical decision making both independently and concurrently to solve nursing-related problems. It is suggested that O'Neill's clinical decision-making model could be tested by educators and experienced nurses to assess the efficacy of this hybrid approach to decision making.

Racial and ethnic disparities in the clinical practice of emergency medicine.

PubMed

Richardson, Lynne D; Babcock Irvin, Charlene; Tamayo-Sarver, Joshua H

2003-11-01

There is convincing evidence that racial and ethnic disparities exist in the provision of health care, including the provision of emergency care; and that stereotyping, biases, and uncertainty on the part of health care providers all contribute to unequal treatment. Situations, such as the emergency department (ED), that are characterized by time pressure, incomplete information, and high demands on attention and cognitive resources increase the likelihood that stereotypes and bias will affect diagnostic and treatment decisions. It is likely that there are many as-yet-undocumented disparities in clinical emergency practice. Racial and ethnic disparities may arise in decisions made by out-of-hospital personnel regarding ambulance destination, triage assessments made by nursing personnel, diagnostic testing ordered by physicians or physician-extenders, and in disposition decisions. The potential for disparate treatment includes the timing and intensity of ED therapy as well as patterns of referral, prescription choices, and priority for hospital admission and bed assignment. At a national roundtable discussion, strategies suggested to address these disparities included: increased use of evidence-based clinical guidelines; use of continuous quality improvement methods to document individual and institutional disparities in performance; zero tolerance for stereotypical remarks in the workplace; cultural competence training for emergency providers; increased workforce diversity; and increased epidemiologic, clinical, and services research. Careful scrutiny of the clinical practice of emergency medicine and diligent implementation of strategies to prevent disparities will be required to eliminate the individual behaviors and systemic processes that result in the delivery of disparate care in EDs.

Factors affecting the decision to hospitalise children admitted to the emergency department due to non-fatal suicide attempts by pills.

PubMed

Gokalp, Gamze; Anil, Murat; Bal, Alkan; Bicilioglu, Yuksel; Kamit Can, Fulya; Anil, Ayse Berna

2016-01-01

Suicide attempts (SAs) in the paediatric age group represent an important cause of morbidity and mortality. Our aim was to examine the factors affecting the decision to hospitalize children with a diagnosis of non-fatal SA by pills. Children <18 years of age admitted with SA by pills during 2014 were evaluated retrospectively. Patients were divided into two groups: Group-I comprised hospitalised patients and Group-II included those who were discharged from the PED. These two groups were compared in terms of clinical and demographic characteristics recorded upon PED admission. A total of 196 patients were included in the study. The number of pills taken for self-poisoning in Group-I (median: 20 pills) was higher than that in Group-II (median: 12 pills) (p < 0.001), and the rate of pathological findings during the first paediatric psychiatric consultation was higher in Group-I (91.1%) than in the Group-II (54.8%) (p < 0.001). Factors affecting the disposition decision in cases of children who performed non-fatal SA via pills included the amount of medication taken for the suicide attempt and the presence of psychiatric disorders, as determined by a paediatric psychiatrist during the acute phase.

Atypia in random periareolar fine-needle aspiration affects the decision of women at high risk to take tamoxifen for breast cancer chemoprevention.

PubMed

Goldenberg, Vanessa K; Seewaldt, Victoria L; Scott, Victoria; Bean, Gregory R; Broadwater, Gloria; Fabian, Carol; Kimler, Bruce; Zalles, Carola; Lipkus, Isaac M

2007-05-01

Random periareolar fine-needle aspiration (RPFNA) is a research procedure designed to (a) evaluate short-term breast cancer risk in women at high risk for developing breast cancer, and (b) track response to chemoprevention. Of import, cellular atypia in breast RPFNA is prospectively associated with a 5.6-fold increase in breast cancer risk in women at high risk. Among 99 women attending a clinic for high-risk breast cancer, we explored the effects of RPFNA cytology results on decision making pertaining to the use of tamoxifen for breast cancer chemoprevention. No patient with nonproliferative or hyperplastic cytology subsequently elected to take tamoxifen. Only 7% of subjects with borderline atypia elected to take tamoxifen. In contrast, 50% with atypia elected to take tamoxifen. These results suggest that the provision of a biomarker of short-term risk can affect the motivation to take tamoxifen for chemoprevention. This conclusion is informative given that tamoxifen, due to its side effects, is often underused by women at high risk of developing breast cancer. Further research is needed to determine the mechanisms through which RPFNA results affect the decision to use tamoxifen, or any other breast cancer chemopreventive agent.

Effective communication about the use of complementary and integrative medicine in cancer care.

PubMed

Frenkel, Moshe; Cohen, Lorenzo

2014-01-01

Complementary and integrative medicine (CIM) is becoming an increasingly popular and visible component of oncology care. Many patients affected by cancer and their family members are looking for informed advice and desire communication with their physicians about CIM use. Patients affected by cancer come to discuss CIM use with intense emotions and are experiencing an existential crisis that cannot be ignored. Effective communication is crucial in establishing trust with these patients and their families. Communication is now recognized as a core clinical skill in medicine, including cancer care, and is important to the delivery of high-quality care. The quality of communication affects patient satisfaction, decision-making, patient distress and well-being, compliance, and even malpractice litigation. The communication process about CIM use requires a very sensitive approach that depends on effective communication skills, such as experience in listening, encouraging hope, and ability to convey empathy and compassion. This process can be divided into two parts: the "how" and the "what". The "how" relates to the change in clinician attitude, the process of gathering information, addressing patients' unmet needs and emotions, and dealing with uncertainty. The "what" relates to the process of information exchange while assisting patients in decisions about CIM use by using reliable information sources, leading to informed decision-making.

Balancing emotion and cognition: a case for decision aiding in conservation efforts.

PubMed

Wilson, Robyn S

2008-12-01

Despite advances in the quality of participatory decision making for conservation, many current efforts still suffer from an inability to bridge the gap between science and policy. Judgment and decision-making research suggests this gap may result from a person's reliance on affect-based shortcuts in complex decision contexts. I examined the results from 3 experiments that demonstrate how affect (i.e., the instantaneous reaction one has to a stimulus) influences individual judgments in these contexts and identified techniques from the decision-aiding literature that help encourage a balance between affect-based emotion and cognition in complex decision processes. In the first study, subjects displayed a lack of focus on their stated conservation objectives and made decisions that reflected their initial affective impressions. Value-focused approaches may help individuals incorporate all the decision-relevant objectives by making the technical and value-based objectives more salient. In the second study, subjects displayed a lack of focus on statistical risk and again made affect-based decisions. Trade-off techniques may help individuals incorporate relevant technical data, even when it conflicts with their initial affective impressions or other value-based objectives. In the third study, subjects displayed a lack of trust in decision-making authorities when the decision involved a negatively affect-rich outcome (i.e., a loss). Identifying shared salient values and increasing procedural fairness may help build social trust in both decision-making authorities and the decision process.

Fear and decision-making in narcissistic personality disorder—a link between psychoanalysis and neuroscience

PubMed Central

Ronningstam, Elsa; Baskin-Sommers, Arielle R.

2013-01-01

Linking psychoanalytic studies with neuroscience has proven increasingly productive for identifying and understanding personality functioning. This article focuses on pathological narcissism and narcissistic personality disorder (NPD), with the aim of exploring two clinically relevant aspects of narcissistic functioning also recognized in psychoanalysis: fear and decision-making. Evidence from neuroscientific studies of related conditions, such as psychopathy, suggests links between affective and cognitive functioning that can influence the sense of self-agency and narcissistic self-regulation. Attention can play a crucial role in moderating fear and self-regulatory deficits, and the interaction between experience and emotion can be central for decision-making. In this review we will explore fear as a motivating factor in narcissistic personality functioning, and the impact fear may have on decision-making in people with pathological narcissism and NPD. Understanding the processes and neurological underpinnings of fear and decision-making can potentially influence both the diagnosis and treatment of NPD. PMID:24174893

Physician, Patient and Contextual Factors Affecting Treatment Decisions in Older Adults with Cancer: A Literature Review

PubMed Central

Tariman, J. D.; Berry, D. L.; Cochrane, B.; Doorenbos, A.; Schepp, K.

2010-01-01

Purpose/Objectives To review physician, patient, and contextual factors that affect treatment decision-making in older adults diagnosed with cancer and relate these factors to theoretical models of decision-making. Data Sources PubMed (1966-April 2010), PsycINFO (1967-April 2010) and CINAHL (1982-April 2010) databases were searched to access relevant medical, psychological and nursing literature. Data Synthesis Physician factors in treatment decisions include physician personal beliefs and values, expertise, practice type, perception of lowered life expectancy, medical factors, power, and communication style. Patient factors include personal beliefs and values, ethnicity, decisional control preferences, previous health-related experience, perception of the decision-making process, and personal factors. Contextual factors include availability of caregiver, lack of insurance, poor financial status, and geographical barrier. The interplay of physician, patient, and contextual factors are not well understood. Existing models of decision-making are not sufficient to explicate TDM process in older adults diagnosed with cancer. Conclusions Clinical studies in older adult patient population using a longitudinal and prospective design are needed to examine real-time interplay of patient, physician, and contextual factors and to better understand how these divergent factors influenced actual treatment decisions. Implications for Nursing Oncology nurses can advocate for a patient’s autonomy during TDM by coaching them to seek evidence-based discussion of various treatment options, benefits and risks assessments, and truthful discussion of the probability of success for each treatment option from their physicians. Oncology nurses must promote an informed treatment decisions that are consistent with a patient’s personal preference and values within the limits of the patient’s personal contexts. PMID:22201670

Patients' views of consent in clinical trials for acute myocardial infarction: impact of trial design.

PubMed

Dickert, Neal W; Hendershot, Kristopher A; Speight, Candace D; Fehr, Alexandra E

2017-08-01

Seeking prospective informed consent is difficult in clinical trials for emergent conditions such as acute myocardial infarction (AMI). Prior data suggest that enrolment decisions of patients are often poorly informed in AMI trials but that patients prefer to be asked permission before enrolment. It is unknown whether this is true across trial designs or in comparative effectiveness research (CER) with approved treatments. Structured interviews were conducted with 30 patients with AMI. Participants considered three scenarios: (1) a CER trial of approved antiplatelet drugs; (2) a placebo-controlled trial of a novel drug to reduce myocardial injury and (3) a CER trial of an intra-aortic balloon pump versus medication. Participants were asked their desired involvement in enrolment decisions and willingness to participate. Descriptive analysis was performed of Likert scale data, and qualitative descriptive analysis was performed of textual data. Across scenarios, most participants (73%-80%) preferred to be asked permission prior to trial enrolment. Reasons for involvement included wanting to be the decision maker and a desire for transparency. Willingness to enrol was affected by trial type. Fewer participants stated they would likely enrol in a CER procedural trial than in a CER trial of approved medications (p=0.012). These findings suggest that patients prefer prospective involvement in enrolment decisions to enrolment without consent across trial types. However, their desire to participate was affected by trial type. There is a need to develop and evaluate context-sensitive approaches to consent in AMI trials that account for both the acuity of the situation and trial characteristics. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Attributions of responsibility and affective reactions to decision outcomes.

PubMed

Zeelenberg, M; van der Pligt, J; de Vries, N K

2000-06-01

Immediate affective reactions to outcomes are more intense following decisions to act than following decisions not to act. This finding holds for both positive and negative outcomes. We relate this "actor-effect" to attribution theory and argue that decision makers are seen as more responsible for outcomes when these are the result of a decision to act as compared to a decision not to act. Experiment 1 (N = 80) tests the main assumption underlying our reasoning and shows that affective reactions to decision outcomes are indeed more intense when the decision maker is seen as more responsible. Experiment 2 (N = 40) tests whether the actor effect can be predicted on the basis of differential attributions following action and inaction. Participants read vignettes in which active and passive actors obtained a positive or negative outcome. Action resulted in more intense affect than inaction, and positive outcomes resulted in more intense affect than negative outcomes. Experiment 2 further shows that responsibility attributions and affective reactions to outcomes are highly correlated; that is, more extreme affective reactions are associated with more internal attributions. We discuss the implications for research on post-decisional reactions.

Beyond individualism: Is there a place for relational autonomy in clinical practice and research?

PubMed Central

Kelly, Susan E; Lucivero, Federica; Machirori, Mavis; Dheensa, Sandi; Prainsack, Barbara

2017-01-01

The dominant, individualistic understanding of autonomy that features in clinical practice and research is underpinned by the idea that people are, in their ideal form, independent, self-interested and rational gain-maximising decision-makers. In recent decades, this paradigm has been challenged from various disciplinary and intellectual directions. Proponents of ‘relational autonomy’ in particular have argued that people’s identities, needs, interests – and indeed autonomy – are always also shaped by their relations to others. Yet, despite the pronounced and nuanced critique directed at an individualistic understanding of autonomy, this critique has had very little effect on ethical and legal instruments in clinical practice and research so far. In this article, we use four case studies to explore to what extent, if at all, relational autonomy can provide solutions to ethical and practical problems in clinical practice and research. We conclude that certain forms of relational autonomy can have a tangible and positive impact on clinical practice and research. These solutions leave the ultimate decision to the person most affected, but encourage and facilitate the consideration of this person’s care and responsibility for connected others. PMID:28989327

Factors affecting delays in first trimester pregnancy termination services in New Zealand.

PubMed

Silva, Martha; McNeill, Rob; Ashton, Toni

2011-04-01

To identify the factors affecting the timeliness of services in first trimester abortion service in New Zealand. Primary data were collected from all patients attending nine abortion clinics between February and May 2009. The outcome measured was delay between the first visit with a referring doctor and the date of the abortion procedure. Patient records (n=2,950) were audited to determine the timeline between the first point of entry to the health system and the date of abortion. Women were also invited to fill out a questionnaire identifying personal factors affecting access to services (n=1,086, response rate = 36.8%). Women who went to private clinic had a significantly shorter delay compared to public clinics. Controlling for clinic type, women who went to clinics that offered medical abortions or clinics that offered single day services experienced less delay. Also, women who had more than one visit with their referring doctor experienced a greater delay than those who had a single visit. The earlier in pregnancy women sought services the longer the delay. Women's decision-making did not have a significant effect on delay. Several clinic level and systemic factors are significantly associated with delay in first trimester abortion services. In order to ensure the best physical and emotional outcomes, timeliness of services must improve. © 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia.

Return to Play After Infectious Mononucleosis

PubMed Central

Becker, Jonathan A.; Smith, Julie Anne

2014-01-01

Context: Infectious mononucleosis is a disease primarily of adolescence and early adulthood. The risk of splenic injury and chronic fatigue make return-to-play decisions a challenge for the clinician caring for athletes with infectious mononucleosis. Evidence Acquisition: Data were obtained from the PubMed and MEDLINE databases through December 2012 by searching for epidemiology, diagnosis, clinical manifestations, management, and the role of the spleen in infectious mononucleosis. Study Design: Clinical review. Level of Evidence: Level 4. Results: Infectious mononucleosis is commonly encountered in young athletes. Its disease pattern is variable and can affect multiple organ systems. Supportive care is the cornerstone, with little role for medications such as corticosteroids. Physical examination is unreliable for the spleen, and ultrasound imaging has limitations in its ability to guide return-to-play decisions. Exercise does not appear to place the young athlete at risk for chronic fatigue, but determining who is at risk for persistent symptoms is a challenge. Conclusion: Return-to-play decisions for the athlete with infectious mononucleosis need to be individualized because of the variable disease course and lack of evidence-based guidelines. PMID:24790693

Clinical decision rules, spinal pain classification and prediction of treatment outcome: A discussion of recent reports in the rehabilitation literature

PubMed Central

2012-01-01

Clinical decision rules are an increasingly common presence in the biomedical literature and represent one strategy of enhancing clinical-decision making with the goal of improving the efficiency and effectiveness of healthcare delivery. In the context of rehabilitation research, clinical decision rules have been predominantly aimed at classifying patients by predicting their treatment response to specific therapies. Traditionally, recommendations for developing clinical decision rules propose a multistep process (derivation, validation, impact analysis) using defined methodology. Research efforts aimed at developing a “diagnosis-based clinical decision rule” have departed from this convention. Recent publications in this line of research have used the modified terminology “diagnosis-based clinical decision guide.” Modifications to terminology and methodology surrounding clinical decision rules can make it more difficult for clinicians to recognize the level of evidence associated with a decision rule and understand how this evidence should be implemented to inform patient care. We provide a brief overview of clinical decision rule development in the context of the rehabilitation literature and two specific papers recently published in Chiropractic and Manual Therapies. PMID:22726639

Emergency physicians' attitudes and preferences regarding computed tomography, radiation exposure, and imaging decision support.

PubMed

Griffey, Richard T; Jeffe, Donna B; Bailey, Thomas

2014-07-01

Although computerized decision support for imaging is often recommended for optimizing computed tomography (CT) use, no studies have evaluated emergency physicians' (EPs') preferences regarding computerized decision support in the emergency department (ED). In this needs assessment, the authors sought to determine if EPs view overutilization as a problem, if they want decision support, and if so, the kinds of support they prefer. A 42-item, Web-based survey of EPs was developed and used to measure EPs' attitudes, preferences, and knowledge. Key contacts at local EDs sent letters describing the study to their physicians. Exploratory principal components analysis (PCA) was used to determine the underlying factor structure of multi-item scales, Cronbach's alpha was used to measure internal consistency of items on a scale, Spearman correlations were used to describe bivariate associations, and multivariable linear regression analysis was used to identify variables independently associated with physician interest in decision support. Of 235 surveys sent, 155 (66%) EPs responded. Five factors emerged from the PCA. EPs felt that: 1) CT overutilization is a problem in the ED (α = 0.75); 2) a patient's cumulative CT study count affects decisions of whether and what type of imaging study to order only some of the time (α = 0.75); 3) knowledge that a patient has had prior CT imaging for the same indication makes EPs less likely to order a CT (α = 0.42); 4) concerns about malpractice, patient satisfaction, or insistence on CTs affect CT ordering decisions (α = 0.62); and 5) EPs want decision support before ordering CTs (α = 0.85). Performance on knowledge questions was poor, with only 18% to 39% correctly responding to each of the three multiple-choice items about effective radiation doses of chest radiograph and single-pass abdominopelvic CT, as well as estimated increased risk of cancer from a 10-mSv exposure. Although EPs wanted information on patients' cumulative exposures, they feel inadequately familiar with this information to make use of it clinically. If provided with patients' cumulative radiation exposures from CT, 87% of EPs said that they would use this information to discuss imaging options with their patients. In the multiple regression model, which included all variables associated with interest in decision support at p < 0.10 in bivariate tests, items independently associated with EPs' greater interest in all types of decision support proposed included lower total knowledge scores, greater frequency that cumulative CT study count affects EP's decision to order CTs, and greater agreement that overutilization of CT is a problem and that awareness of multiple prior CTs for a given indication affects CT ordering decisions. Emergency physicians view overutilization of CT scans as a problem with potential for improvement in the ED and would like to have more information to discuss risks with their patients. EPs are interested in all types of imaging decision support proposed to help optimize imaging ordering in the ED and to reduce radiation to their patients. Findings reveal several opportunities that could potentially affect CT utilization. © 2014 by the Society for Academic Emergency Medicine.

Emergency Physicians’ Attitudes and Preferences Regarding Computed Tomography, Radiation Exposure, and Imaging Decision Support

PubMed Central

Griffey, Richard T.; Jeffe, Donna B.; Bailey, Thomas

2014-01-01

Objectives Although computerized decision support for imaging is often recommended for optimizing computed tomography (CT) use, no studies have evaluated emergency physicians’ (EPs’) preferences regarding computerized decision support in the emergency department (ED). In this needs assessment, the authors sought to determine if EPs view overutilization as a problem, if they want decision support, and if so, the kinds of support they prefer. Methods A 42-item, Web-based survey of EPs was developed and used to measure EPs’ attitudes, preferences, and knowledge. Key contacts at local EDs sent letters describing the study to their physicians. Exploratory principal components analysis (PCA) was used to determine the underlying factor structure of multi-item scales, Cronbach’s alpha was used to measure internal consistency of items on a scale, Spearman correlations were used to describe bivariate associations, and multivariable linear regression analysis was used to identify variables independently associated with physician interest in decision support. Results Of 235 surveys sent, 155 (66%) EPs responded. Five factors emerged from the PCA. EPs felt that: 1) CT overutilization is a problem in the ED (α = 0.75); 2) a patient’s cumulative CT study count affects decisions of whether and what type of imaging study to order only some of the time (α = 0.75); 3) knowledge that a patient has had prior CT imaging for the same indication makes EPs less likely to order a CT (α = 0.42); 4) concerns about malpractice, patient satisfaction, or insistence on CTs affect CT ordering decisions (α = 0.62); and 5) EPs want decision support before ordering CTs (α = 0.85). Performance on knowledge questions was poor, with only 18% to 39% correctly responding to each of the three multiple-choice items about effective radiation doses of chest radiograph and single-pass abdominopelvic CT, as well as estimated increased risk of cancer from a 10-mSv exposure. Although EPs wanted information on patients’ cumulative exposures, they feel inadequately familiar with this information to make use of it clinically. If provided with patients’ cumulative radiation exposures from CT, 87% of EPs said that they would use this information to discuss imaging options with their patients. In the multiple regression model, which included all variables associated with interest in decision support at p < 0.10 in bivariate tests, items independently associated with EPs’ greater interest in all types of decision support proposed included lower total knowledge scores, greater frequency that cumulative CT study count affects EP’s decision to order CTs, and greater agreement that overutilization of CT is a problem and that awareness of multiple prior CTs for a given indication affects CT ordering decisions. Conclusions Emergency physicians view overutilization of CT scans as a problem with potential for improvement in the ED and would like to have more information to discuss risks with their patients. EPs are interested in all types of imaging decision support proposed to help optimize imaging ordering in the ED and to reduce radiation to their patients. Findings reveal several opportunities that could potentially affect CT utilization. PMID:25125272

Clinical appearances, healing patterns, risk factors, and outcomes of horses with fungal keratitis: 53 cases (1978-1996)

PubMed

Gaarder, J E; Rebhun, W C; Ball, M A; Patten, V; Shin, S; Erb, H

1998-07-01

To compare initial clinical appearances, healing mechanisms, risk factors, and outcomes of horses with fungal keratitis. Retrospective analysis. 52 horses (53 eyes) with fungal keratitis. Medical records and clinical photographs of eyes were reviewed. Keratomycoses were categorized on the basis of clinical appearance at initial examination and pattern of healing. Five distinct forms of mycotic keratitis were recognized. Of 53 affected eyes, 34 (64%) retained sight and had varying degrees of corneal scarring after treatment, 6 (11%) had a cosmetic appearance but were blind, and 13 (25%) were enucleated. Bacterial-like ulcers were the most frequent type and the most difficult for predicting outcome. Eyes affected by superficial fungal keratitis were likely to be chronically infected and to require debridement and extended treatment but usually healed with minimal scarring. Keratomycosis with a surrounding furrow resulted in a grave prognosis. Aspergillus organisms were isolated from 9 of 10 such eyes. Cake-frosting material was a positive prognostic sign. Fungal corneal stromal abscesses tended to be caused by yeast. This information will aid practitioners in recognizing various forms of fungal keratitis and guide them when making therapeutic decisions and prognoses for affected horses.

Two decision aids for mode of delivery among women with previous caesarean section: randomised controlled trial.

PubMed

Montgomery, Alan A; Emmett, Clare L; Fahey, Tom; Jones, Claire; Ricketts, Ian; Patel, Roshni R; Peters, Tim J; Murphy, Deirdre J

2007-06-23

To determine the effects of two computer based decision aids on decisional conflict and mode of delivery among pregnant women with a previous caesarean section. Randomised trial, conducted from May 2004 to August 2006. Four maternity units in south west England, and Scotland. 742 pregnant women with one previous lower segment caesarean section and delivery expected at >or=37 weeks. Non-English speakers were excluded. Usual care: standard care given by obstetric and midwifery staff. Information programme: women navigated through descriptions and probabilities of clinical outcomes for mother and baby associated with planned vaginal birth, elective caesarean section, and emergency caesarean section. Decision analysis: mode of delivery was recommended based on utility assessments performed by the woman combined with probabilities of clinical outcomes within a concealed decision tree. Both interventions were delivered via a laptop computer after brief instructions from a researcher. Total score on decisional conflict scale, and mode of delivery. Women in the information programme (adjusted difference -6.2, 95% confidence interval -8.7 to -3.7) and the decision analysis (-4.0, -6.5 to -1.5) groups had reduced decisional conflict compared with women in the usual care group. The rate of vaginal birth was higher for women in the decision analysis group compared with the usual care group (37% v 30%, adjusted odds ratio 1.42, 0.94 to 2.14), but the rates were similar in the information programme and usual care groups. Decision aids can help women who have had a previous caesarean section to decide on mode of delivery in a subsequent pregnancy. The decision analysis approach might substantially affect national rates of caesarean section. Trial Registration Current Controlled Trials ISRCTN84367722.

Practice databases and their uses in clinical research.

PubMed

Tierney, W M; McDonald, C J

1991-04-01

A few large clinical information databases have been established within larger medical information systems. Although they are smaller than claims databases, these clinical databases offer several advantages: accurate and timely data, rich clinical detail, and continuous parameters (for example, vital signs and laboratory results). However, the nature of the data vary considerably, which affects the kinds of secondary analyses that can be performed. These databases have been used to investigate clinical epidemiology, risk assessment, post-marketing surveillance of drugs, practice variation, resource use, quality assurance, and decision analysis. In addition, practice databases can be used to identify subjects for prospective studies. Further methodologic developments are necessary to deal with the prevalent problems of missing data and various forms of bias if such databases are to grow and contribute valuable clinical information.

Influence of negative affect on decision making in women with restrictive and binge-purge type anorexia nervosa.

PubMed

Danner, Unna N; Sternheim, Lot; Bijsterbosch, Jojanneke M; Dingemans, Alexandra E; Evers, Catharine; van Elburg, Annemarie A

2016-05-30

The present study aims to examine the influence of negative affect on decision making in women with anorexia nervosa (AN) compared to healthy control women and, secondly, to assess differences between the restrictive (ANR) and binge-purge (ANBP) subtypes. One hundred four women (32 with ANR, 32 with ANBP, and 40 healthy controls) participated. All women were asked to watch either a negative or a control film fragment, both followed by the Bechara Gambling Task (BGT). Before and after the fragments negative affect was measured. Additionally, relevant characteristics (e.g., overall depressive symptoms) were assessed. Differences in negative affect did not influence decision making performance. Independent of affective state, decision making was found to be impaired in women with ANBP (no learning effect on the BGT), but not in women with ANR. These findings highlight the importance of considering different AN subtypes when examining decision making processes. However, the role of negative affect on decision making remains uncertain. Since other affect related factors such as affect dysregulation may also play a role, future studies on decision making in AN should take the role of affect into account. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Protocol-based care: the standardisation of decision-making?

PubMed

Rycroft-Malone, Jo; Fontenla, Marina; Seers, Kate; Bick, Debra

2009-05-01

To explore how protocol-based care affects clinical decision-making. In the context of evidence-based practice, protocol-based care is a mechanism for facilitating the standardisation of care and streamlining decision-making through rationalising the information with which to make judgements and ultimately decisions. However, whether protocol-based care does, in the reality of practice, standardise decision-making is unknown. This paper reports on a study that explored the impact of protocol-based care on nurses' decision-making. Theoretically informed by realistic evaluation and the promoting action on research implementation in health services framework, a case study design using ethnographic methods was used. Two sites were purposively sampled; a diabetic and endocrine unit and a cardiac medical unit. Within each site, data collection included observation, postobservation semi-structured interviews with staff and patients, field notes, feedback sessions and document review. Data were inductively and thematically analysed. Decisions made by nurses in both sites were varied according to many different and interacting factors. While several standardised care approaches were available for use, in reality, a variety of information sources informed decision-making. The primary approach to knowledge exchange and acquisition was person-to-person; decision-making was a social activity. Rarely were standardised care approaches obviously referred to; nurses described following a mental flowchart, not necessarily linked to a particular guideline or protocol. When standardised care approaches were used, it was reported that they were used flexibly and particularised. While the logic of protocol-based care is algorithmic, in the reality of clinical practice, other sources of information supported nurses' decision-making process. This has significant implications for the political goal of standardisation. The successful implementation and judicious use of tools such as protocols and guidelines will likely be dependant on approaches that facilitate the development of nurses' decision-making processes in parallel to paying attention to the influence of context.

8th edition AJCC/UICC staging of cancers of the esophagus and esophagogastric junction: application to clinical practice.

PubMed

Rice, Thomas W; Patil, Deepa T; Blackstone, Eugene H

2017-03-01

The 8th edition of the American Joint Committee on Cancer (AJCC) staging of epithelial cancers of the esophagus and esophagogastric junction (EGJ) presents separate classifications for clinical (cTNM), pathologic (pTNM), and postneoadjuvant (ypTNM) stage groups. Histopathologic cell type markedly affects survival of clinically and pathologically staged patients, requiring separate groupings for each cell type, but ypTNM groupings are identical for both cell types. Clinical categories, typically obtained by imaging with minimal histologic information, are limited by resolution of each method. Strengths and shortcomings of clinical staging methods should be recognized. Complementary cytology or histopathology findings may augment imaging and aid initial treatment decision-making. However, prognostication using clinical stage groups remains coarse and inaccurate compared with pTNM. Pathologic staging is losing its relevance for advanced-stage cancer as neoadjuvant therapy replaces esophagectomy alone. However, it remains relevant for early-stage cancers and as a staging and survival reference point. Although pathologic stage could facilitate decision-making, its use to direct postoperative adjuvant therapy awaits more effective treatment. Prognostication using pathologic stage groups is the most refined of all classifications. Postneoadjuvant staging (ypTNM) is introduced by the AJCC but not adopted by the Union for International Cancer Control (UICC). Drivers of this addition include absence of equivalent pathologic (pTNM) categories for categories peculiar to the postneoadjuvant state (ypT0N0-3M0 and ypTisN0-3M0), dissimilar stage group compositions, and markedly different survival profiles. Thus, prognostication is specific for patients undergoing neoadjuvant therapy. The role of ypTNM classification in additional treatment decision-making is currently limited. Precision cancer care advances are necessary for this information to be clinically useful.

Parent-Child Engagement in Decision Making and the Development of Adolescent Affective Decision Capacity and Binge Drinking

PubMed Central

Xiao, Lin; Bechara, Antoine; Palmer, Paula H.; Trinidad, Dennis R.; Wei, Yonglan; Jia, Yong; Johnson, C. Anderson

2010-01-01

The goal of this study was to investigate how parents’ engagement of their child in everyday decision-making influenced their adolescent’s development on two neuropsychological functions, namely, affective decision-making and working memory, and its effect on adolescent binge-drinking behavior. We conducted a longitudinal study of 192 Chinese adolescents. In 10th grade, the adolescents were tested for their affective decision-making ability using the Iowa Gambling Task (IGT) and working memory capacity using the Self-ordered Pointing Test (SOPT). Questionnaires were used to assess perceived parent-child engagement in decision-making, academic performance and drinking behavior. At one-year follow-up, the same neuropsychological tasks and questionnaires were repeated. Results indicate that working memory and academic performance were uninfluenced by parent-child engagement in decision-making. However, compared to adolescents whose parents made solitary decisions for them, adolescents engaged in everyday decision-making showed significant improvement on affective decision capacity and significantly less binge-drinking one year later. These findings suggest that parental engagement of children in everyday decision-making might foster the development of neurocognitive functioning relative to affective decision-making and reduce adolescent substance use behaviors. PMID:21804682

Unconscious race and social class bias among acute care surgical clinicians and clinical treatment decisions.

PubMed

Haider, Adil H; Schneider, Eric B; Sriram, N; Dossick, Deborah S; Scott, Valerie K; Swoboda, Sandra M; Losonczy, Lia; Haut, Elliott R; Efron, David T; Pronovost, Peter J; Lipsett, Pamela A; Cornwell, Edward E; MacKenzie, Ellen J; Cooper, Lisa A; Freischlag, Julie A

2015-05-01

Significant health inequities persist among minority and socially disadvantaged patients. Better understanding of how unconscious biases affect clinical decision making may help to illuminate clinicians' roles in propagating disparities. To determine whether clinicians' unconscious race and/or social class biases correlate with patient management decisions. We conducted a web-based survey among 230 physicians from surgery and related specialties at an academic, level I trauma center from December 1, 2011, through January 31, 2012. We administered clinical vignettes, each with 3 management questions. Eight vignettes assessed the relationship between unconscious bias and clinical decision making. We performed ordered logistic regression analysis on the Implicit Association Test (IAT) scores and used multivariable analysis to determine whether implicit bias was associated with the vignette responses. Differential response times (D scores) on the IAT as a surrogate for unconscious bias. Patient management vignettes varied by patient race or social class. Resulting D scores were calculated for each management decision. In total, 215 clinicians were included and consisted of 74 attending surgeons, 32 fellows, 86 residents, 19 interns, and 4 physicians with an undetermined level of education. Specialties included surgery (32.1%), anesthesia (18.1%), emergency medicine (18.1%), orthopedics (7.9%), otolaryngology (7.0%), neurosurgery (7.0%), critical care (6.0%), and urology (2.8%); 1.9% did not report a departmental affiliation. Implicit race and social class biases were present in most respondents. Among all clinicians, mean IAT D scores for race and social class were 0.42 (95% CI, 0.37-0.48) and 0.71 (95% CI, 0.65-0.78), respectively. Race and class scores were similar across departments (general surgery, orthopedics, urology, etc), race, or age. Women demonstrated less bias concerning race (mean IAT D score, 0.39 [95% CI, 0.29-0.49]) and social class (mean IAT D score, 0.66 [95% CI, 0.57-0.75]) relative to men (mean IAT D scores, 0.44 [95% CI, 0.37-0.52] and 0.82 [95% CI, 0.75-0.89], respectively). In univariate analyses, we found an association between race/social class bias and 3 of 27 possible patient-care decisions. Multivariable analyses revealed no association between the IAT D scores and vignette-based clinical assessments. Unconscious social class and race biases were not significantly associated with clinical decision making among acute care surgical clinicians. Further studies involving real physician-patient interactions may be warranted.

The patient perspective of clinical training-an empirical study about patient motives to participate.

PubMed

Drevs, Florian; Gebele, Christoph; Tscheulin, Dieter K

2014-10-01

This study introduces a comprehensive model to explain patients' prosocial behavioral intentions to participate in clinical training. Using the helping decision model, the authors analyze the combined impact of factors that affect participation intentions. The model includes intrapersonal and interpersonal appraisals triggered by an awareness of the societal need for clinical training as a practical part of medical education. The results of our empirical study (N=317) show that personal costs and anxiety as negative appraisals and a warm glow as a positive appraisal affect participation intentions and fully mediate the effect of the patient's awareness of the societal need. The study results indicate that communication strategies should address patient beliefs about negative personal consequences of participation rather than highlighting the societal need for practical medical education related to clinical training. Based on the results, medical associations could develop guidelines and provide training for physicians on how to motivate patients to participate in clinical training, resulting in more patient-centered standardized consent discussions. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Addressing Barriers to Shared Decision Making Among Latino LGBTQ Patients and Healthcare Providers in Clinical Settings.

PubMed

Baig, Arshiya A; Lopez, Fanny Y; DeMeester, Rachel H; Jia, Justin L; Peek, Monica E; Vela, Monica B

2016-10-01

Effective shared decision making (SDM) between patients and healthcare providers has been positively associated with health outcomes. However, little is known about the SDM process between Latino patients who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ), and their healthcare providers. Our review of the literature identified unique aspects of Latino LGBTQ persons' culture, health beliefs, and experiences that may affect their ability to engage in SDM with their healthcare providers. Further research needs to examine Latino LGBTQ patient-provider experiences with SDM and develop tools that can better facilitate SDM in this patient population.

Addressing Barriers to Shared Decision Making Among Latino LGBTQ Patients and Healthcare Providers in Clinical Settings

PubMed Central

Lopez, Fanny Y.; DeMeester, Rachel H.; Jia, Justin L.; Peek, Monica E.; Vela, Monica B.

2016-01-01

Abstract Effective shared decision making (SDM) between patients and healthcare providers has been positively associated with health outcomes. However, little is known about the SDM process between Latino patients who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ), and their healthcare providers. Our review of the literature identified unique aspects of Latino LGBTQ persons’ culture, health beliefs, and experiences that may affect their ability to engage in SDM with their healthcare providers. Further research needs to examine Latino LGBTQ patient–provider experiences with SDM and develop tools that can better facilitate SDM in this patient population. PMID:27617356

Added Value of Contrast-Enhanced Ultrasound on Biopsies of Focal Hepatic Lesions Invisible on Fusion Imaging Guidance

PubMed Central

Kang, Tae Wook; Song, Kyoung Doo; Kim, Mimi; Kim, Seung Soo; Kim, Seong Hyun; Ha, Sang Yun

2017-01-01

Objective To assess whether contrast-enhanced ultrasonography (CEUS) with Sonazoid can improve the lesion conspicuity and feasibility of percutaneous biopsies for focal hepatic lesions invisible on fusion imaging of real-time ultrasonography (US) with computed tomography/magnetic resonance images, and evaluate its impact on clinical decision making. Materials and Methods The Institutional Review Board approved this retrospective study. Between June 2013 and January 2015, 711 US-guided percutaneous biopsies were performed for focal hepatic lesions. Biopsies were performed using CEUS for guidance if lesions were invisible on fusion imaging. We retrospectively evaluated the number of target lesions initially invisible on fusion imaging that became visible after applying CEUS, using a 4-point scale. Technical success rates of biopsies were evaluated based on histopathological results. In addition, the occurrence of changes in clinical decision making was assessed. Results Among 711 patients, 16 patients (2.3%) were included in the study. The median size of target lesions was 1.1 cm (range, 0.5–1.9 cm) in pre-procedural imaging. After CEUS, 15 of 16 (93.8%) focal hepatic lesions were visualized. The conspicuity score was significantly increased after adding CEUS, as compared to that on fusion imaging (p < 0.001). The technical success rate of biopsy was 87.6% (14/16). After biopsy, there were changes in clinical decision making for 11 of 16 patients (68.8%). Conclusion The addition of CEUS could improve the conspicuity of focal hepatic lesions invisible on fusion imaging. This dual guidance using CEUS and fusion imaging may affect patient management via changes in clinical decision-making. PMID:28096725

Temporal characteristics of decisions in hospital encounters: a threshold for shared decision making? A qualitative study.

PubMed

Ofstad, Eirik H; Frich, Jan C; Schei, Edvin; Frankel, Richard M; Gulbrandsen, Pål

2014-11-01

To identify and characterize physicians' statements that contained evidence of clinically relevant decisions in encounters with patients in different hospital settings. Qualitative analysis of 50 videotaped encounters from wards, the emergency room (ER) and outpatient clinics in a department of internal medicine at a Norwegian university hospital. Clinical decisions could be grouped in a temporal order: decisions which had already been made, and were brought into the encounter by the physician (preformed decisions), decisions made in the present (here-and-now decisions), and decisions prescribing future actions given a certain course of events (conditional decisions). Preformed decisions were a hallmark in the ward and conditional decisions a main feature of ER encounters. Clinical decisions related to a patient-physician encounter spanned a time frame exceeding the duration of the encounter. While a distribution of decisions over time and space fosters sharing and dilution of responsibility between providers, it makes the decision making process hard to access for patients. In order to plan when and how to involve patients in decisions, physicians need increased awareness of when clinical decisions are made, who usually makes them, and who should make them. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

The strange case of Mr. H. Starting dialysis at 90 years of age: clinical choices impact on ethical decisions.

PubMed

Piccoli, Giorgina Barbara; Sofronie, Andreea Corina; Coindre, Jean-Philippe

2017-11-09

Starting dialysis at an advanced age is a clinical challenge and an ethical dilemma. The advantages of starting dialysis at "extreme" ages are questionable as high dialysis-related morbidity induces a reflection on the cost- benefit ratio of this demanding and expensive treatment in a person that has a short life expectancy. Where clinical advantages are doubtful, ethical analysis can help us reach decisions and find adapted solutions. Mr. H is a ninety-year-old patient with end-stage kidney disease that is no longer manageable with conservative care, in spite of optimal nutritional management, good blood pressure control and strict clinical and metabolic evaluations; dialysis is the next step, but its morbidity is challenging. The case is analysed according to principlism (beneficence, non-maleficence, justice and respect for autonomy). In the setting of care, dialysis is available without restriction; therefore the principle of justice only partially applied, in the absence of restraints on health-care expenditure. The final decision on whether or not to start dialysis rested with Mr. H (respect for autonomy). However, his choice depended on the balance between beneficence and non-maleficence. The advantages of dialysis in restoring metabolic equilibrium were clear, and the expected negative effects of dialysis were therefore decisive. Mr. H has a contraindication to peritoneal dialysis (severe arthritis impairing self-performance) and felt performing it with nursing help would be intrusive. Post dialysis fatigue, poor tolerance, hypotension and intrusiveness in daily life of haemodialysis patients are closely linked to the classic thrice-weekly, four-hour schedule. A personalized incremental dialysis approach, starting with one session per week, adapting the timing to the patient's daily life, can limit side effects and "dialysis shock". An individualized approach to complex decisions such as dialysis start can alter the delicate benefit/side-effect balance, ultimately affecting the patient's choice, and points to a narrative, tailor-made approach as an alternative to therapeutic nihilism, in very old and fragile patients.

Personalized Clinical Diagnosis in Data Bases for Treatment Support in Phthisiology.

PubMed

Lugovkina, T K; Skornyakov, S N; Golubev, D N; Egorov, E A; Medvinsky, I D

2016-01-01

The decision-making is a key event in the clinical practice. The program products with clinical decision support models in electronic data-base as well as with fixed decision moments of the real clinical practice and treatment results are very actual instruments for improving phthisiological practice and may be useful in the severe cases caused by the resistant strains of Mycobacterium tuberculosis. The methodology for gathering and structuring of useful information (critical clinical signals for decisions) is described. Additional coding of clinical diagnosis characteristics was implemented for numeric reflection of the personal situations. The created methodology for systematization and coding Clinical Events allowed to improve the clinical decision models for better clinical results.

Extensions to decision curve analysis, a novel method for evaluating diagnostic tests, prediction models and molecular markers

PubMed Central

Vickers, Andrew J; Cronin, Angel M; Elkin, Elena B; Gonen, Mithat

2008-01-01

Background Decision curve analysis is a novel method for evaluating diagnostic tests, prediction models and molecular markers. It combines the mathematical simplicity of accuracy measures, such as sensitivity and specificity, with the clinical applicability of decision analytic approaches. Most critically, decision curve analysis can be applied directly to a data set, and does not require the sort of external data on costs, benefits and preferences typically required by traditional decision analytic techniques. Methods In this paper we present several extensions to decision curve analysis including correction for overfit, confidence intervals, application to censored data (including competing risk) and calculation of decision curves directly from predicted probabilities. All of these extensions are based on straightforward methods that have previously been described in the literature for application to analogous statistical techniques. Results Simulation studies showed that repeated 10-fold crossvalidation provided the best method for correcting a decision curve for overfit. The method for applying decision curves to censored data had little bias and coverage was excellent; for competing risk, decision curves were appropriately affected by the incidence of the competing risk and the association between the competing risk and the predictor of interest. Calculation of decision curves directly from predicted probabilities led to a smoothing of the decision curve. Conclusion Decision curve analysis can be easily extended to many of the applications common to performance measures for prediction models. Software to implement decision curve analysis is provided. PMID:19036144

Extensions to decision curve analysis, a novel method for evaluating diagnostic tests, prediction models and molecular markers.

PubMed

Vickers, Andrew J; Cronin, Angel M; Elkin, Elena B; Gonen, Mithat

2008-11-26

Decision curve analysis is a novel method for evaluating diagnostic tests, prediction models and molecular markers. It combines the mathematical simplicity of accuracy measures, such as sensitivity and specificity, with the clinical applicability of decision analytic approaches. Most critically, decision curve analysis can be applied directly to a data set, and does not require the sort of external data on costs, benefits and preferences typically required by traditional decision analytic techniques. In this paper we present several extensions to decision curve analysis including correction for overfit, confidence intervals, application to censored data (including competing risk) and calculation of decision curves directly from predicted probabilities. All of these extensions are based on straightforward methods that have previously been described in the literature for application to analogous statistical techniques. Simulation studies showed that repeated 10-fold crossvalidation provided the best method for correcting a decision curve for overfit. The method for applying decision curves to censored data had little bias and coverage was excellent; for competing risk, decision curves were appropriately affected by the incidence of the competing risk and the association between the competing risk and the predictor of interest. Calculation of decision curves directly from predicted probabilities led to a smoothing of the decision curve. Decision curve analysis can be easily extended to many of the applications common to performance measures for prediction models. Software to implement decision curve analysis is provided.

Treatment decision-making strategies and influences in patients with localized prostate carcinoma.

PubMed

Gwede, Clement K; Pow-Sang, Julio; Seigne, John; Heysek, Randy; Helal, Mohamed; Shade, Kristin; Cantor, Alan; Jacobsen, Paul B

2005-10-01

Patients diagnosed with localized prostate carcinoma need to interpret complicated medical information to make an informed treatment selection from among treatments that have comparable efficacy but differing side effects. The authors reported initial results for treatment decision-making strategies among men receiving definitive treatment for localized prostate carcinoma. One hundred nineteen men treated with radical prostatectomy (44%) or brachytherapy (56%) consented to participate. Guided by a cognitive-affective theoretic framework, the authors assessed differences in decision-making strategies, and treatment and disease-relevant beliefs and affects, in addition to demographic and clinical variables. Approximately half of patients reported difficulty (49%) and distress (45%) while making treatment decisions, but no regrets (74%) regarding the treatment choice they made. Patients who underwent prostatectomy were younger, were more likely to be employed, had worse tumor grade, and had a shorter time since diagnosis (P < 0.01) compared with patients who did not undergo prostatectomy. In multivariate analyses, compared with patients who received radical prostatectomy, patients who received brachytherapy were more likely to say that they chose this treatment because it was "the least invasive" and they "wanted to avoid surgery" (P < 0.0001). In general, patients who received brachytherapy chose this treatment because of quality of life considerations, whereas "cure" and complete removal of the tumor were the main motivations for patients selecting radical prostatectomy. Long-term data are needed to evaluate distress and decisional regret as patients experience treatment-related chronic side effects and efficacy outcomes. Decision-making aids or other interventions to reduce decisional difficulty and emotional distress during decision making were indicated.

Emotion and decision making: multiple modulatory neural circuits.

PubMed

Phelps, Elizabeth A; Lempert, Karolina M; Sokol-Hessner, Peter

2014-01-01

Although the prevalent view of emotion and decision making is derived from the notion that there are dual systems of emotion and reason, a modulatory relationship more accurately reflects the current research in affective neuroscience and neuroeconomics. Studies show two potential mechanisms for affect's modulation of the computation of subjective value and decisions. Incidental affective states may carry over to the assessment of subjective value and the decision, and emotional reactions to the choice may be incorporated into the value calculation. In addition, this modulatory relationship is reciprocal: Changing emotion can change choices. This research suggests that the neural mechanisms mediating the relation between affect and choice vary depending on which affective component is engaged and which decision variables are assessed. We suggest that a detailed and nuanced understanding of emotion and decision making requires characterizing the multiple modulatory neural circuits underlying the different means by which emotion and affect can influence choices.

Clinical Data Warehouse: An Effective Tool to Create Intelligence in Disease Management.

PubMed

Karami, Mahtab; Rahimi, Azin; Shahmirzadi, Ali Hosseini

Clinical business intelligence tools such as clinical data warehouse enable health care organizations to objectively assess the disease management programs that affect the quality of patients' life and well-being in public. The purpose of these programs is to reduce disease occurrence, improve patient care, and decrease health care costs. Therefore, applying clinical data warehouse can be effective in generating useful information about aspects of patient care to facilitate budgeting, planning, research, process improvement, external reporting, benchmarking, and trend analysis, as well as to enable the decisions needed to prevent the progression or appearance of the illness aligning with maintaining the health of the population. The aim of this review article is to describe the benefits of clinical data warehouse applications in creating intelligence for disease management programs.

Decision tool for clients with medical issues: a framework for identifying driving risk and potential to return to driving.

PubMed

Dickerson, Anne E; Bédard, Michel

2014-04-01

This paper offers occupational therapy generalists and specialists a new framework by which to consider clinical evaluation data and an older adult's driving risk and potential to resume this previously learned skill. Based on Michon's model describing the hierarchy of driving levels, clinical questions identify the factors that may affect a client's fitness to drive. The first part is intended to support clinical judgment of whether a client needs a driving evaluation by a driver rehabilitation specialist. The second part offers a framework to organize clinical data that are already known and determine what other evaluation information is justified and necessary to make a driving recommendation. Methods and rational for use are discussed.

Performing a secondary executive task with affective stimuli interferes with decision making under risk conditions.

PubMed

Gathmann, Bettina; Pawlikowski, Mirko; Schöler, Tobias; Brand, Matthias

2014-05-01

Previous studies demonstrated that executive functions are crucial for advantageous decision making under risk and that therefore decision making is disrupted when working memory capacity is demanded while working on a decision task. While some studies also showed that emotions can affect decision making under risk, it is unclear how affective processing and executive functions predict decision-making performance in interaction. The current experimental study used a between-subjects design to examine whether affective pictures (positive and negative pictures compared to neutral pictures), included in a parallel executive task (working memory 2-back task), have an impact on decision making under risk as assessed by the Game of Dice Task (GDT). Moreover, the performance GDT plus 2-back task was compared to the performance in the GDT without any additional task (GDT solely). The results show that the performance in the GDT differed between groups (positive, negative, neutral, and GDT solely). The groups with affective pictures, especially those with positive pictures in the 2-back task, showed more disadvantageous decisions in the GDT than the groups with neutral pictures and the group performing the GDT without any additional task. However, executive functions moderated the effect of the affective pictures. Regardless of affective influence, subjects with good executive functions performed advantageously in the GDT. These findings support the assumption that executive functions and emotional processing interact in predicting decision making under risk.

Selecting a provider: what factors influence patients' decision making?

PubMed

Abraham, Jean; Sick, Brian; Anderson, Joseph; Berg, Andrea; Dehmer, Chad; Tufano, Amanda

2011-01-01

Each year consumers make a variety of decisions relating to their healthcare. Some experts argue that stronger consumer engagement in decisions about where to obtain medical care is an important mechanism for improving efficiency in healthcare delivery and financing. Consumers' ability and motivation to become more active decision makers are affected by several factors, including financial incentives and access to information. This study investigates the set of factors that consumers consider when selecting a provider, including attributes of the provider and the care experience and the reputation of the provider. Additionally, the study evaluates consumers awareness and use of formal sources of provider selection information. Our results from analyzing data from a survey of 467 patients at four clinics in Minnesota suggest that the factors considered of greatest importance include reputation of the physician and reputation of the healthcare organization. Contractual and logistical factors also play a role, with respondents highlighting the importance of seeing a provider affiliated with their health plan and appointment availability. Few respondents indicated that advertisements or formal sources of quality information affected their decision making. The key implication for provider organizations is to carefully manage referral sources to ensure that they consistently meet the needs of referrers. Excellent service to existing patients and to the network of referring physicians yields patient and referrer satisfaction that is critical to attracting new patients. Finally, organizations more generally may want to explore the capabilities of new media and social networking sites for building reputation.

Understanding Resident Performance, Mindfulness, and Communication in Critical Care Rotations.

PubMed

Real, Kevin; Fields-Elswick, Katelyn; Bernard, Andrew C

Evidence from the medical literature suggests that surgical trainees can benefit from mindful practices. Surgical educators are challenged with the need to address resident core competencies, some of which may be facilitated by higher levels of mindfulness. This study explores whether mindful residents perform better than their peers as members of the health care team. This study employed a multiphase, multimethod design to assess resident mindfulness, communication, and clinical performance. Academic, tertiary medical center. Residents (N = 51) working in an intensive care unit. In phase I, medical residents completed a self-report survey of mindfulness, communication, emotional affect, and clinical decision-making. In phase II, resident performance was assessed using independent ratings of mindfulness and clinical decision-making by attending physicians and registered nurses. In phase 1, a significant positive relationship was found between resident performance and mindfulness, positive affect (PA), and communication. In phase 2, attending physicians/registered nurses' perceptions of residents' mindfulness were positively correlated with communication and inversely related to negative affect (NA). The top quartile of residents for performance and mindfulness had the lowest NA. Higher-rated residents underestimated their performance/mindfulness, whereas those in the lowest quartile overestimated these factors. This study offers a number of implications for medical resident education. First, mindfulness was perceived to be a significant contributor to self-assessments of competency and performance. Second, both PA and NA were important to mindfulness and performance. Third, communication was associated with resident performance, mindfulness, and PA. These implications suggest that individual characteristics of mindfulness, communication, and affect, all potentially modifiable, influence care quality and safety. To improve low performers, surgical educators could screen and identify residents with inaccurate self-assessments. Residents open to feedback will improve faster and develop awareness toward situations and interactions with patients, colleagues, attending physicians, and staff. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Future of electronic health records: implications for decision support.

PubMed

Rothman, Brian; Leonard, Joan C; Vigoda, Michael M

2012-01-01

The potential benefits of the electronic health record over traditional paper are many, including cost containment, reductions in errors, and improved compliance by utilizing real-time data. The highest functional level of the electronic health record (EHR) is clinical decision support (CDS) and process automation, which are expected to enhance patient health and healthcare. The authors provide an overview of the progress in using patient data more efficiently and effectively through clinical decision support to improve health care delivery, how decision support impacts anesthesia practice, and how some are leading the way using these systems to solve need-specific issues. Clinical decision support uses passive or active decision support to modify clinician behavior through recommendations of specific actions. Recommendations may reduce medication errors, which would result in considerable savings by avoiding adverse drug events. In selected studies, clinical decision support has been shown to decrease the time to follow-up actions, and prediction has proved useful in forecasting patient outcomes, avoiding costs, and correctly prompting treatment plan modifications by clinicians before engaging in decision-making. Clinical documentation accuracy and completeness is improved by an electronic health record and greater relevance of care data is delivered. Clinical decision support may increase clinician adherence to clinical guidelines, but educational workshops may be equally effective. Unintentional consequences of clinical decision support, such as alert desensitization, can decrease the effectiveness of a system. Current anesthesia clinical decision support use includes antibiotic administration timing, improved documentation, more timely billing, and postoperative nausea and vomiting prophylaxis. Electronic health record implementation offers data-mining opportunities to improve operational, financial, and clinical processes. Using electronic health record data in real-time for decision support and process automation has the potential to both reduce costs and improve the quality of patient care. © 2012 Mount Sinai School of Medicine.

The impact of emotion on perception, attention, memory, and decision-making.

PubMed

Brosch, Tobias; Scherer, Klaus R; Grandjean, Didier; Sander, David

2013-05-14

Reason and emotion have long been considered opposing forces. However, recent psychological and neuroscientific research has revealed that emotion and cognition are closely intertwined. Cognitive processing is needed to elicit emotional responses. At the same time, emotional responses modulate and guide cognition to enable adaptive responses to the environment. Emotion determines how we perceive our world, organise our memory, and make important decisions. In this review, we provide an overview of current theorising and research in the Affective Sciences. We describe how psychological theories of emotion conceptualise the interactions of cognitive and emotional processes. We then review recent research investigating how emotion impacts our perception, attention, memory, and decision-making. Drawing on studies with both healthy participants and clinical populations, we illustrate the mechanisms and neural substrates underlying the interactions of cognition and emotion.

Motivation for health information seeking and processing about clinical trial enrollment.

PubMed

Yang, Z Janet; McComas, Katherine; Gay, Geri; Leonard, John P; Dannenberg, Andrew J; Dillon, Hildy

2010-07-01

Low patient accrual in clinical trials poses serious concerns for the advancement of medical science in the United States. Past research has identified health communication as a crucial step in overcoming barriers to enrollment. However, few communication scholars have studied this problem from a sociopsychological perspective to understand what motivates people to look for or pay attention to information about clinical trial enrollment. This study applies the model of Risk Information Seeking and Processing (RISP) to this context of health decision making. By recognizing the uncertainties embedded in clinical trials, we view clinical trial enrollment as a case study of risk. With data from a random-digit-dial telephone survey of 500 adults living in the United States, we used structural equation modeling to test the central part of the RISP model. In particular, we examined the role of optimistic feelings, as a type of positive affect, in motivating information seeking and processing. Our results indicated that rather than exerting an indirect influence on information seeking through motivating a psychological need for more information, optimistic feelings have more direct relationships with information seeking and processing. Similarly, informational subjective norms also exhibit a more direct relationship with information seeking and processing. These results suggest merit in applying the RISP model to study health decision making related to clinical trial enrollment. Our findings also render practical implications on how to improve communication about clinical trial enrollment.

Using virtual human technology to provide immediate feedback about participants' use of demographic cues and knowledge of their cue use.

PubMed

Wandner, Laura D; Letzen, Janelle E; Torres, Calia A; Lok, Benjamin; Robinson, Michael E

2014-11-01

Demographic characteristics have been found to influence pain management decisions, but limited focus has been placed on participants' reactions to feedback about their use of sex, race, or age to make these decisions. The present study aimed to examine the effects of providing feedback about the use of demographic cues to participants making pain management decisions. Participants (N = 107) viewed 32 virtual human patients with standardized levels of pain and provided ratings for virtual humans' pain intensity and their treatment decisions. Real-time lens model idiographic analyses determined participants' decision policies based on cues used. Participants were subsequently informed about cue use and completed feedback questions. Frequency analyses were conducted on responses to these questions. Between 7.4 and 89.4% of participants indicated awareness of their use of demographic or pain expression cues. Of those individuals, 26.9 to 55.5% believed this awareness would change their future clinical decisions, and 66.6 to 75.9% endorsed that their attitudes affect their imagined clinical practice. Between 66.6 and 79.1% of participants who used cues reported willingness to complete an online tutorial about pain across demographic groups. This study was novel because it provided participants feedback about their cue use. Most participants who used cues indicated willingness to participate in an online intervention, suggesting this technology's utility for modifying biases. This is the first study to make individuals aware of whether a virtual human's sex, race, or age influences their decision making. Findings suggest that a majority of the individuals who were made aware of their use of demographic cues would be willing to participate in an online intervention. Copyright © 2014 American Pain Society. Published by Elsevier Inc. All rights reserved.

Moral Stress and Job Burnout Among Frontline Staff Conducting Clinical Research on Affective and Anxiety Disorders

PubMed Central

Fried, Adam L.; Fisher, Celia B.

2016-01-01

There has been increased attention on job-related stress and burnout experienced by clinicians working with vulnerable and at-risk populations, including effects on personal mental health, therapeutic decision-making, and job effectiveness. Little is known, however, about the job-related stressors and symptoms of burnout experienced by clinical research staff working with similar populations, especially in terms of moral stress they may experience when adherence to scientific procedures appears to conflict with their personal commitment to address the clinical needs of their research participants or role as health care provider. In this national study, 125 frontline research workers conducting clinical research studies with individuals diagnosed with affective and anxiety disorders completed an online survey including measures assessing research work related moral stress, job burnout, organizational ethics climate and organizational research support. Results indicated that younger research workers, those whose research work was part of a graduate assistantship and perceptions of higher participant research risk were associated with higher levels of moral stress and job burnout. Supportive organizational climates were associated with lower levels of moral stress and job burnout. Recommendations for clinical research workers, supervisors and clinical training directors are discussed. PMID:28484305

Moral Stress and Job Burnout Among Frontline Staff Conducting Clinical Research on Affective and Anxiety Disorders.

PubMed

Fried, Adam L; Fisher, Celia B

2016-06-01

There has been increased attention on job-related stress and burnout experienced by clinicians working with vulnerable and at-risk populations, including effects on personal mental health, therapeutic decision-making, and job effectiveness. Little is known, however, about the job-related stressors and symptoms of burnout experienced by clinical research staff working with similar populations, especially in terms of moral stress they may experience when adherence to scientific procedures appears to conflict with their personal commitment to address the clinical needs of their research participants or role as health care provider. In this national study, 125 frontline research workers conducting clinical research studies with individuals diagnosed with affective and anxiety disorders completed an online survey including measures assessing research work related moral stress, job burnout, organizational ethics climate and organizational research support. Results indicated that younger research workers, those whose research work was part of a graduate assistantship and perceptions of higher participant research risk were associated with higher levels of moral stress and job burnout. Supportive organizational climates were associated with lower levels of moral stress and job burnout. Recommendations for clinical research workers, supervisors and clinical training directors are discussed.

Undetected cognitive impairment and decision-making capacity in patients receiving hospice care.

PubMed

Burton, Cynthia Z; Twamley, Elizabeth W; Lee, Lana C; Palmer, Barton W; Jeste, Dilip V; Dunn, Laura B; Irwin, Scott A

2012-04-01

: Cognitive dysfunction is common in patients with advanced, life-threatening illness and can be attributed to a variety of factors (e.g., advanced age, opiate medication). Such dysfunction likely affects decisional capacity, which is a crucial consideration as the end-of-life approaches and patients face multiple choices regarding treatment, family, and estate planning. This study examined the prevalence of cognitive impairment and its impact on decision-making abilities among hospice patients with neither a chart diagnosis of a cognitive disorder nor clinically apparent cognitive impairment (e.g., delirium, unresponsiveness). : A total of 110 participants receiving hospice services completed a 1-hour neuropsychological battery, a measure of decisional capacity, and accompanying interviews. : In general, participants were mildly impaired on measures of verbal learning, verbal memory, and verbal fluency; 54% of the sample was classified as having significant, previously undetected cognitive impairment. These individuals performed significantly worse than the other participants on all neuropsychological and decisional capacity measures, with effect sizes ranging from medium to very large (0.43-2.70). A number of verbal abilities as well as global cognitive functioning significantly predicted decision-making capacity. : Despite an absence of documented or clinically obvious impairment, more than half of the sample had significant cognitive impairments. Assessment of cognition in hospice patients is warranted, including assessment of verbal abilities that may interfere with understanding or reasoning related to treatment decisions. Identification of patients at risk for impaired cognition and decision making may lead to effective interventions to improve decision making and honor the wishes of patients and families.

Types of vicarious learning experienced by pre-dialysis patients.

PubMed

McCarthy, Kate; Sturt, Jackie; Adams, Ann

2015-01-01

Haemodialysis and peritoneal dialysis renal replacement treatment options are in clinical equipoise, although the cost of haemodialysis to the National Health Service is £16,411/patient/year greater than peritoneal dialysis. Treatment decision-making takes place during the pre-dialysis year when estimated glomerular filtration rate drops to between 15 and 30 mL/min/1.73 m(2). Renal disease can be familial, and the majority of patients have considerable health service experience when they approach these treatment decisions. Factors affecting patient treatment decisions are currently unknown. The objective of this article is to explore data from a wider study in specific relation to the types of vicarious learning experiences reported by pre-dialysis patients. A qualitative study utilised unstructured interviews and grounded theory analysis during the participant's pre-dialysis year. The interview cohort comprised 20 pre-dialysis participants between 24 and 80 years of age. Grounded theory design entailed thematic sampling and analysis, scrutinised by secondary coding and checked with participants. Participants were recruited from routine renal clinics at two local hospitals when their estimated glomerular filtration rate was between 15 and 30 mL/min/1.73 m(2). Vicarious learning that contributed to treatment decision-making fell into three main categories: planned vicarious leaning, unplanned vicarious learning and historical vicarious experiences. Exploration and acknowledgement of service users' prior vicarious learning, by healthcare professionals, is important in understanding its potential influences on individuals' treatment decision-making. This will enable healthcare professionals to challenge heuristic decisions based on limited information and to encourage analytic thought processes.

Relative effectiveness assessments of oncology medicines for pricing and reimbursement decisions in European countries.

PubMed

Kleijnen, S; Lipska, I; Leonardo Alves, T; Meijboom, K; Elsada, A; Vervölgyi, V; d'Andon, A; Timoney, A; Leufkens, H G; De Boer, A; Goettsch, W G

2016-09-01

There is a debate on the added clinical value of new, expensive, anticancer treatments. Among European decision makers, the relevance of commonly used end points in trials, especially overall survival (OS), progression-free survival (PFS) and quality of life (QoL), varies, leading to the available evidence being valued differently. This research studies the extent to which the value of end points for cancer medicines differs among European decision makers. We compared guidelines and relative effectiveness assessments (REAs) of medicines for pricing or reimbursement decisions in England, France, Germany, The Netherlands, Poland, and Scotland. Anticancer medicines that received marketing authorization in Europe between 2011 and 2013 with at least four available national REAs were evaluated. A total of 79 REAs were included. Health technology assessment (HTA) guidelines indicate a preference for clinically and patient relevant end points such as OS and QoL above surrogate end points. Most guidelines do not specify whether PFS is considered a surrogate or patient-relevant end point. The number of REAs included per jurisdiction varied between 7 (The Netherlands) and 18 (Germany). OS data were included in all REAs and were the preferred end point by HTA agencies, but these data were not always mature or robust. QoL data are included in only 54% of the REAs, with a limited impact on the recommendations. PFS data are included in 70% of the REAs, but the extent to which HTA agencies find PFS relevant varies. European decision-making on relative effectiveness of anticancer medicines is affected by a gap in requested versus available clinical evidence, mainly because the regulator is willing to accept some degree of clinical uncertainty. A multi-stakeholder debate would be essential to align concrete robust evidence requirements in oncology and a collectively shared definition for relevant clinical benefit, which will benefit patients and society in general. © The Author 2016. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Factors influencing the clinical decision-making of midwives: a qualitative study.

PubMed

Daemers, Darie O A; van Limbeek, Evelien B M; Wijnen, Hennie A A; Nieuwenhuijze, Marianne J; de Vries, Raymond G

2017-10-06

Although midwives make clinical decisions that have an impact on the health and well-being of mothers and babies, little is known about how they make those decisions. Wide variation in intrapartum decisions to refer women to obstetrician-led care suggests that midwives' decisions are based on more than the evidence based medicine (EBM) model - i.e. clinical evidence, midwife's expertise, and woman's values - alone. With this study we aimed to explore the factors that influence clinical decision-making of midwives who work independently. We used a qualitative approach, conducting in-depth interviews with a purposive sample of 11 Dutch primary care midwives. Data collection took place between May and September 2015. The interviews were semi-structured, using written vignettes to solicit midwives' clinical decision-making processes (Think Aloud method). We performed thematic analysis on the transcripts. We identified five themes that influenced clinical decision-making: the pregnant woman as a whole person, sources of knowledge, the midwife as a whole person, the collaboration between maternity care professionals, and the organisation of care. Regarding the midwife, her decisions were shaped not only by her experience, intuition, and personal circumstances, but also by her attitudes about physiology, woman-centredness, shared decision-making, and collaboration with other professionals. The nature of the local collaboration between maternity care professionals and locally-developed protocols dominated midwives' clinical decision-making. When midwives and obstetricians had different philosophies of care and different practice styles, their collaborative efforts were challenged. Midwives' clinical decision-making is a more varied and complex process than the EBM framework suggests. If midwives are to succeed in their role as promoters and protectors of physiological pregnancy and birth, they need to understand how clinical decisions in a multidisciplinary context are actually made.

Decision-making theories and their usefulness to the midwifery profession both in terms of midwifery practice and the education of midwives.

PubMed

Jefford, Elaine; Fahy, Kathleen; Sundin, Deborah

2011-06-01

What are the strengths and limitations of existing Decision-Making Theories as a basis for guiding best practice clinical decision-making within a framework of midwifery philosophy? Each theory is compared in relation with how well they provide a teachable framework for midwifery clinical reasoning that is consistent with midwifery philosophy. Hypothetico-Deductive Theory, from which medical clinical reasoning is based; intuitive decision-making; Dual Processing Theory; The International Confederation of Midwives Clinical Decision-Making Framework; Australian Nursing and Midwifery Council Midwifery Practice Decisions Flowchart and Midwifery Practice. Best practice midwifery clinical Decision-Making Theory needs to give guidance about: (i) effective use of cognitive reasoning processes; (ii) how to include contextual and emotional factors; (iii) how to include the interests of the baby as an integral part of the woman; (iv) decision-making in partnership with woman; and (v) how to recognize/respond to clinical situations outside the midwife's legal/personal scope of practice. No existing Decision-Making Theory meets the needs of midwifery. Medical clinical reasoning has a good contribution to make in terms of cognitive reasoning processes. Two limitations of medical clinical reasoning are its reductionistic focus and privileging of reason to the exclusion of emotional and contextual factors. Hypothetico-deductive clinical reasoning is a necessary but insufficient condition for best practice clinical decision-making in midwifery. © 2011 Blackwell Publishing Asia Pty Ltd.

A multiple-scenario assessment of the effect of a continuous-care, guideline-based decision support system on clinicians' compliance to clinical guidelines.

PubMed

Shalom, Erez; Shahar, Yuval; Parmet, Yisrael; Lunenfeld, Eitan

2015-04-01

To quantify the effect of a new continuous-care guideline (GL)-application engine, the Picard decision support system (DSS) engine, on the correctness and completeness of clinicians' decisions relative to an established clinical GL, and to assess the clinicians' attitudes towards a specific DSS. Thirty-six clinicians, including residents at different training levels and board-certified specialists at an academic OB/GYN department that handles around 15,000 deliveries annually, agreed to evaluate our continuous-care guideline-based DSS and to perform a cross-over assessment of the effects of using our guideline-based DSS. We generated electronic patient records that realistically simulated the longitudinal course of six different clinical scenarios of the preeclampsia/eclampsia/toxemia (PET) GL, encompassing 60 different decision points in total. Each clinician managed three scenarios manually without the Picard DSS engine (Non-DSS mode) and three scenarios when assisted by the Picard DSS engine (DSS mode). The main measures in both modes were correctness and completeness of actions relative to the PET GL. Correctness was further decomposed into necessary and redundant actions, relative to the guideline and the actual patient data. At the end of the assessment, a questionnaire was administered to the clinicians to assess their perceptions regarding use of the DSS. With respect to completeness, the clinicians applied approximately 41% of the GL's recommended actions in the non-DSS mode. Completeness increased to the performance of approximately 93% of the guideline's recommended actions, when using the DSS mode. With respect to correctness, approximately 94.5% of the clinicians' decisions in the non-DSS mode were correct. However, these included 68% of the actions that were correct but redundant, given the patient's data (e.g., repeating tests that had been performed), and 27% of the actions, which were necessary in the context of the GL and of the given scenario. Only 5.5% of the decisions were definite errors. In the DSS mode, 94% of the clinicians' decisions were correct, which included 3% that were correct but redundant, and 91% of the actions that were correct and necessary in the context of the GL and of the given scenario. Only 6% of the DSS-mode decisions were erroneous. The DSS was assessed by the clinicians as potentially useful. Support from the GL-based DSS led to uniformity in the quality of the decisions, regardless of the particular clinician, any particular clinical scenario, any particular decision point, or any decision type within the scenarios. Using the DSS dramatically enhances completeness (i.e., performance of guideline-based recommendations) and seems to prevent the performance of most of the redundant actions, but does not seem to affect the rate of performance of incorrect actions. The redundancy rate is enhanced by similar recent findings in recent studies. Clinicians mostly find this support to be potentially useful for their daily practice. A continuous-care GL-based DSS, such as the Picard DSS engine, has the potential to prevent most errors of omission by ensuring uniformly high quality of clinical decision making (relative to a GL-based norm), due to the increased adherence (i.e., completeness) to the GL, and most of the errors of commission that increase therapy costs, by reducing the rate of redundant actions. However, to prevent clinical errors of commission, the DSS needs to be accompanied by additional modules, such as automated control of the quality of the physician's actual actions. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Creating and sharing clinical decision support content with Web 2.0: Issues and examples.

PubMed

Wright, Adam; Bates, David W; Middleton, Blackford; Hongsermeier, Tonya; Kashyap, Vipul; Thomas, Sean M; Sittig, Dean F

2009-04-01

Clinical decision support is a powerful tool for improving healthcare quality and patient safety. However, developing a comprehensive package of decision support interventions is costly and difficult. If used well, Web 2.0 methods may make it easier and less costly to develop decision support. Web 2.0 is characterized by online communities, open sharing, interactivity and collaboration. Although most previous attempts at sharing clinical decision support content have worked outside of the Web 2.0 framework, several initiatives are beginning to use Web 2.0 to share and collaborate on decision support content. We present case studies of three efforts: the Clinfowiki, a world-accessible wiki for developing decision support content; Partners Healthcare eRooms, web-based tools for developing decision support within a single organization; and Epic Systems Corporation's Community Library, a repository for sharing decision support content for customers of a single clinical system vendor. We evaluate the potential of Web 2.0 technologies to enable collaborative development and sharing of clinical decision support systems through the lens of three case studies; analyzing technical, legal and organizational issues for developers, consumers and organizers of clinical decision support content in Web 2.0. We believe the case for Web 2.0 as a tool for collaborating on clinical decision support content appears strong, particularly for collaborative content development within an organization.

Selective exposure to information: how different modes of decision making affect subsequent confirmatory information processing.

PubMed

Fischer, Peter; Fischer, Julia; Weisweiler, Silke; Frey, Dieter

2010-12-01

We investigated whether different modes of decision making (deliberate, intuitive, distracted) affect subsequent confirmatory processing of decision-consistent and inconsistent information. Participants showed higher levels of confirmatory information processing when they made a deliberate or an intuitive decision versus a decision under distraction (Studies 1 and 2). As soon as participants have a cognitive (i.e., deliberate cognitive analysis) or affective (i.e., intuitive and gut feeling) reason for their decision, the subjective confidence in the validity of their decision increases, which results in increased levels of confirmatory information processing (Study 2). In contrast, when participants are distracted during decision making, they are less certain about the validity of their decision and thus are subsequently more balanced in the processing of decision-relevant information.

Exploring factors affecting registered nurses' pursuit of postgraduate education in Australia.

PubMed

Ng, Linda; Eley, Robert; Tuckett, Anthony

2016-12-01

The aim of this study was to explore the factors influencing registered nurses' pursuit of postgraduate education in specialty nursing practice in Australia. Despite the increased requirement for postgraduate education for advanced practice, little has been reported on the contributory factors involved in the decision to undertake further education. The Nurses' Attitudes Towards Postgraduate Education instrument was administered to 1632 registered nurses from the Nurses and Midwives e-Cohort Study across Australia, with a response rate of 35.9% (n = 568). Data reduction techniques using principal component analysis with varimax rotation were used. The analysis identified a three-factor solution for 14 items, accounting for 52.5% of the variance of the scale: "facilitators," "professional recognition," and "inhibiting factors." Facilitators of postgraduate education accounted for 28.5% of the variance, including: (i) improves knowledge; (ii) increases nurses' confidence in clinical decision-making; (iii) enhances nurses' careers; (iv) improves critical thinking; (v) improves nurses' clinical skill; and (vi) increased job satisfaction. This new instrument has potential clinical and research applications to support registered nurses' pursuit of postgraduate education. © 2016 John Wiley & Sons Australia, Ltd.

[Factors influencing nurses' clinical decision making--focusing on critical thinking disposition].

PubMed

Park, Seungmi; Kwon, In Gak

2007-10-01

The purpose of this study was to investigate the factors influencing nurses' clinical decision making focusing on critical thinking disposition. The subjects of this study consisted of 505 nurses working at one of the general hospitals located in Seoul. Data was collected by a self-administered questionnaire between December 2006 and January 2007. Data was analyzed by one way ANOVA, Pearson correlation coefficients, and stepwise multiple regression using SPSS Win 14.0. The mean scores of critical thinking disposition and clinical decision making were 99.10 and 134.32 respectively. Clinical decision making scores were significantly higher in groups under continuing education, with a master or higher degree, with clinical experience more than 5 years, or with experts. Critical thinking disposition and its subscales have a significant correlation with clinical decision making. Intellectual eagerness/curiosity, prudence, clinical experience, intellectual honesty, self-confidence, and healthy skepticism were important factors influencing clinical decision making(adjusted R(2)=33%). Results of this study suggest that various strategies such as retaining experienced nurses, encouraging them to continue with education and enhancing critical thinking disposition are warranted for development of clinical decision making.

Nurse leaders as stewards at the point of service.

PubMed

Murphy, Norma; Roberts, Deborah

2008-03-01

Nurse leaders, including clinical nurse educators, who exercise stewardship at the point of service, may facilitate practising nurses' articulation of their shared value priorities, including respect for persons' dignity and self-determination, as well as equity and fairness. A steward preserves and promotes what is intrinsically valuable in an experience. Theories of virtue ethics and discourse ethics supply contexts for clinical nurse educators to clarify how they may facilitate nurses' articulation of their shared value priorities through particularism and universalism, as well as how they may safeguard nurses' self-interpretation and discursive reasoning. Together, clinical nurse educators and nurses may contribute to management decisions that affect the point of service, and thus the health care organization.

Chemistry, mechanism and clinical status of antisense oligonucleotides and duplex RNAs

PubMed Central

Shen, Xiulong; Corey, David R

2018-01-01

Abstract RNA plays a central role in the expression of all genes. Because any sequence within RNA can be recognized by complementary base pairing, synthetic oligonucleotides and oligonucleotide mimics offer a general strategy for controlling processes that affect disease. The two primary antisense approaches for regulating expression through recognition of cellular RNAs are single-stranded antisense oligonucleotides and duplex RNAs. This review will discuss the chemical modifications and molecular mechanisms that make synthetic nucleic acid drugs possible. Lessons learned from recent clinical trials will be summarized. Ongoing clinical trials are likely to decisively test the adequacy of our current generation of antisense nucleic acid technologies and highlight areas where more basic research is needed. PMID:29240946

Gathering Real World Evidence with Cluster Analysis for Clinical Decision Support.

PubMed

Xia, Eryu; Liu, Haifeng; Li, Jing; Mei, Jing; Li, Xuejun; Xu, Enliang; Li, Xiang; Hu, Gang; Xie, Guotong; Xu, Meilin

2017-01-01

Clinical decision support systems are information technology systems that assist clinical decision-making tasks, which have been shown to enhance clinical performance. Cluster analysis, which groups similar patients together, aims to separate patient cases into phenotypically heterogenous groups and defining therapeutically homogeneous patient subclasses. Useful as it is, the application of cluster analysis in clinical decision support systems is less reported. Here, we describe the usage of cluster analysis in clinical decision support systems, by first dividing patient cases into similar groups and then providing diagnosis or treatment suggestions based on the group profiles. This integration provides data for clinical decisions and compiles a wide range of clinical practices to inform the performance of individual clinicians. We also include an example usage of the system under the scenario of blood lipid management in type 2 diabetes. These efforts represent a step toward promoting patient-centered care and enabling precision medicine.

Differential Weighting for Subcomponent Measures of Integrated Clinical Encounter Scores Based on the USMLE Step 2 CS Examination: Effects on Composite Score Reliability and Pass-Fail Decisions.

PubMed

Park, Yoon Soo; Lineberry, Matthew; Hyderi, Abbas; Bordage, Georges; Xing, Kuan; Yudkowsky, Rachel

2016-11-01

Medical schools administer locally developed graduation competency examinations (GCEs) following the structure of the United States Medical Licensing Examination Step 2 Clinical Skills that combine standardized patient (SP)-based physical examination and the patient note (PN) to create integrated clinical encounter (ICE) scores. This study examines how different subcomponent scoring weights in a locally developed GCE affect composite score reliability and pass-fail decisions for ICE scores, contributing to internal structure and consequential validity evidence. Data from two M4 cohorts (2014: n = 177; 2015: n = 182) were used. The reliability of SP encounter (history taking and physical examination), PN, and communication and interpersonal skills scores were estimated with generalizability studies. Composite score reliability was estimated for varying weight combinations. Faculty were surveyed for preferred weights on the SP encounter and PN scores. Composite scores based on Kane's method were compared with weighted mean scores. Faculty suggested weighting PNs higher (60%-70%) than the SP encounter scores (30%-40%). Statistically, composite score reliability was maximized when PN scores were weighted at 40% to 50%. Composite score reliability of ICE scores increased by up to 0.20 points when SP-history taking (SP-Hx) scores were included; excluding SP-Hx only increased composite score reliability by 0.09 points. Classification accuracy for pass-fail decisions between composite and weighted mean scores was 0.77; misclassification was < 5%. Medical schools and certification agencies should consider implications of assigning weights with respect to composite score reliability and consequences on pass-fail decisions.

Therapeutic Decision-Making in Endoscopically Unmanageable Nonvariceal Upper Gastrointestinal Hemorrhage

DOE Office of Scientific and Technical Information (OSTI.GOV)

Defreyne, Luc, E-mail: Luc.Defreyne@UGent.b; Schrijver, Ignace De; Decruyenaere, Johan

2008-09-15

The purpose of this study was to identify endoscopic and clinical parameters influencing the decision-making in salvage of endoscopically unmanageable, nonvariceal upper gastrointestinal hemorrhage (UGIH) and to report the outcome of selected therapy. We retrospectively retrieved all cases of surgery and arteriography for arrest of endoscopically unmanageable UGIH. Only patients with overt bleeding on endoscopy within the previous 24 h were included. Patients with preceding nonendoscopic hemostatic interventions, portal hypertension, malignancy, and transpapillar bleeding were excluded. Potential clinical and endoscopic predictors of allocation to either surgery or arteriography were tested using statistical models. Outcome and survival were regressed on themore » choice of rescue and clinical variables. Forty-six arteriographed and 51 operated patients met the inclusion criteria. Univariate analysis revealed a higher number of patients with a coagulation disorder in the catheterization group (41.4%, versus 20.4% in the laparotomy group; p = 0.044). With multivariate analysis, the identification of a bleeding peptic ulcer at endoscopy significantly steered decision-making toward surgical rescue (OR = 5.2; p = 0.021). Taking into account reinterventions, hemostasis was achieved in nearly 90% of cases in both groups. Overall therapy failure (no survivors), rebleeding within 3 days (OR = 3.7; p = 0.042), and corticosteroid use (OR = 5.2; p = 0.017) had a significant negative impact on survival. The odds of dying were not different for embolotherapy or surgery. In conclusion, decision-making was endoscopy-based, with bleeding peptic ulcer significantly directing the choice of rescue toward surgery. Unsuccessful hemostasis and corticosteroid use, but not the choice of rescue, negatively affected outcome.« less

Dual processing model of medical decision-making.

PubMed

Djulbegovic, Benjamin; Hozo, Iztok; Beckstead, Jason; Tsalatsanis, Athanasios; Pauker, Stephen G

2012-09-03

Dual processing theory of human cognition postulates that reasoning and decision-making can be described as a function of both an intuitive, experiential, affective system (system I) and/or an analytical, deliberative (system II) processing system. To date no formal descriptive model of medical decision-making based on dual processing theory has been developed. Here we postulate such a model and apply it to a common clinical situation: whether treatment should be administered to the patient who may or may not have a disease. We developed a mathematical model in which we linked a recently proposed descriptive psychological model of cognition with the threshold model of medical decision-making and show how this approach can be used to better understand decision-making at the bedside and explain the widespread variation in treatments observed in clinical practice. We show that physician's beliefs about whether to treat at higher (lower) probability levels compared to the prescriptive therapeutic thresholds obtained via system II processing is moderated by system I and the ratio of benefit and harms as evaluated by both system I and II. Under some conditions, the system I decision maker's threshold may dramatically drop below the expected utility threshold derived by system II. This can explain the overtreatment often seen in the contemporary practice. The opposite can also occur as in the situations where empirical evidence is considered unreliable, or when cognitive processes of decision-makers are biased through recent experience: the threshold will increase relative to the normative threshold value derived via system II using expected utility threshold. This inclination for the higher diagnostic certainty may, in turn, explain undertreatment that is also documented in the current medical practice. We have developed the first dual processing model of medical decision-making that has potential to enrich the current medical decision-making field, which is still to the large extent dominated by expected utility theory. The model also provides a platform for reconciling two groups of competing dual processing theories (parallel competitive with default-interventionalist theories).

Impact of different training strategies on the accuracy of a Bayesian network for predicting hospital admission.

PubMed

Leegon, Jeffrey; Aronsky, Dominik

2006-01-01

The healthcare environment is constantly changing. Probabilistic clinical decision support systems need to recognize and incorporate the changing patterns and adjust the decision model to maintain high levels of accuracy. Using data from >75,000 ED patients during a 19-month study period we examined the impact of various static and dynamic training strategies on a decision support system designed to predict hospital admission status for ED patients. Training durations ranged from 1 to 12 weeks. During the study period major institutional changes occurred that affected the system's performance level. The average area under the receiver operating characteristic curve was higher and more stable when longer training periods were used. The system showed higher accuracy when retrained an updated with more recent data as compared to static training period. To adjust for temporal trends the accuracy of decision support systems can benefit from longer training periods and retraining with more recent data.

Does a Physician’s Attitude toward a Patient with Mental Illness Affect Clinical Management of Diabetes? Results from a Mixed-Method Study

PubMed Central

Welch, Lisa C; Litman, Heather J; Borba, Christina PC; Vincenzi, Brenda; Henderson, David C

2015-01-01

Objective To determine whether physician’s attitudes toward patients with comorbid mental illness affect management of a chronic disease. Data Source A total of 256 primary care physicians interviewed in 2010. Study Design This randomized factorial experiment entailed physicians observing video vignettes of patient-actors with poorly controlled diabetes. Patients were balanced across age, gender, race, and comorbidity (schizophrenia with bizarre or normal affect, depression, eczema). Data Collection Physicians completed structured and semistructured interviews plus chart notes about clinical management and attitudes. Principal Findings Physicians reported more negative attitudes for patients with schizophrenia with bizarre affect (SBA). There were few differences in clinical decisions measured quantitatively or in charting, but qualitative data revealed less trust of patients with SBA as reporters, with more reliance on sources other than engaging the patient in care. Physicians often alerted colleagues about SBA, thereby shaping expectations before interactions occurred. Conclusions Results are consistent with common stereotypes about people with serious mental illness. Vignettes did not include intentional indication of unreliable reporting or danger. Reducing health care disparities requires attention to subtle aspects of managing patients—particularly those with atypical affect—as seemingly slight differences could engender disparate patient experiences over time. PMID:25487069

The role of economic evaluation in the decision-making process of family physicians: design and methods of a qualitative embedded multiple-case study

PubMed Central

Lessard, Chantale; Contandriopoulos, André-Pierre; Beaulieu, Marie-Dominique

2009-01-01

Background A considerable amount of resource allocation decisions take place daily at the point of the clinical encounter; especially in primary care, where 80 percent of health problems are managed. Ignoring economic evaluation evidence in individual clinical decision-making may have a broad impact on the efficiency of health services. To date, almost all studies on the use of economic evaluation in decision-making used a quantitative approach, and few investigated decision-making at the clinical level. An important question is whether economic evaluations affect clinical practice. The project is an intervention research study designed to understand the role of economic evaluation in the decision-making process of family physicians (FPs). The contributions of the project will be from the perspective of Pierre Bourdieu's sociological theory. Methods/design A qualitative research strategy is proposed. We will conduct an embedded multiple-case study design. Ten case studies will be performed. The FPs will be the unit of analysis. The sampling strategies will be directed towards theoretical generalization. The 10 selected cases will be intended to reflect a diversity of FPs. There will be two embedded units of analysis: FPs (micro-level of analysis) and field of family medicine (macro-level of analysis). The division of the determinants of practice/behaviour into two groups, corresponding to the macro-structural level and the micro-individual level, is the basis for Bourdieu's mode of analysis. The sources of data collection for the micro-level analysis will be 10 life history interviews with FPs, documents and observational evidence. The sources of data collection for the macro-level analysis will be documents and 9 open-ended, focused interviews with key informants from medical associations and academic institutions. The analytic induction approach to data analysis will be used. A list of codes will be generated based on both the original framework and new themes introduced by the participants. We will conduct within-case and cross-case analyses of the data. Discussion The question of the role of economic evaluation in FPs' decision-making is of great interest to scientists, health care practitioners, managers and policy-makers, as well as to consultants, industry, and society. It is believed that the proposed research approach will make an original contribution to the development of knowledge, both empirical and theoretical. PMID:19210787

[Perioperative onset of sarcoidosis : Rare differential diagnosis of a difficult airway].

PubMed

Jansen, G; Nowak, A

2018-05-01

Sarcoidosis is a rare multisystemic chronic inflammatory condition. Typically, there is a big discrepancy between the patient's subjectively perceived symptoms and the presence of clinical signs. Due to the high number of potential sites of onset (e. g. larynx, lungs, heart, liver, kidneys) the affected organs may show functional restrictions that are relevant for decisions related to anesthesia. Therefore, an anesthetists working in a clinical setting should be familiar with the special needs of this patient collective. This article describes the onset of sarcoidosis in a case of an unexpected difficult airway.

Threats from patients and their effects on medical decision making: a cross-sectional, randomised trial.

PubMed

Kristiansen, I S; Førde, O H; Aasland, O; Hotvedt, R; Johnsen, R; Førde, R

2001-04-21

Negative experiences are not uncommon among doctors in Norway. Our aim was to find out about the various types of negative reactions (eg, complaints, negative exposure to the media, financial claims, and notification to the police) received by physicians from patients or relatives in response to treatment, to identify their cause, and to study their effects on subsequent clinical decisions. We posted questionnaires about negative reactions of patients to a random sample (n=1260) of Norwegian doctors. Each doctor was additionally sent five written case simulations and asked to choose one of several proposed clinical strategies. Half (630) the physicians received cases containing threats from the patient or their relatives. 988 (78%) physicians returned the questionnaire, 463 (47%) of whom reported negative experiences. Such experiences were reported more frequently by men (357 [51%]) and family physicians (157 [58%]) than by other participants. Negative experiences did not affect choice of strategy for case simulations. For the first case, chest pain, 217 (44%) physicians presented with a threat chose a defensive strategy compared with 145 (30%) of those who were not (difference 14%; 95% CI 8-20). For the second case, a headache case, the corresponding numbers were 278 (57%) and 118 (25%) (32%; 26-38). Physician age, sex, specialty, or experience of negative reactions of patients did not alter the effect of threats received during our study. Negative experiences do not affect subsequent decision making. However, doctors do comply with wishes from patients or relatives when presented with direct threats.

Digital technology and clinical decision making in depression treatment: Current findings and future opportunities.

PubMed

Hallgren, Kevin A; Bauer, Amy M; Atkins, David C

2017-06-01

Clinical decision making encompasses a broad set of processes that contribute to the effectiveness of depression treatments. There is emerging interest in using digital technologies to support effective and efficient clinical decision making. In this paper, we provide "snapshots" of research and current directions on ways that digital technologies can support clinical decision making in depression treatment. Practical facets of clinical decision making are reviewed, then research, design, and implementation opportunities where technology can potentially enhance clinical decision making are outlined. Discussions of these opportunities are organized around three established movements designed to enhance clinical decision making for depression treatment, including measurement-based care, integrated care, and personalized medicine. Research, design, and implementation efforts may support clinical decision making for depression by (1) improving tools to incorporate depression symptom data into existing electronic health record systems, (2) enhancing measurement of treatment fidelity and treatment processes, (3) harnessing smartphone and biosensor data to inform clinical decision making, (4) enhancing tools that support communication and care coordination between patients and providers and within provider teams, and (5) leveraging treatment and outcome data from electronic health record systems to support personalized depression treatment. The current climate of rapid changes in both healthcare and digital technologies facilitates an urgent need for research, design, and implementation of digital technologies that explicitly support clinical decision making. Ensuring that such tools are efficient, effective, and usable in frontline treatment settings will be essential for their success and will require engagement of stakeholders from multiple domains. © 2017 Wiley Periodicals, Inc.

Fluctuating capacity and advance decision-making in Bipolar Affective Disorder - Self-binding directives and self-determination.

PubMed

Gergel, Tania; Owen, Gareth S

2015-01-01

For people with Bipolar Affective Disorder, a self-binding (advance) directive (SBD), by which they commit themselves to treatment during future episodes of mania, even if unwilling, can seem the most rational way to deal with an imperfect predicament. Knowing that mania will almost certainly cause enormous damage to themselves, their preferred solution may well be to allow trusted others to enforce treatment and constraint, traumatic though this may be. No adequate provision exists for drafting a truly effective SBD and efforts to establish such provision are hampered by very valid, but also paralysing ethical, clinical and legal concerns. Effectively, the autonomy and rights of people with bipolar are being 'protected' through being denied an opportunity to protect themselves. From a standpoint firmly rooted in the clinical context and experience of mania, this article argues that an SBD, based on a patient-centred evaluation of capacity to make treatment decisions (DMC-T) and grounded within the clinician-patient relationship, could represent a legitimate and ethically coherent form of self-determination. After setting out background information on fluctuating capacity, mania and advance directives, this article proposes a framework for constructing such an SBD, and considers common objections, possible solutions and suggestions for future research. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.

Fluctuating capacity and advance decision-making in Bipolar Affective Disorder — Self-binding directives and self-determination

PubMed Central

Gergel, Tania; Owen, Gareth S.

2015-01-01

For people with Bipolar Affective Disorder, a self-binding (advance) directive (SBD), by which they commit themselves to treatment during future episodes of mania, even if unwilling, can seem the most rational way to deal with an imperfect predicament. Knowing that mania will almost certainly cause enormous damage to themselves, their preferred solution may well be to allow trusted others to enforce treatment and constraint, traumatic though this may be. No adequate provision exists for drafting a truly effective SBD and efforts to establish such provision are hampered by very valid, but also paralysing ethical, clinical and legal concerns. Effectively, the autonomy and rights of people with bipolar are being ‘protected’ through being denied an opportunity to protect themselves. From a standpoint firmly rooted in the clinical context and experience of mania, this article argues that an SBD, based on a patient-centred evaluation of capacity to make treatment decisions (DMC-T) and grounded within the clinician–patient relationship, could represent a legitimate and ethically coherent form of self-determination. After setting out background information on fluctuating capacity, mania and advance directives, this article proposes a framework for constructing such an SBD, and considers common objections, possible solutions and suggestions for future research. PMID:25939286

Neurologic Complications in Infective Endocarditis

PubMed Central

Morris, Nicholas A.; Matiello, Marcelo; Samuels, Martin A.

2014-01-01

Neurologic complications of infective endocarditis (IE) are common and frequently life threatening. Neurologic events are not always obvious. The prediction and management of neurologic complications of IE are not easily approached algorithmically, and the impact they have on timing and ability to surgically repair or replace the affected valve often requires a painstaking evaluation and joint effort across multiple medical disciplines in order to achieve the best possible outcome. Although specific recommendations are always tailored to the individual patient, there are some guiding principles that can be used to help direct the decision-making process. Herein, we review the pathophysiology, epidemiology, manifestations, and diagnosis of neurological complications of IE and further consider the impact they have on clinical decision making. PMID:25360207

Should I go with my gut? Investigating the benefits of emotion-focused decision making.

PubMed

Mikels, Joseph A; Maglio, Sam J; Reed, Andrew E; Kaplowitz, Lee J

2011-08-01

Deliberative decision strategies have historically been considered the surest path to sound decisions; however, recent evidence and theory suggest that affective strategies may be equally as effective. In four experiments we examined conditions under which affective versus deliberative decision strategies might result in higher decision quality. While consciously focusing on feelings versus details, participants made choices that varied in complexity, in extent of subsequent conscious deliberation allowed, and in domain. Results indicate that focusing on feelings versus details led to superior objective and subjective decision quality for complex decisions. However, when using a feeling-focused approach, subsequent deliberation after encoding resulted in reduced choice quality. These results suggest that affective decision strategies may be more effective relative to deliberative strategies for certain complex decisions. 2011 APA, all rights reserved

Biased and unbiased perceptual decision-making on vocal emotions.

PubMed

Dricu, Mihai; Ceravolo, Leonardo; Grandjean, Didier; Frühholz, Sascha

2017-11-24

Perceptual decision-making on emotions involves gathering sensory information about the affective state of another person and forming a decision on the likelihood of a particular state. These perceptual decisions can be of varying complexity as determined by different contexts. We used functional magnetic resonance imaging and a region of interest approach to investigate the brain activation and functional connectivity behind two forms of perceptual decision-making. More complex unbiased decisions on affective voices recruited an extended bilateral network consisting of the posterior inferior frontal cortex, the orbitofrontal cortex, the amygdala, and voice-sensitive areas in the auditory cortex. Less complex biased decisions on affective voices distinctly recruited the right mid inferior frontal cortex, pointing to a functional distinction in this region following decisional requirements. Furthermore, task-induced neural connectivity revealed stronger connections between these frontal, auditory, and limbic regions during unbiased relative to biased decision-making on affective voices. Together, the data shows that different types of perceptual decision-making on auditory emotions have distinct patterns of activations and functional coupling that follow the decisional strategies and cognitive mechanisms involved during these perceptual decisions.

Enhancing clinical decision making: development of a contiguous definition and conceptual framework.

PubMed

Tiffen, Jennifer; Corbridge, Susan J; Slimmer, Lynda

2014-01-01

Clinical decision making is a term frequently used to describe the fundamental role of the nurse practitioner; however, other terms have been used interchangeably. The purpose of this article is to begin the process of developing a definition and framework of clinical decision making. The developed definition was "Clinical decision making is a contextual, continuous, and evolving process, where data are gathered, interpreted, and evaluated in order to select an evidence-based choice of action." A contiguous framework for clinical decision making specific for nurse practitioners is also proposed. Having a clear and unique understanding of clinical decision making will allow for consistent use of the term, which is relevant given the changing educational requirements for nurse practitioners and broadening scope of practice. Copyright © 2014 Elsevier Inc. All rights reserved.

Use of antipsychotic blood levels in clinician decision making: A cross-over study using clinical vignettes of patients with schizophrenia.

PubMed

Savitz, Adam; Melkote, Rama; Riley, Ralph; Pobre, Maria A; McQuarrie, Kelly; Williamson, David; Banderas, Benjamin

2018-05-19

The cause of treatment failure of antipsychotic medications is often difficult to determine in patients with schizophrenia. Evaluation of antipsychotic blood levels (ABLs) may aid clinicians in determining the cause of antipsychotic failure. The Clinical Assessment of the Schizophrenia Patient (CASP) was developed to evaluate clinical decision making during outpatient visits. The CASP assesses changes in medications, psychosocial treatments, and acute interventions along with factors influencing clinical decision making. Nine vignettes representative of clinical situations in patients with schizophrenia were created in two versions (one with ABLs, one without ABLs). The CASP was used to evaluate clinical decisions using the vignettes. Thirty-four clinicians participated in the study. In 8 out of 9 vignettes, most clinicians (at least 89.7%) made a different clinical decision with ABLs compared to without ABLs. In assessing the usefulness of ABLs, a majority (60.7%-85.7%, depending on the vignette) of clinicians responded that ABLs changed their clinical decision for 8 vignettes. Most clinicians (79%-93%) responded that they were more confident in their decisions with ABL information. This study demonstrated that ABLs have the potential to influence clinical decision making in the treatment of patients with schizophrenia. Copyright © 2018. Published by Elsevier B.V.

Electronic decision support for diagnostic imaging in a primary care setting

PubMed Central

Reed, Martin H

2011-01-01

Methods Clinical guideline adherence for diagnostic imaging (DI) and acceptance of electronic decision support in a rural community family practice clinic was assessed over 36 weeks. Physicians wrote 904 DI orders, 58% of which were addressed by the Canadian Association of Radiologists guidelines. Results Of those orders with guidelines, 76% were ordered correctly; 24% were inappropriate or unnecessary resulting in a prompt from clinical decision support. Physicians followed suggestions from decision support to improve their DI order on 25% of the initially inappropriate orders. The use of decision support was not mandatory, and there were significant variations in use rate. Initially, 40% reported decision support disruptive in their work flow, which dropped to 16% as physicians gained experience with the software. Conclusions Physicians supported the concept of clinical decision support but were reluctant to change clinical habits to incorporate decision support into routine work flow. PMID:21486884

Implementation of workflow engine technology to deliver basic clinical decision support functionality.

PubMed

Huser, Vojtech; Rasmussen, Luke V; Oberg, Ryan; Starren, Justin B

2011-04-10

Workflow engine technology represents a new class of software with the ability to graphically model step-based knowledge. We present application of this novel technology to the domain of clinical decision support. Successful implementation of decision support within an electronic health record (EHR) remains an unsolved research challenge. Previous research efforts were mostly based on healthcare-specific representation standards and execution engines and did not reach wide adoption. We focus on two challenges in decision support systems: the ability to test decision logic on retrospective data prior prospective deployment and the challenge of user-friendly representation of clinical logic. We present our implementation of a workflow engine technology that addresses the two above-described challenges in delivering clinical decision support. Our system is based on a cross-industry standard of XML (extensible markup language) process definition language (XPDL). The core components of the system are a workflow editor for modeling clinical scenarios and a workflow engine for execution of those scenarios. We demonstrate, with an open-source and publicly available workflow suite, that clinical decision support logic can be executed on retrospective data. The same flowchart-based representation can also function in a prospective mode where the system can be integrated with an EHR system and respond to real-time clinical events. We limit the scope of our implementation to decision support content generation (which can be EHR system vendor independent). We do not focus on supporting complex decision support content delivery mechanisms due to lack of standardization of EHR systems in this area. We present results of our evaluation of the flowchart-based graphical notation as well as architectural evaluation of our implementation using an established evaluation framework for clinical decision support architecture. We describe an implementation of a free workflow technology software suite (available at http://code.google.com/p/healthflow) and its application in the domain of clinical decision support. Our implementation seamlessly supports clinical logic testing on retrospective data and offers a user-friendly knowledge representation paradigm. With the presented software implementation, we demonstrate that workflow engine technology can provide a decision support platform which evaluates well against an established clinical decision support architecture evaluation framework. Due to cross-industry usage of workflow engine technology, we can expect significant future functionality enhancements that will further improve the technology's capacity to serve as a clinical decision support platform.

Identifying design considerations for a shared decision aid for use at the point of outpatient clinical care: An ethnographic study at an inner city clinic.

PubMed

Hajizadeh, Negin; Perez Figueroa, Rafael E; Uhler, Lauren M; Chiou, Erin; Perchonok, Jennifer E; Montague, Enid

2013-03-06

Computerized decision aids could facilitate shared decision-making at the point of outpatient clinical care. The objective of this study was to investigate whether a computerized shared decision aid would be feasible to implement in an inner-city clinic by evaluating the current practices in shared decision-making, clinicians' use of computers, patient and clinicians' attitudes and beliefs toward computerized decision aids, and the influence of time on shared decision-making. Qualitative data analysis of observations and semi-structured interviews with patients and clinicians at an inner-city outpatient clinic. The findings provided an exploratory look at the prevalence of shared decision-making and attitudes about health information technology and decision aids. A prominent barrier to clinicians engaging in shared decision-making was a lack of perceived patient understanding of medical information. Some patients preferred their clinicians make recommendations for them rather than engage in formal shared decision-making. Health information technology was an integral part of the clinic visit and welcomed by most clinicians and patients. Some patients expressed the desire to engage with health information technology such as viewing their medical information on the computer screen with their clinicians. All participants were receptive to the idea of a decision aid integrated within the clinic visit although some clinicians were concerned about the accuracy of prognostic estimates for complex medical problems. We identified several important considerations for the design and implementation of a computerized decision aid including opportunities to: bridge clinician-patient communication about medical information while taking into account individual patients' decision-making preferences, complement expert clinician judgment with prognostic estimates, take advantage of patient waiting times, and make tasks involved during the clinic visit more efficient. These findings should be incorporated into the design and implementation of a computerized shared decision aid at an inner-city hospital.

User-centered design to improve clinical decision support in primary care.

PubMed

Brunner, Julian; Chuang, Emmeline; Goldzweig, Caroline; Cain, Cindy L; Sugar, Catherine; Yano, Elizabeth M

2017-08-01

A growing literature has demonstrated the ability of user-centered design to make clinical decision support systems more effective and easier to use. However, studies of user-centered design have rarely examined more than a handful of sites at a time, and have frequently neglected the implementation climate and organizational resources that influence clinical decision support. The inclusion of such factors was identified by a systematic review as "the most important improvement that can be made in health IT evaluations." (1) Identify the prevalence of four user-centered design practices at United States Veterans Affairs (VA) primary care clinics and assess the perceived utility of clinical decision support at those clinics; (2) Evaluate the association between those user-centered design practices and the perceived utility of clinical decision support. We analyzed clinic-level survey data collected in 2006-2007 from 170 VA primary care clinics. We examined four user-centered design practices: 1) pilot testing, 2) provider satisfaction assessment, 3) formal usability assessment, and 4) analysis of impact on performance improvement. We used a regression model to evaluate the association between user-centered design practices and the perceived utility of clinical decision support, while accounting for other important factors at those clinics, including implementation climate, available resources, and structural characteristics. We also examined associations separately at community-based clinics and at hospital-based clinics. User-centered design practices for clinical decision support varied across clinics: 74% conducted pilot testing, 62% conducted provider satisfaction assessment, 36% conducted a formal usability assessment, and 79% conducted an analysis of impact on performance improvement. Overall perceived utility of clinical decision support was high, with a mean rating of 4.17 (±.67) out of 5 on a composite measure. "Analysis of impact on performance improvement" was the only user-centered design practice significantly associated with perceived utility of clinical decision support, b=.47 (p<.001). This association was present in hospital-based clinics, b=.34 (p<.05), but was stronger at community-based clinics, b=.61 (p<.001). Our findings are highly supportive of the practice of analyzing the impact of clinical decision support on performance metrics. This was the most common user-centered design practice in our study, and was the practice associated with higher perceived utility of clinical decision support. This practice may be particularly helpful at community-based clinics, which are typically less connected to VA medical center resources. Published by Elsevier B.V.

Cognitive and Affective Aspects of Creative Option Generation in Everyday Life Situations

PubMed Central

Schweizer, T. Sophie; Schmalenberger, Katja M.; Eisenlohr-Moul, Tory A.; Mojzisch, Andreas; Kaiser, Stefan; Funke, Joachim

2016-01-01

Which factors influence a human being’s ability to develop new perspectives and be creative? This ability is pivotal for any context in which new cognitions are required, such as innovative endeavors in science and art, or psychotherapeutic settings. In this article, we seek to bring together two research programs investigating the generation of creative options: On the one hand, research on option generation in the decision-making literature and, on the other hand, cognitive and clinical creativity research. Previous decision-making research has largely neglected the topic of generating creative options. Experiments typically provided participants with a clear set of options to choose from, but everyday life situations are less structured and allow countless ways to react. Before choosing an option, agents have to self-generate a set of options to choose from. Such option generation processes have only recently moved to the center of attention. The present study examines the creative quality of self-generated options in daily life situations. A student sample (N = 48) generated options for action in 70 briefly described everyday life scenarios. We rated the quality of the options on three dimensions of creativity- originality, feasibility, and divergence -and linked these qualities to option generation fluency (speed and number of generated options), situational features like the familiarity and the affective valence of the situation in which the options were generated, and trait measures of cognitive performance. We found that when situations were familiar to the participant, greater negative affective valence of the situation was associated with more originality and divergence of generated options. We also found that a higher option generation fluency was associated with a greater maximal originality of options. We complete our article with a joint research agenda for researchers in the decision-making field focusing on option generation and, on the other hand, researchers working on the cognitive and clinical aspects of creativity. PMID:27536258

Cognitive and Affective Aspects of Creative Option Generation in Everyday Life Situations.

PubMed

Schweizer, T Sophie; Schmalenberger, Katja M; Eisenlohr-Moul, Tory A; Mojzisch, Andreas; Kaiser, Stefan; Funke, Joachim

2016-01-01

Which factors influence a human being's ability to develop new perspectives and be creative? This ability is pivotal for any context in which new cognitions are required, such as innovative endeavors in science and art, or psychotherapeutic settings. In this article, we seek to bring together two research programs investigating the generation of creative options: On the one hand, research on option generation in the decision-making literature and, on the other hand, cognitive and clinical creativity research. Previous decision-making research has largely neglected the topic of generating creative options. Experiments typically provided participants with a clear set of options to choose from, but everyday life situations are less structured and allow countless ways to react. Before choosing an option, agents have to self-generate a set of options to choose from. Such option generation processes have only recently moved to the center of attention. The present study examines the creative quality of self-generated options in daily life situations. A student sample (N = 48) generated options for action in 70 briefly described everyday life scenarios. We rated the quality of the options on three dimensions of creativity- originality, feasibility, and divergence -and linked these qualities to option generation fluency (speed and number of generated options), situational features like the familiarity and the affective valence of the situation in which the options were generated, and trait measures of cognitive performance. We found that when situations were familiar to the participant, greater negative affective valence of the situation was associated with more originality and divergence of generated options. We also found that a higher option generation fluency was associated with a greater maximal originality of options. We complete our article with a joint research agenda for researchers in the decision-making field focusing on option generation and, on the other hand, researchers working on the cognitive and clinical aspects of creativity.

Addressing standards of care in resource-limited settings.

PubMed

Dawson, Liza; Klingman, Karin L; Marrazzo, Jeanne

2014-01-01

: The choice between "best-known" standards of care (SOC) or "best available" standards as the control arm in a clinical trial is a fundamental dilemma in clinical research in resource-limited settings (RLS). When the health system is delivering less than an optimal level of care, using highest standard of care in a clinical trial may produce results that cannot be implemented or sustained locally. On the other hand, using interventions that are more feasible in the local setting may involve suboptimal care, and clinical outcomes may be affected. The need for improved standards in health systems in RLS, and the difficulty in securing them, has led many researchers advocate for policy changes at the national or international level to improve clinical care more systemically. SOC decisions in a clinical trial affect the level of benefit provided to study participants and the policy implications of the trial findings. SOC choices should provide high-quality care to help advance the health care system in host countries participating in the trial, but balancing the scientific and ethical objectives of SOC choices is difficult, and there is no single formula for selecting the appropriate SOC. Despite the challenges, well-designed and conducted clinical trials can and should make significant contributions to health systems in RLS.

Models based on value and probability in health improve shared decision making.

PubMed

Ortendahl, Monica

2008-10-01

Diagnostic reasoning and treatment decisions are a key competence of doctors. A model based on values and probability provides a conceptual framework for clinical judgments and decisions, and also facilitates the integration of clinical and biomedical knowledge into a diagnostic decision. Both value and probability are usually estimated values in clinical decision making. Therefore, model assumptions and parameter estimates should be continually assessed against data, and models should be revised accordingly. Introducing parameter estimates for both value and probability, which usually pertain in clinical work, gives the model labelled subjective expected utility. Estimated values and probabilities are involved sequentially for every step in the decision-making process. Introducing decision-analytic modelling gives a more complete picture of variables that influence the decisions carried out by the doctor and the patient. A model revised for perceived values and probabilities by both the doctor and the patient could be used as a tool for engaging in a mutual and shared decision-making process in clinical work.

Using Best Practices to Extract, Organize, and Reuse Embedded Decision Support Content Knowledge Rules from Mature Clinical Systems.

PubMed

DesAutels, Spencer J; Fox, Zachary E; Giuse, Dario A; Williams, Annette M; Kou, Qing-Hua; Weitkamp, Asli; Neal R, Patel; Bettinsoli Giuse, Nunzia

2016-01-01

Clinical decision support (CDS) knowledge, embedded over time in mature medical systems, presents an interesting and complex opportunity for information organization, maintenance, and reuse. To have a holistic view of all decision support requires an in-depth understanding of each clinical system as well as expert knowledge of the latest evidence. This approach to clinical decision support presents an opportunity to unify and externalize the knowledge within rules-based decision support. Driven by an institutional need to prioritize decision support content for migration to new clinical systems, the Center for Knowledge Management and Health Information Technology teams applied their unique expertise to extract content from individual systems, organize it through a single extensible schema, and present it for discovery and reuse through a newly created Clinical Support Knowledge Acquisition and Archival Tool (CS-KAAT). CS-KAAT can build and maintain the underlying knowledge infrastructure needed by clinical systems.

The use of emotional intelligence capabilities in clinical reasoning and decision-making: A qualitative, exploratory study.

PubMed

Hutchinson, Marie; Hurley, John; Kozlowski, Desirée; Whitehair, Leeann

2018-02-01

To explore clinical nurses' experiences of using emotional intelligence capabilities during clinical reasoning and decision-making. There has been little research exploring whether, or how, nurses employ emotional intelligence (EI) in clinical reasoning and decision-making. Qualitative phase of a larger mixed-methods study. Semistructured qualitative interviews with a purposive sample of registered nurses (n = 12) following EI training and coaching. Constructivist thematic analysis was employed to analyse the narrative transcripts. Three themes emerged: the sensibility to engage EI capabilities in clinical contexts, motivation to actively engage with emotions in clinical decision-making and incorporating emotional and technical perspectives in decision-making. Continuing to separate cognition and emotion in research, theorising and scholarship on clinical reasoning is counterproductive. Understanding more about nurses' use of EI has the potential to improve the calibre of decisions, and the safety and quality of care delivered. © 2017 John Wiley & Sons Ltd.

Does soy protein affect circulating levels of unbound IGF-1?

PubMed

Messina, Mark; Magee, Pamela

2018-03-01

Despite the enormous amount of research that has been conducted on the role of soyfoods in the prevention and treatment of chronic disease, the mechanisms by which soy exerts its physiological effects are not fully understood. The clinical data show that neither soyfoods nor soy protein nor isoflavones affect circulating levels of reproductive hormones in men or women. However, some research suggests that soy protein, but not isoflavones, affects insulin-like growth factor I (IGF-1). Since IGF-1 may have wide-ranging physiological effects, we sought to determine the effect of soy protein on IGF-1 and its major binding protein insulin-like growth factor-binding protein (IGFBP-3). Six clinical studies were identified that compared soy protein with a control protein, albeit only two studies measured IGFBP-3 in addition to IGF-1. Although the data are difficult to interpret because of the different experimental designs employed, there is some evidence that large amounts of soy protein (>25 g/day) modestly increase IGF-1 levels above levels observed with the control protein. The clinical data suggest that a decision to incorporate soy into the diet should not be based on its possible effects on IGF-1.

When to trust our learners? Clinical teachers' perceptions of decision variables in the entrustment process.

PubMed

Duijn, Chantal C M A; Welink, Lisanne S; Bok, Harold G J; Ten Cate, Olle T J

2018-06-01

Clinical training programs increasingly use entrustable professional activities (EPAs) as focus of assessment. However, questions remain about which information should ground decisions to trust learners. This qualitative study aimed to identify decision variables in the workplace that clinical teachers find relevant in the elaboration of the entrustment decision processes. The findings can substantiate entrustment decision-making in the clinical workplace. Focus groups were conducted with medical and veterinary clinical teachers, using the structured consensus method of the Nominal Group Technique to generate decision variables. A ranking was made based on a relevance score assigned by the clinical teachers to the different decision variables. Field notes, audio recordings and flip chart lists were analyzed and subsequently translated and, as a form of axial coding, merged into one list, combining the decision variables that were similar in their meaning. A list of 11 and 17 decision variables were acknowledged as relevant by the medical and veterinary teacher groups, respectively. The focus groups yielded 21 unique decision variables that were considered relevant to inform readiness to perform a clinical task on a designated level of supervision. The decision variables consisted of skills, generic qualities, characteristics, previous performance or other information. We were able to group the decision variables into five categories: ability, humility, integrity, reliability and adequate exposure. To entrust a learner to perform a task at a specific level of supervision, a supervisor needs information to support such a judgement. This trust cannot be credited on a single case at a single moment of assessment, but requires different variables and multiple sources of information. This study provides an overview of decision variables giving evidence to justify the multifactorial process of making an entrustment decision.

Ethical issues in neurogenetics.

PubMed

Uhlmann, Wendy R; Roberts, J Scott

2018-01-01

Many neurogenetic conditions are inherited and therefore diagnosis of a patient will have implications for the patient's relatives and can raise ethical issues. Predictive genetic testing offers asymptomatic relatives the opportunity to determine their risk status for a neurogenetic condition, and professional guidelines emphasize patients' autonomy and informed, voluntary decision making. Beneficence and nonmaleficence both need to be considered when making decisions about disclosure and nondisclosure of genetic information and test results. There can be disclosure concerns and challenges in determining whose autonomy to prioritize when a patient makes a genetic testing decision that can reveal the genetic status of a relative (e.g., testing an adult child when the at-risk parent has not been tested). Ethical issues are prominent when genetic testing for neurogenetic conditions is requested prenatally, on minors, adoptees, adult children at 25% risk, and for individuals with psychiatric issues or cognitive impairment. Neurogenetic conditions can result in cognitive decline which can affect decisional capacity and lead to ethical challenges with decision making, informed consent, and determining the patient's ability to comprehend test results. The ethical implications of genetic testing and emerging issues, including direct-to-consumer genetic testing, disclosure of secondary findings from genomic sequencing, and use of apolipoprotein E testing in clinical and research settings, are also discussed. Resources for information about genetic testing practice guidelines, insurance laws, and directories of genetics clinics are included. Copyright © 2018 Elsevier B.V. All rights reserved.

Ethical Issues in Neurogenetics

PubMed Central

Uhlmann, Wendy R.; Roberts, J. Scott

2018-01-01

Many neurogenetic conditions are inherited and therefore diagnosis of a patient will have implications for their relatives and can raise ethical issues. Predictive genetic testing offers asymptomatic relatives the opportunity to determine their risk status for a neurogenetic condition, and professional guidelines emphasize patients’ autonomy and informed, voluntary decision-making. Beneficence and non-maleficence both need to be considered when making decisions about disclosure and nondisclosure of genetic information and test results. There can be disclosure concerns and issues of determining whose autonomy to prioritize when a patient makes a genetic testing decision that can reveal the genetic status of a relative (e.g. testing an adult child when the at-risk parent has not been tested). Ethical issues are prominent when genetic testing for neurogenetic conditions is requested prenatally, on minors, adoptees, adult children at 25% risk, and for individuals with psychiatric issues or cognitive impairment. Neurogenetic conditions can result in cognitive decline which can affect decisional capacity and lead to ethical challenges with decision-making, informed consent and determining the patient’s ability to comprehend test results. The ethical implications of genetic testing and emerging issues, including direct-to-consumer genetic testing, disclosure of secondary findings from genomic sequencing, and use of APOE testing in clinical and research settings, are also discussed. Resources for information about genetic testing practice guidelines, insurance laws and directories of genetics clinics are included. PMID:29325614

Assessing the quality of informed consent in a resource-limited setting: a cross-sectional study.

PubMed

Kiguba, Ronald; Kutyabami, Paul; Kiwuwa, Stephen; Katabira, Elly; Sewankambo, Nelson K

2012-08-21

The process of obtaining informed consent continues to be a contentious issue in clinical and public health research carried out in resource-limited settings. We sought to evaluate this process among human research participants in randomly selected active research studies approved by the School of Medicine Research and Ethics Committee at the College of Health Sciences, Makerere University. Data were collected using semi-structured interviewer-administered questionnaires on clinic days after initial or repeat informed consent procedures for the respective clinical studies had been administered to each study participant. Of the 600 participants interviewed, two thirds (64.2%, 385/600) were female. Overall mean age of study participants was 37.6 (SD = 7.7) years. Amongst all participants, less than a tenth (5.9%, 35/598) reported that they were not given enough information before making a decision to participate. A similar proportion (5.7%, 34/597) reported that they had not signed a consent form prior to making a decision to participate in the study. A third (33.7%, 201/596) of the participants were not aware that they could, at any time, voluntarily withdraw participation from these studies. Participants in clinical trials were 50% less likely than those in observational studies [clinical trial vs. observational; (odds ratio, OR = 0.5; 95% CI: 0.35-0.78)] to perceive that refusal to participate in the parent research project would affect their regular medical care. Most of the participants signed informed consent forms and a vast majority felt that they received enough information before deciding to participate. On the contrary, several were not aware that they could voluntarily withdraw their participation. Participants in observational studies were more likely than those in clinical trials to perceive that refusal to participate in the parent study would affect their regular medical care.

A two-stage clinical decision support system for early recognition and stratification of patients with sepsis: an observational cohort study.

PubMed

Amland, Robert C; Lyons, Jason J; Greene, Tracy L; Haley, James M

2015-10-01

To examine the diagnostic accuracy of a two-stage clinical decision support system for early recognition and stratification of patients with sepsis. Observational cohort study employing a two-stage sepsis clinical decision support to recognise and stratify patients with sepsis. The stage one component was comprised of a cloud-based clinical decision support with 24/7 surveillance to detect patients at risk of sepsis. The cloud-based clinical decision support delivered notifications to the patients' designated nurse, who then electronically contacted a provider. The second stage component comprised a sepsis screening and stratification form integrated into the patient electronic health record, essentially an evidence-based decision aid, used by providers to assess patients at bedside. Urban, 284 acute bed community hospital in the USA; 16,000 hospitalisations annually. Data on 2620 adult patients were collected retrospectively in 2014 after the clinical decision support was implemented. 'Suspected infection' was the established gold standard to assess clinical decision support clinimetric performance. A sepsis alert activated on 417 (16%) of 2620 adult patients hospitalised. Applying 'suspected infection' as standard, the patient population characteristics showed 72% sensitivity and 73% positive predictive value. A postalert screening conducted by providers at bedside of 417 patients achieved 81% sensitivity and 94% positive predictive value. Providers documented against 89% patients with an alert activated by clinical decision support and completed 75% of bedside screening and stratification of patients with sepsis within one hour from notification. A clinical decision support binary alarm system with cross-checking functionality improves early recognition and facilitates stratification of patients with sepsis.

Reasoning Backwards by Design: Commentary on "Moral Reasoning among HEC Members".

PubMed

Stephens, Ashley L; Heitman, Elizabeth

2015-01-01

Empirical assessment of the practice of clinical ethics is made difficult by the limited standardization of settings, structures, processes, roles, and training for ethics consultation, as well as by whether individual ethics consultants or hospital ethics committees (HECs) provide consultation. Efforts to study the relationship between theory and practice in the work of HECs likewise require the spelling out of assumptions and definition of key variables, based in knowledge of the core concepts of clinical ethics and logistics of clinical consultation. The survey of HEC members reported by Wasserman and colleagues illustrates the difficulty of such research and calls attention to need for studies of real-time, complex decision making to inform conclusions about how theory affects practice. Copyright 2015 The Journal of Clinical Ethics. All rights reserved.

Implementation of a cystic fibrosis lung transplant referral patient decision aid in routine clinical practice: an observational study.

PubMed

Stacey, Dawn; Vandemheen, Katherine L; Hennessey, Rosamund; Gooyers, Tracy; Gaudet, Ena; Mallick, Ranjeeta; Salgado, Josette; Freitag, Andreas; Berthiaume, Yves; Brown, Neil; Aaron, Shawn D

2015-02-07

The decision to have lung transplantation as treatment for end-stage lung disease from cystic fibrosis (CF) has benefits and serious risks. Although patient decision aids are effective interventions for helping patients reach a quality decision, little is known about implementing them in clinical practice. Our study evaluated a sustainable approach for implementing a patient decision aid for adults with CF considering referral for lung transplantation. A prospective pragmatic observational study was guided by the Knowledge-to-Action Framework. Healthcare professionals in all 23 Canadian CF clinics were eligible. We surveyed participants regarding perceived barriers and facilitators to patient decision aid use. Interventions tailored to address modifiable identified barriers included training, access to decision aids, and conference calls. The primary outcome was >80% use of the decision aid in year 2. Of 23 adult CF clinics, 18 participated (78.2%) and 13 had healthcare professionals attend training. Baseline barriers were healthcare professionals' inadequate knowledge for supporting patients making decisions (55%), clarifying patients' values for outcomes of options (58%), and helping patients handle conflicting views of others (71%). Other barriers were lack of time (52%) and needing to change how transplantation is discussed (42%). Baseline facilitators were healthcare professionals feeling comfortable discussing bad transplantation outcomes (74%), agreeing the decision aid would be easy to experiment with (71%) and use in the CF clinic (87%), and agreeing that using the decision aid would not require reorganization of the CF clinic (90%). After implementing the decision aid with interventions tailored to the barriers, decision aid use increased from 29% at baseline to 85% during year 1 and 92% in year 2 (p < 0.001). Compared to baseline, more healthcare professionals at the end of the study were confident in supporting decision-making (p = 0.03) but continued to feel inadequate ability with supporting patients to handle conflicting views (p = 0.01). Most Canadian CF clinics agreed to participate in the study. Interventions were used to target identified modifiable barriers to using the patient decision aid in routine CF clinical practice. CF clinics reported using it with almost all patients in the second year.

Decision making in the ageing brain: changes in affective and motivational circuits.

PubMed

Samanez-Larkin, Gregory R; Knutson, Brian

2015-05-01

As the global population ages, older decision makers will be required to take greater responsibility for their own physical, psychological and financial well-being. With this in mind, researchers have begun to examine the effects of ageing on decision making and associated neural circuits. A new 'affect-integration-motivation' (AIM) framework may help to clarify how affective and motivational circuits support decision making. Recent research has shed light on whether and how ageing influences these circuits, providing an interdisciplinary account of how ageing can alter decision making.

Decision making in the ageing brain: Changes in affective and motivational circuits

PubMed Central

Samanez-Larkin, Gregory R.; Knutson, Brian

2017-01-01

As the global population ages, older decision makers will be required to take greater responsibility for their own physical, psychological and financial well-being. With this in mind, researchers have begun to examine the effects of ageing on decision making and associated neural circuits. A new “affect, integration, motivation” (or AIM) framework may help clarify how affective and motivational circuits support decision making. Recent research has shed light on whether and how ageing influences these circuits, providing an interdisciplinary account of how ageing can alter decision making. PMID:25873038

Expert opinion and controversies in sports and musculoskeletal medicine: concussion in the young athlete.

PubMed

Standaert, Christopher J; Herring, Stanley A; Cantu, Robert C

2007-08-01

Concussion is a common injury in young athletes and can be very challenging for clinicians to diagnose and manage. Debate exists over not only the incidence of long-term risks of multiple concussions but also the potential for catastrophic outcomes after sports-related head injury. Decisions on returning athletes to competition can be difficult, and there are limited prospective data on which to make these decisions. This has resulted in the existence of a number of published guidelines and consensus statements on the management of concussion in athletes. Athletes sustaining a concussion need appropriate on-field care and structured follow-up. Baseline cognitive assessments can be helpful, but clinicians must be aware that head trauma may result in a wide array of clinical signs and symptoms. Delivery of care and decisions on return to play need to be based on an individual assessment of the affected athlete.

The Patient Self-Determination Act. A matter of life and death.

PubMed

Kelley, K

1995-03-01

The Patient Self-Determination Act (PSDA) is a federal law, and compliance is mandatory. It is the purpose of this act to ensure that a patient's right to self-determination in health care decisions be communicated and protected. Through advance directives--the living will and the durable power of attorney--the right to accept or reject medical or surgical treatment is available to adults while competent, so that in the event that such adults become incompetent to make decisions, they would more easily continue to control decisions affecting their health care. Without advance directives and the proper adherence to such directives, former President Richard Nixon and former First Lady Jacqueline Kennedy Onassis might still be alive today, in persistent vegetative states. This article examines the history of the act, its importance to each individual, the clinical, ethical and legal issues, and the role of health care professionals in effectively implementing and ensuring compliance of the PSDA.

Personal finances for the physician: a primer on maintaining and protecting your earnings.

PubMed

Hill, Austin D; Ortega, Marc E; Williams, Anthony C

2014-07-01

Personal finance is a key component to your success as a physician. Your clinical practice does not exist in a vacuum unaffected by circumstances and decisions in your personal life. Though some events in your personal life that can negatively affect your practice are random and unavoidable, consistently making sound decisions regarding your personal life and finances will allow you to continue practicing at a high level. Most core principles of personal finance are common sense and do not involve high level math. Although the concepts are straightforward, people, including physicians, routinely fail to make good decisions at the most elementary level. The core common sense principles for financial success are: do not get divorced, manage your own money, live in a state without state income tax, and drive an old car. Follow these tenants and the path to successful and satisfactory retirement will be smooth.

From data to evidence: evaluative methods in evidence-based medicine.

PubMed

Landry, M D; Sibbald, W J

2001-11-01

The amount of published information is increasing exponentially, and recent technologic advances have created systems whereby mass distribution of this information can occur at an infinite rate. This is particularly true in the broad field of medicine, as the absolute volume of data available to the practicing clinician is creating new challenges in the management of relevant information flow. Evidence-based medicine (EBM) is an information management and learning strategy that seeks to integrate clinical expertise with the best evidence available in order to make effective clinical decisions that will ultimately improve patient care. The systematic approach underlying EBM encourages the clinician to formulate specific and relevant questions, which are answered in an iterative manner through accessing the best available published evidence. The arguments against EBM stem from the idea that there are inherent weaknesses in research methodologies and that emphasis placed on published research may ignore clinical skills and individual patient needs. Despite these arguments, EBM is gaining momentum and is consistently used as a method of learning and improving health care delivery. However, if EBM is to be effective, the clinician needs to have a critical understanding of research methodology in order to judge the value and level of a particular data source. Without critical analysis of research methodology, there is an inherent risk of drawing incorrect conclusions that may affect clinical decision-making. Currently, there is a trend toward using secondary pre-appraised data rather than primary sources as best evidence. We review the qualitative and quantitative methodology commonly used in EBM and argue that it is necessary for the clinician to preferentially use primary rather than secondary sources in making clinically relevant decisions.

Clinical decision-making among new graduate nurses attending residency programs in Saudi Arabia.

PubMed

Al-Dossary, Reem Nassar; Kitsantas, Panagiota; Maddox, P J

2016-02-01

This study examined the impact of residency programs on clinical decision-making of new Saudi graduate nurses who completed a residency program compared to new Saudi graduate nurses who did not participate in residency programs. This descriptive study employed a convenience sample (N=98) of new graduate nurses from three hospitals in Saudi Arabia. A self-administered questionnaire was used to collect data. Clinical decision-making skills were measured using the Clinical Decision Making in Nursing Scale. Descriptive statistics, independent t-tests, and multiple linear regression analysis were utilized to examine the effect of residency programs on new graduate nurses' clinical decision-making skills. On average, resident nurses had significantly higher levels of clinical decision-making skills than non-residents (t=23.25, p=0.000). Enrollment in a residency program explained 86.9% of the variance in total clinical decision making controlling for age and overall grade point average. The findings of this study support evidence in the nursing literature conducted primarily in the US and Europe that residency programs have a positive influence on new graduate nurses' clinical decision-making skills. This is the first study to examine the impact of residency programs on clinical decision-making among new Saudi graduate nurses who completed a residency program. The findings of this study underscore the need for the development and implementation of residency programs for all new nurses. Copyright © 2015 Elsevier Inc. All rights reserved.

[Clinical and Sociodemographic Characteristics That Affect the Recommendation for Assignment of A Legal Representative in Patients With Bipolar Disorder].

PubMed

Akıncı, Erhan; Öncü, Fatih; Ger, Can; Sabuncuoğlu, Mustafa; Kırmızı, Anıl; Eradamlar, Nezih

2017-01-01

In this study, we aimed to evaluate the clinical and sociodemographic characteristics of patients with bipolar disorder who had been sent to the Forensic Psychiatry Unit by the court in order to determine factors that affected the decision to appoint a legal representative. The reports of health council, follow-up outpatient, and hospitalization files of a total of 78 patients with bipolar disorder who had been sent to the Department of Forensic Psychiatry Outpatient Clinic of Bakirköy Mental Health and Neurological Diseases Education and Research Hospital between 1st June 2009-31st December 2011 were examined. Patients had been sent by the court in order to determine whether a legal representative was required. Seventy patients meeting enough to sociodemographic and clinical form were separated as appointment group of legal representative or not and decision variables were compared statistically. Forty-six patients (66%) were recommended assignment of a legal representative. In the patients with bipolar disorder for whom a legal representative was recommended, the presence of other first axis comorbidity, the presence of psychotic episodes, delusions of persecution and reference, hallucinations, the total number of manic and mixed episodes, incidence of alcohol and substance abuse, lifetime total number of attacks, and the total number and duration of hospitalizations were found to be significantly higher. The probability of assignment of a legal representative was increased 11-fold by the presence of first axis comorbidity, 1.3-fold by the number of manic episodes, and 2.2-fold by the number of mixed episodes were specified. In the practice of forensic psychiatry, clinicians should focus on the course of the disease, especially the number and frequency of manic or mixed episodes, total number of episodes and hospitalizations, duration of hospitalizations, alcohol and substance use, the presence of episodes accompanied by psychosis with paranoid delusions and hallucinations, and the presence of the other first axis comorbidity in the patient with bipolar disorder for assessment of the decision to appoint a legal representative.

Effect of clinical information and previous exam execution on observer agreement and reliability in the analysis of hysteroscopic video-recordings.

PubMed

Martinho, Margarida Suzel Lopes; da Costa Santos, Cristina Maria Nogueira; Silva Carvalho, João Luís Mendonça; Bernardes, João Francisco Montenegro Andrade Lima

2018-02-01

Inter-observer agreement and reliability in hysteroscopic image assessment remain uncertain and the type of factors that may influence it has only been studied in relation to the experience of hysteroscopists. We aim to assess the effect of clinical information and previous exam execution on observer agreement and reliability in the analysis of hysteroscopic video-recordings. Ninety hysteroscopies were video-recorded and randomized into a group without (Group 1) and with clinical information (Group 2). The videos were independently analyzed by three hysteroscopists, regarding lesion location, dimension, and type, as well as decision to perform a biopsy. One of the hysteroscopists had executed all the exams before. Proportions of agreement (PA) and kappa statistics (κ) with 95% confidence intervals (95% CI) were used. In Group 2, there was a higher proportion of a normal diagnosis (p < 0.001) and a lower proportion of biopsies recommended (p = 0.027). Observer agreement and reliability were better in Group 2, with the PA and κ ranging, respectively, from 0.73 (95% CI 0.62, 0.83) and 0.44 (95% CI 0.26, 0.63), for image quality, to 0.94 (95% CI 0.88, 0.99) and 0.85 (95% CI 0.65, 0.95), for the decision to perform a biopsy. Execution of the exams before the analysis of the video-recordings did not significantly affect the results. With clinical information, agreement and reliability in the overall analysis of hysteroscopic video-recordings may reach almost perfect results and this was not significantly affected by the execution of the exams before the analysis. However, there is still uncertainty in the analysis of specific endometrial cavity abnormalities.

Assessing Decline: Visualising Progression in Huntington's Disease using a Clinical Dashboard with Enroll-HD Data.

PubMed

Walker, Thomas; Ghosh, Boyd; Kipps, Christopher

2017-01-01

In Huntington's disease (HD), it remains unclear how symptom severity and rate of symptomatic change relates to age and CAG repeat number (CAGn). It is often difficult for clinicians to assess whether an affected individual's symptoms are progressing at a similar rate to their affected peers, limiting their ability to intervene at the most appropriate time. To develop a clinical dashboard that compares an individual's total motor score (TMS), total functional capacity (TFC) and symbol digit modality test (SDMT) scores against a global cohort, controlling for age and CAGn. The dashboard could then be used by clinicians to identify individuals progressing at a disproportionate rate to his or her peers. Annualised longitudinal clinical assessment scores from the Enroll-HD dataset were used to generate decline trajectories of the global cohort, allowing cross-sectional (TMS n = 734; TFC n = 734; SDMT n = 694) and longitudinal (TMS n = 270; TFC n = 270; SDMT n = 247) comparison with individual clinical symptom rating scores, to assess decline relative to affected peers. An electronic dashboard with a dynamic output display was created that rapidly compares clinical symptom rating scores of a specific individual against affected peers from a global cohort of comparable CAGn. This study shows the potential for use of multi-centre trial data in allowing comparison of the individual to a larger group to facilitate improved decision-making for individual patients. Visualisation of these metrics via a clinical dashboard demonstrates how it may aid identification of those with disproportionate decline, offering potential for intervention at specific critical points in the disease course.

Attributes Affecting Computer-Aided Decision Making--A Literature Survey.

ERIC Educational Resources Information Center

Moldafsky, Neil I; Kwon, Ik-Whan

1994-01-01

Reviews current literature about personal, demographic, situational, and cognitive attributes that affect computer-aided decision making. The effectiveness of computer-aided decision making is explored in relation to decision quality, effectiveness, and confidence. Studies of the effects of age, anxiety, cognitive type, attitude, gender, and prior…

Combined Goal Management Training and Mindfulness meditation improve executive functions and decision-making performance in abstinent polysubstance abusers.

PubMed

Alfonso, José P; Caracuel, Alfonso; Delgado-Pastor, Luis C; Verdejo-García, Antonio

2011-08-01

The clinical relevance of neuropsychological deficits in addicted individuals has fostered interest in treatment strategies aimed to effectively target executive and decision-making dysfunction. One of the best-validated interventions for executive dysfunction is Goal Management Training (GMT) (Robertson et al., 2005), an interactive program aimed at improving participants' organization and ability to achieve goals. Mindfulness-based meditation can complement GMT training in order to improve attentional scanning and "reading" of emotional signals involved in adaptive decision-making. In this pilot study we investigated the efficacy of a 7-week program including GMT+Mindfulness (GMT+MF), as compared to standard treatment alone (STx), for reducing executive and decision-making deficits in an outpatient sample of alcohol and polysubstance abusers. Eighteen participants were enrolled in the GMT+MF group, whereas 16 participants formed the STx group; both groups were matched for relevant demographic and clinical variables, and pre-treatment degree of executive dysfunction. Results showed that the individuals enrolled in GMT+MF significantly improved their performance on neuropsychological measures of working memory (Letter Number Sequencing), response inhibition (Stroop) and decision-making (Iowa Gambling Task) after the treatment; whereas individuals enrolled in STx alone failed to show significant changes. These preliminary results indicate that the GMT+MF intervention may be effective in reducing executive and decision-making deficits in polysubstance abusers, and they support future randomized controlled studies aimed at examining the extent to which these improvements may generalize to every day functioning and may affect the capacity of addicted individuals to achieve and maintain abstinence. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Clinical and genetic correlates of decision making in anorexia nervosa.

PubMed

Tenconi, Elena; Degortes, Daniela; Clementi, Maurizio; Collantoni, Enrico; Pinato, Claudia; Forzan, Monica; Cassina, Matteo; Santonastaso, Paolo; Favaro, Angela

2016-01-01

Decision-making (DM) abilities have been found to be impaired in anorexia nervosa (AN), but few data are available about the characteristics and correlates of this cognitive function. The aim of the present study was to provide data on DM functioning in AN using both veridical and adaptive paradigms. While in veridical DM tasks, the individual's ability to predict a true/false response is measured, adaptive DM is the ability to consider both internal and external demands in order to make a good choice, in the absence of a single true "correct" answer. The participants were 189 women, of whom 91 were eating-disordered patients with a lifetime diagnosis of anorexia nervosa, and 98 were healthy women. All the participants underwent clinical, neuropsychological, and genetic assessment. The cognitive evaluation included a set of neuropsychological tasks and two decision-making tests: The Iowa Gambling Task and the Cognitive Bias Task. Anorexia nervosa patients showed significantly poorer performances on both decision-making tasks than healthy women. The Cognitive Bias Task revealed that anorexia nervosa patients employed significantly more context-independent decision-making strategies, which were independent from diagnostic subtype, handedness, education, and psychopathology. In the whole sample (patients and controls), Cognitive Bias Task performance was independently predicted by lifetime anorexia nervosa diagnosis, body mass index at assessment, and 5-HTTLPR genotype. Patients displayed poor decision-making functioning in both veridical and adaptive situations. The difficulties detected in anorexia nervosa individuals may affect not only the ability to consider the future outcomes of their actions (leading to "myopia for the future"), but also the capacity to update and review one's own mindset according to new environmental stimuli.

What motivates family physicians to participate in training programs in shared decision making?

PubMed

Allaire, Anne-Sophie; Labrecque, Michel; Giguere, Anik; Gagnon, Marie-Pierre; Légaré, France

2012-01-01

Little is known about the factors that influence family physician (FP) participation in continuing professional development (CPD) programs in shared decision making (SDM). We sought to identify the factors that motivate FPs to participate in DECISION+, a CPD program in SDM. In 2007-2008, we collected data from 39 FPs who participated in a pilot randomized trial of DECISION+. In 2010, we collected data again from 11 of those participants and from 12 new subjects. Based on the theory of planned behavior, our questionnaire assessed FPs' intentions to participate in a CPD program in SDM and evaluated FPs' attitudes, subjective norms and perceived behavioral control. We also conducted 4 focus groups to explore FPs' salient beliefs. In 2010, FPs' mean intention to participate in a CPD program in SDM was relatively strong (2.6 ± 0.5 on a scale from -3 = "strongly disagree" to +3 = "strongly agree"). Affective attitude was the only factor significantly associated with intention (r = .51, p = .04). FPs identified the attractions of participating in a CPD program in SDM as (1) its interest, (2) the pleasure of learning, and (3) professional stimulation. Facilitators of their participation were (1) a relevant clinical topic, (2) an interactive program, (3) an accessible program, and (4) decision support tools. To attract FPs to a CPD program in SDM, CPD developers should make the program interesting, enjoyable, and professionally stimulating. They should choose a clinically relevant topic, ensure that the program is interactive and accessible, and include decision support tools. Copyright © 2012 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education.

A review of the literature: midwifery decision-making and birth.

PubMed

Jefford, Elaine; Fahy, Kathleen; Sundin, Deborah

2010-12-01

Clinical decision-making was initially studied in medicine where hypothetico-deductive reasoning is the model for decision-making. The nursing perspective on clinical decision-making has largely been shaped by Patricia Benner's ground breaking work. Benner claimed expert nurses use humanistic-intuitive ways of making clinical decisions rather than the 'rational reasoning' as claimed by medicine. Clinical decision-making in midwifery is not the same as either nursing or medical decision-making because of the woman-midwife partnership where the woman is the ultimate decision-maker. CINHAL, Medline and Cochrane databases were systematically searched using key words derived from the guiding question. A review of the decision-making research literature in midwifery was undertaken where studies were published in English. The selection criteria for papers were: only research papers of direct relevance to the guiding research question were included in the review. Decision-making is under-researched in midwifery and more specifically birth, as only 4 research articles met the inclusion criteria in this review. Three of the studies involved qualified midwives, and one involved student midwives. Two studies were undertaken in England, one in Scotland and one in Sweden. The major findings synthesised from this review, are that; (1) midwifery decision-making during birth is socially negotiated involving hierarchies of surveillance and control; (2) the role of the woman in shared decision-making during birth has not been explored by midwifery research; (3) clinical decision-making encompasses clinical reasoning as essential but not sufficient for midwives to actually implement their preferred decision. We argue that existing research does not inform the discipline of the complexity of midwifery clinical decision-making during birth. A well-designed study would involve investigating the clinical reasoning skills of the midwife, her relationship with the woman, the context of the particular birthing unit and the employment status of the midwife. The role of the woman as decision-maker in her own care during birth also needs careful research attention. Copyright © 2010 Australian College of Midwives. All rights reserved.

Effects of Clinical Decision Topic on Patients' Involvement in and Satisfaction With Decisions and Their Subsequent Implementation.

PubMed

Freidl, Marion; Pesola, Francesca; Konrad, Jana; Puschner, Bernd; Kovacs, Attila Istvan; De Rosa, Corrado; Fiorillo, Andrea; Krogsgaard Bording, Malene; Kawohl, Wolfram; Rössler, Wulf; Nagy, Marietta; Munk-Jørgensen, Povl; Slade, Mike

2016-06-01

Clinical decision making is an important aspect of mental health care. Predictors of how patients experience decision making and whether decisions are implemented are underresearched. This study investigated the relationship between decision topic and involvement in the decision, satisfaction with it, and its subsequent implementation from both staff and patient perspectives. As part of the Clinical Decision Making and Outcome in Routine Care for People With Severe Mental Illness study, patients (N=588) and their providers (N=213) were recruited from community-based mental health services in six European countries. Both completed bimonthly assessments for one year using the Clinical Decision Making in Routine Care Scale to assess the decision topic and implementation; both also completed the Clinical Decision Making Involvement and Satisfaction Scale. Three categories of decision topics were determined: treatment (most frequently cited), social, and financial. The topic identified as most important remained stable over the follow-up. Patients were more likely to rate their involvement as active rather than passive for social decisions (odds ratio [OR]=5.7, p<.001) and financial decisions (OR=9.5, p<.001). They were more likely to report higher levels of satisfaction rather than lower levels for social decisions (OR=1.5, p=.01) and financial decisions (OR=1.7, p=.01). Social decisions were more likely to be partly implemented (OR=3.0, p<.001) or fully implemented (OR=1.7, p=.03) than not implemented. Patients reported poorer involvement, satisfaction, and implementation in regard to treatment-related decisions, compared with social and financial decisions. Clinicians may need to employ different interactional styles for different types of decisions to maximize satisfaction and decision implementation.

A web-based neurological pain classifier tool utilizing Bayesian decision theory for pain classification in spinal cord injury patients

NASA Astrophysics Data System (ADS)

Verma, Sneha K.; Chun, Sophia; Liu, Brent J.

2014-03-01

Pain is a common complication after spinal cord injury with prevalence estimates ranging 77% to 81%, which highly affects a patient's lifestyle and well-being. In the current clinical setting paper-based forms are used to classify pain correctly, however, the accuracy of diagnoses and optimal management of pain largely depend on the expert reviewer, which in many cases is not possible because of very few experts in this field. The need for a clinical decision support system that can be used by expert and non-expert clinicians has been cited in literature, but such a system has not been developed. We have designed and developed a stand-alone tool for correctly classifying pain type in spinal cord injury (SCI) patients, using Bayesian decision theory. Various machine learning simulation methods are used to verify the algorithm using a pilot study data set, which consists of 48 patients data set. The data set consists of the paper-based forms, collected at Long Beach VA clinic with pain classification done by expert in the field. Using the WEKA as the machine learning tool we have tested on the 48 patient dataset that the hypothesis that attributes collected on the forms and the pain location marked by patients have very significant impact on the pain type classification. This tool will be integrated with an imaging informatics system to support a clinical study that will test the effectiveness of using Proton Beam radiotherapy for treating spinal cord injury (SCI) related neuropathic pain as an alternative to invasive surgical lesioning.

Use of Biomarkers to Guide Decisions on Systemic Therapy for Women With Metastatic Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline

PubMed Central

Van Poznak, Catherine; Somerfield, Mark R.; Bast, Robert C.; Cristofanilli, Massimo; Goetz, Matthew P.; Gonzalez-Angulo, Ana M.; Hicks, David G.; Hill, Elizabeth G.; Liu, Minetta C.; Lucas, Wanda; Mayer, Ingrid A.; Mennel, Robert G.; Symmans, William F.; Hayes, Daniel F.; Harris, Lyndsay N.

2015-01-01

Purpose To provide recommendations on the appropriate use of breast tumor biomarker assay results to guide decisions on systemic therapy for metastatic breast cancer. Methods A literature search and prospectively defined study selection identified systematic reviews, meta-analyses, randomized controlled trials (RCTs), prospective–retrospective studies, and prospective comparative observational studies published from 2006 through September 2014. Results The literature search revealed 17 articles that met criteria for further review: 11 studies reporting discordances between primary tumors and metastases in expression of hormone receptors or human epidermal growth factor receptor 2 (HER2), one RCT that addressed the use of a biomarker to decide whether to change or continue a treatment regimen, and five prospective–retrospective studies that evaluated the clinical utility of biomarkers. Recommendations In patients with accessible metastases, biopsy for confirmation of disease process and retesting of estrogen receptor, progesterone receptor, and HER2 status should be offered, but evidence is lacking to determine whether changing anticancer treatment on the basis of change in receptor status affects clinical outcomes. With discordance of results between primary and metastatic tissues, the Panel consensus is to use preferentially the estrogen receptor, progesterone receptor, and HER2 status of the metastasis to direct therapy if supported by the clinical scenario and patient's goals for care. Carcinoembryonic antigen, cancer antigen 15-3, and cancer antigen 27-29 may be used as adjunctive assessments, but not alone, to contribute to decisions regarding therapy. Recommendations for tumor rebiopsy and use of circulating tumor markers are based on clinical experience and Panel informal consensus in the absence of studies designed to evaluate the clinical utility of the markers. As such, it is also reasonable for clinicians to not use these markers as adjunctive assessments. PMID:26195705

Nursing students' assessment of pain and decision of triage for different ethnic groups: An experimental study.

PubMed

Chan, Joanne C Y; Hamamura, Takeshi

2015-08-01

Pain management is a priority in nursing care but little is known about the factors that affect nursing students' assessment of pain expressed by patients of different ethnic backgrounds. This study examined undergraduate nursing students' assessment of pain and decision of triage when pain was expressed in different languages and their relation to students' empathy and social identity. Comparison between students with and without clinical experience was also carried out. This is a cross-sectional quantitative design. This study took place at a university in Hong Kong. 74 female undergraduate nursing students. Students listened to eight audio recordings in which an individual expressed pain in one of the two dialects of Chinese, either Cantonese or Putonghua. For each dialect, two recordings depicted mild pain and two depicted severe pain. After listening to each recording, students rated the pain level and indicated their decision of triage. Subsequently, students completed a questionnaire that measured their empathy and social identity and reported their demographics. The data were analyzed by descriptive statistics, correlational analyses, and t-tests. Severe pain described in Putonghua was rated as more intense than that described in Cantonese but it was not classified as more urgent. Students with clinical experience tended to perceive mild pain as less painful and less urgent than those without clinical experience. For mild pain described in Cantonese, students with clinical experience evaluated it as more urgent than those without such experience. The empathy level of students with and without clinical experience was comparable. Students with more empathy, especially those without clinical experience, reported heightened perceived intensity of severe pain described in Putonghua. Nurse educators should note that empathy, social identity, and clinical experience may alter students' pain assessment of patients from different ethnicities. Pain education needs to be reinforced. Copyright © 2015 Elsevier Ltd. All rights reserved.

Urban green space and vibrant communities: exploring the linkage in the Portland Vancouver area

Treesearch

Edward A. Stone; JunJie Wu; Ralph Alig

2015-01-01

This report investigates the interactions between household location decisions and community characteristics, including green space. Household location decisions are a primary driver of land-use change, and collective location decisions affect community characteristics. At the same time, community characteristics affect location decisions. Neighborhoods or communities...

An Analysis of the Associations among Cognitive Impulsiveness, Reasoning Process, and Rational Decision Making

PubMed Central

Jelihovschi, Ana P. G.; Cardoso, Ricardo L.; Linhares, Alexandre

2018-01-01

Impulsivity may lead to several unfortunate consequences and maladaptive behaviors for both clinical and nonclinical people. It has a key role in many forms of psychopathology. Although literature has discussed the negative impact of impulsivity, few have emphasized the relationship between cognitive impulsiveness and decision making. The aim of this study is to investigate the effects of cognitive impulsiveness on decision making and explore the strategies used by participants to solve problems. For this purpose, we apply two measures of impulsivity: the self-report Barratt Impulsiveness Scale (BIS-11) and the performance based Cognitive Reflection Test (CRT). Moreover, we evaluate participants' reasoning processes employed to answer CRT questions based on the calculation expressions, data organization, and erasures they made while answering the CRT (note that we utilized the instruments using pen and paper). These reasoning processes are related to the role of executive functions in decision making, and its relationship with impulsiveness. The sample consists of 191 adults, who were either professionals or undergraduate students from the fields of business, management, or accounting. The results show that cognitive impulsiveness may negatively affect decision making, and that those who presented the calculation to answer the CRT questions made better decisions. Moreover, there was no difference in the strategies used by impulsive vs. nonimpulsive participants during decision making. Finally, people who inhibited their immediate answers to CRT questions performed better during decision making. PMID:29375440

An Analysis of the Associations among Cognitive Impulsiveness, Reasoning Process, and Rational Decision Making.

PubMed

Jelihovschi, Ana P G; Cardoso, Ricardo L; Linhares, Alexandre

2017-01-01

Impulsivity may lead to several unfortunate consequences and maladaptive behaviors for both clinical and nonclinical people. It has a key role in many forms of psychopathology. Although literature has discussed the negative impact of impulsivity, few have emphasized the relationship between cognitive impulsiveness and decision making. The aim of this study is to investigate the effects of cognitive impulsiveness on decision making and explore the strategies used by participants to solve problems. For this purpose, we apply two measures of impulsivity: the self-report Barratt Impulsiveness Scale (BIS-11) and the performance based Cognitive Reflection Test (CRT). Moreover, we evaluate participants' reasoning processes employed to answer CRT questions based on the calculation expressions, data organization, and erasures they made while answering the CRT (note that we utilized the instruments using pen and paper). These reasoning processes are related to the role of executive functions in decision making, and its relationship with impulsiveness. The sample consists of 191 adults, who were either professionals or undergraduate students from the fields of business, management, or accounting. The results show that cognitive impulsiveness may negatively affect decision making, and that those who presented the calculation to answer the CRT questions made better decisions. Moreover, there was no difference in the strategies used by impulsive vs. nonimpulsive participants during decision making. Finally, people who inhibited their immediate answers to CRT questions performed better during decision making.

Presenting health risk information in different formats: the effect on participants' cognitive and emotional evaluation and decisions.

PubMed

Timmermans, Daniëlle R M; Ockhuysen-Vermey, Caroline F; Henneman, Lidewij

2008-12-01

Effective communication of health risks plays an important role in enabling patients to make adequate decisions. There is little--though contradictory--evidence to indicate which format is most effective for communicating risks, and which risk format is preferred by counselees. In an experiment, subjects were presented health scenarios and risk information in different formats (percentages, frequencies, and population figures) and asked to evaluate the risks and make a decision based on these. Different risk formats had different effects on respondents' evaluation of the health risks presented. Contrary to our expectation, population figures were not evaluated as being the easiest format for all decision problems. Population figures were shown to have the biggest affective impact, and risks presented as population figures were also evaluated as significantly greater than the risks presented in other formats. The format of the presented risks influenced their decision in only one out of four decision-making situations, although in a second situation there was a similar trend. This study suggests that the risk format plays a role in the decision-making process, although it remains unclear which format is the most effective in terms of understanding. More experimental studies based on a theoretical analysis of the factors that promote effective risk communication are needed in the general population as well as in clinical settings with patients actually experiencing the risks and making the decisions.

Assessment of bone health in children with disabilities.

PubMed

Kecskemethy, Heidi H; Harcke, H Theodore

2014-01-01

Evaluating the bone health of children with disabilities is challenging and requires consideration of many factors in clinical decision-making. Feeding problems and growth deficits, immobility/inability to bear weight, effect of medications, and the nature of his or her disease can all directly affect a child's overall picture of bone health. Familiarity with the tools available to assess bone health is important for practitioners. The most commonly used method to assess bone density, dual energy x-ray absorptiometry, can be performed effectively when one appreciates the techniques that make scanning patients with disabilities possible. There are specific techniques that are especially useful for measuring bone density in children with disabilities; standard body sites are not always obtainable. Consideration of clinical condition and treatment must be considered when interpreting dual energy x-ray absorptiometry scans. Serial measurements have been shown to be effective in monitoring change in bone content and in providing information on which to base decisions regarding medical treatment.

Personalizing prenatal care using family health history: identifying a panel of conditions for a novel electronic genetic screening tool.

PubMed

Lin, Bruce K; Edelman, Emily; McInerney, Joseph D; O'Leary, James; Edelson, Vaughn; Hughes, Kevin S; Drohan, Brian; Kyler, Penny; Lloyd-Puryear, Michele; Scott, Joan; Dolan, Siobhan M

2013-05-01

In the age of genomic medicine, family health history (FHH) remains an important tool for personalized risk assessment as it can inform approaches to disease prevention and management. In primary care, including in prenatal settings, providers recognize that FHH enables them to assess the risk for birth defects and complex conditions that not only affect the fetus health, but also the mother's. However, many providers lack the time to gather FHH or the knowledge to confidently interpret the data. Electronic tools providing clinical decision support using FHH data can aid the busy provider with data collection and interpretation. We describe the scope of conditions included in a patient-entered FHH tool that provides clinical decision support and point-of-care education to assist with patient management. This report details how we selected the conditions for which it is appropriate to use FHH as a means to promote personalized medicine in primary prenatal care.

Regulatory Focus Affects Physician Risk Tolerance

PubMed Central

Veazie, Peter J.; McIntosh, Scott; Chapman, Benjamin P.; Dolan, James G.

2014-01-01

Risk tolerance is a source of variation in physician decision-making. This variation, if independent of clinical concerns, can result in mistaken utilization of health services. To address such problems, it will be helpful to identify nonclinical factors of risk tolerance, particularly those amendable to intervention – regulatory focus theory suggests such a factor. This study tested whether regulatory focus affects risk tolerance among primary care physicians. Twenty-seven primary care physicians were assigned to promotion-focused or prevention-focused manipulations and compared on the Risk Taking Attitudes in Medical Decision Making scale using a randomization test. Results provide evidence that physicians assigned to the promotion-focus manipulation adopted an attitude of greater risk tolerance than the physicians assigned to the prevention-focused manipulation (P=0.01). The Cohen’s d statistic was conventionally large at 0.92. Results imply that situational regulatory focus in primary care physicians affects risk tolerance and may thereby be a nonclinical source of practice variation. Results also provide marginal evidence that chronic regulatory focus is associated with risk tolerance (P=0.05), but the mechanism remains unclear. Research and intervention targeting physician risk tolerance may benefit by considering situational regulatory focus as an explanatory factor. PMID:25431799

Decision Aid for Cigarette Smokers Scheduled for Elective Surgery.

PubMed

Warner, David O; LeBlanc, Annie; Kadimpati, Sandeep; Vickers, Kristin S; Shi, Yu; Montori, Victor M

2015-07-01

Decision aids can increase patient involvement in decision-making about health care. The study goal was to develop and test a decision aid for use by clinicians in discussion options for changing smoking behavior before and after elective surgery. In formative work, a decision aid was designed to facilitate patient-clinician discussion regarding three options: continue smoking, attempt a period of temporary abstinence, and attempt to quit smoking for good. A randomized, two-group pilot study was then conducted in smokers evaluated in preparation for elective surgery in a preoperative clinic to test the hypothesis that the decision aid would improve measures of decisional quality compared with usual care. The final decision aid consisted of three laminated cards. The front of each card included a colorful graphic describing each choice; the reverse including two to three pros and cons for each decision, a simple graphic illustrating the effects of smoking on the body, and a motivational phrase. In the randomized trial of 130 patients, the decision aid significantly (P < 0.05) improved measures of decisional quality and patient involvement in decision making (Cohen's d effect sizes of 0.76 and 1.20 for the Decisional Conflict Scale and Observing PatienT involvement In decisiON-making scale, respectively). However, the decision aid did not affect any aspect of perioperative smoking behavior, including the distribution of or adherence to choices. Although the use of a decision aid to facilitate clinician-patient discussions regarding tobacco use around the time of surgery substantially improved measures of decisional quality, it alone did not change perioperative tobacco use behavior.

Implementation of workflow engine technology to deliver basic clinical decision support functionality

PubMed Central

2011-01-01

Background Workflow engine technology represents a new class of software with the ability to graphically model step-based knowledge. We present application of this novel technology to the domain of clinical decision support. Successful implementation of decision support within an electronic health record (EHR) remains an unsolved research challenge. Previous research efforts were mostly based on healthcare-specific representation standards and execution engines and did not reach wide adoption. We focus on two challenges in decision support systems: the ability to test decision logic on retrospective data prior prospective deployment and the challenge of user-friendly representation of clinical logic. Results We present our implementation of a workflow engine technology that addresses the two above-described challenges in delivering clinical decision support. Our system is based on a cross-industry standard of XML (extensible markup language) process definition language (XPDL). The core components of the system are a workflow editor for modeling clinical scenarios and a workflow engine for execution of those scenarios. We demonstrate, with an open-source and publicly available workflow suite, that clinical decision support logic can be executed on retrospective data. The same flowchart-based representation can also function in a prospective mode where the system can be integrated with an EHR system and respond to real-time clinical events. We limit the scope of our implementation to decision support content generation (which can be EHR system vendor independent). We do not focus on supporting complex decision support content delivery mechanisms due to lack of standardization of EHR systems in this area. We present results of our evaluation of the flowchart-based graphical notation as well as architectural evaluation of our implementation using an established evaluation framework for clinical decision support architecture. Conclusions We describe an implementation of a free workflow technology software suite (available at http://code.google.com/p/healthflow) and its application in the domain of clinical decision support. Our implementation seamlessly supports clinical logic testing on retrospective data and offers a user-friendly knowledge representation paradigm. With the presented software implementation, we demonstrate that workflow engine technology can provide a decision support platform which evaluates well against an established clinical decision support architecture evaluation framework. Due to cross-industry usage of workflow engine technology, we can expect significant future functionality enhancements that will further improve the technology's capacity to serve as a clinical decision support platform. PMID:21477364

Determination of feasibility and utility of microscope-integrated optical coherence tomography during ophthalmic surgery: the DISCOVER Study RESCAN Results.

PubMed

Ehlers, Justis P; Goshe, Jeff; Dupps, William J; Kaiser, Peter K; Singh, Rishi P; Gans, Richard; Eisengart, Jonathan; Srivastava, Sunil K

2015-10-01

Optical coherence tomography (OCT) has transformed the clinical management of a myriad of ophthalmic conditions. Applying OCT to ophthalmic surgery may have implications for surgical decision making and patient outcomes. To assess the feasibility and effect on surgical decision making of a microscope-integrated intraoperative OCT (iOCT) system. Report highlighting the 1-year results (March 2014-February 2015) of the RESCAN 700 portion of the DISCOVER (Determination of Feasibility of Intraoperative Spectral Domain Microscope Combined/Integrated OCT Visualization During En Face Retinal and Ophthalmic Surgery) study, a single-site, multisurgeon, prospective consecutive case series regarding this investigational device. Participants included patients undergoing ophthalmic surgery. Data on clinical characteristics were collected, and iOCT was performed during surgical milestones, as directed by the operating surgeon. A surgeon questionnaire was issued to each surgeon and was completed after each case to evaluate the role of iOCT during surgery and its particular role in select surgical procedures. Percentage of cases with successful acquisition of iOCT (ie, feasibility). Percentage of cases in which iOCT altered surgical decision making (ie, utility). During year 1 of the DISCOVER study, a total of 227 eyes (91 anterior segment cases and 136 posterior segment cases) underwent imaging with the RESCAN 700 system. Successful imaging (eg, the ability to acquire an OCT image of the tissue of interest) was obtained for 224 of 227 eyes (99% [95% CI, 98%-100%]). During lamellar keratoplasty, the iOCT data provided information that altered the surgeon's decision making in 38% of the cases (eg, complete graft apposition when the surgeon believed there was interface fluid). In membrane peeling procedures, iOCT information was discordant with the surgeon's impression of membrane peel completeness in 19% of cases (eg, lack of residual membrane or presence of occult membrane), thus affecting additional surgical maneuvers. The DISCOVER study demonstrates the feasibility of real-time iOCT with a microscope-integrated iOCT system for ophthalmic surgery. The information gained from iOCT appears to allow surgeons to assess subtle details in a unique perspective from standard en face visualization, which can affect surgical decision making some of the time, although the effect of these changes in decision making on outcomes remains unknown. A prospective randomized masked trial is needed to confirm these results.

Using Best Practices to Extract, Organize, and Reuse Embedded Decision Support Content Knowledge Rules from Mature Clinical Systems

PubMed Central

DesAutels, Spencer J.; Fox, Zachary E.; Giuse, Dario A.; Williams, Annette M.; Kou, Qing-hua; Weitkamp, Asli; Neal R, Patel; Bettinsoli Giuse, Nunzia

2016-01-01

Clinical decision support (CDS) knowledge, embedded over time in mature medical systems, presents an interesting and complex opportunity for information organization, maintenance, and reuse. To have a holistic view of all decision support requires an in-depth understanding of each clinical system as well as expert knowledge of the latest evidence. This approach to clinical decision support presents an opportunity to unify and externalize the knowledge within rules-based decision support. Driven by an institutional need to prioritize decision support content for migration to new clinical systems, the Center for Knowledge Management and Health Information Technology teams applied their unique expertise to extract content from individual systems, organize it through a single extensible schema, and present it for discovery and reuse through a newly created Clinical Support Knowledge Acquisition and Archival Tool (CS-KAAT). CS-KAAT can build and maintain the underlying knowledge infrastructure needed by clinical systems. PMID:28269846

Separating Business Logic from Medical Knowledge in Digital Clinical Workflows Using Business Process Model and Notation and Arden Syntax.

PubMed

de Bruin, Jeroen S; Adlassnig, Klaus-Peter; Leitich, Harald; Rappelsberger, Andrea

2018-01-01

Evidence-based clinical guidelines have a major positive effect on the physician's decision-making process. Computer-executable clinical guidelines allow for automated guideline marshalling during a clinical diagnostic process, thus improving the decision-making process. Implementation of a digital clinical guideline for the prevention of mother-to-child transmission of hepatitis B as a computerized workflow, thereby separating business logic from medical knowledge and decision-making. We used the Business Process Model and Notation language system Activiti for business logic and workflow modeling. Medical decision-making was performed by an Arden-Syntax-based medical rule engine, which is part of the ARDENSUITE software. We succeeded in creating an electronic clinical workflow for the prevention of mother-to-child transmission of hepatitis B, where institution-specific medical decision-making processes could be adapted without modifying the workflow business logic. Separation of business logic and medical decision-making results in more easily reusable electronic clinical workflows.

Literature review on the structure and operation of Pharmacy and Therapeutics Committees.

PubMed

Durán-García, Esther; Santos-Ramos, Bernardo; Puigventos-Latorre, Francesc; Ortega, Ana

2011-06-01

To review the literature on the structure and operation of hospital Pharmacy and Therapeutics Committees from an international point of view and examine the factors that influence decision-making of these committees. We performed a literature search in the Medline and Embase databases from 1997 to January 2009 with the search terms: formulary system decision making, pharmacy and therapeutics committee, formularies hospital, drug formulary, survey, drug selection and outcome assessment health care. Inclusion criteria were the following: studies analyzing Pharmacy and Therapeutics Committees published in English or Spanish from 1997 to January 2009. Exclusion criteria were: publications which were editorials or opinion pieces, studies relating to one hospital, and studies where full text could not be attained. The analysis was divided into structural/organizational data and data on factors affecting the decision-making process. Seventeen studies met the inclusion criteria. Pharmacy and Therapeutics Committees and formularies were present in more than 90% of the hospitals in four of the five countries examined. Therapeutic interchange programs existed only in two of these countries. The mean number of committee members ranged between six and eight. More than 89% of the committees included a pharmacist. Standard operating procedures were implemented by 89% of the committees. The most influential factors in the decision-making were clinical trial results or drug costs rather than pharmacoeconomic studies. Other local organization-dependent factors were also important. The structure and operating procedures of Hospital Pharmacy and Therapeutics Committees are similar in select Western countries. Information from clinical trials is the most influential factor in the decision-making process.

Applying a family systems lens to proxy decision making in clinical practice and research.

PubMed

Rolland, John S; Emanuel, Linda L; Torke, Alexia M

2017-03-01

When patients are incapacitated and face serious illness, family members must make medical decisions for the patient. Medical decision sciences give only modest attention to the relationships among patients and their family members, including impact that these relationships have on the decision-making process. A review of the literature reveals little effort to systematically apply a theoretical framework to the role of family interactions in proxy decision making. A family systems perspective can provide a useful lens through which to understand the dynamics of proxy decision making. This article considers the mutual impact of family systems on the processes and outcomes of proxy decision making. The article first reviews medical decision science's evolution and focus on proxy decision making and then reviews a family systems approach, giving particular attention to Rolland's Family Systems Illness Model. A case illustrates how clinical practice and how research would benefit from bringing family systems thinking to proxy decisions. We recommend including a family systems approach in medical decision science research and clinical practices around proxy decisions making. We propose that clinical decisions could be less conflicted and less emotionally troubling for families and clinicians if family systems approaches were included. This perspective opens new directions for research and novel approaches to clinical care. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Accuracy of intuition in clinical decision-making among novice clinicians.

PubMed

Price, Amanda; Zulkosky, Kristen; White, Krista; Pretz, Jean

2017-05-01

To assess the reliance on intuitive and analytical approaches during clinical decision-making among novice clinicians and whether that reliance is associated with accurate decision-making. Nurse educators and managers tend to emphasize analysis over intuition during clinical decision-making though nurses typically report some reliance on intuition in their practice. We hypothesized that under certain conditions, reliance on intuition would support accurate decision-making, even among novices. This study utilized an experimental design with clinical complication (familiar vs. novel) and decision phase (cue acquisition, diagnosis and action) as within-subjects' factors, and simulation role (observer, family, auxiliary nurse and primary nurse) as between-subjects' factor. We examined clinical decision-making accuracy among final semester pre-licensure nursing students in a simulation experience. Students recorded their reasoning about emerging clinical complications with their patient during two distinct points in the simulation; one point involved a familiar complication and the other a relatively novel complication. All data were collected during Spring 2015. Although most participants relied more heavily on analysis than on intuition, use of intuition during the familiar complication was associated with more accurate decision-making, particularly in guiding attention to relevant cues. With the novel complication, use of intuition appeared to hamper decision-making, particularly for those in an observer role. Novice clinicians should be supported by educators and nurse managers to note when their intuitions are likely to be valid. Our findings emphasize the integrated nature of intuition and analysis in clinical decision-making. © 2016 John Wiley & Sons Ltd.

SANDS: a service-oriented architecture for clinical decision support in a National Health Information Network.

PubMed

Wright, Adam; Sittig, Dean F

2008-12-01

In this paper, we describe and evaluate a new distributed architecture for clinical decision support called SANDS (Service-oriented Architecture for NHIN Decision Support), which leverages current health information exchange efforts and is based on the principles of a service-oriented architecture. The architecture allows disparate clinical information systems and clinical decision support systems to be seamlessly integrated over a network according to a set of interfaces and protocols described in this paper. The architecture described is fully defined and developed, and six use cases have been developed and tested using a prototype electronic health record which links to one of the existing prototype National Health Information Networks (NHIN): drug interaction checking, syndromic surveillance, diagnostic decision support, inappropriate prescribing in older adults, information at the point of care and a simple personal health record. Some of these use cases utilize existing decision support systems, which are either commercially or freely available at present, and developed outside of the SANDS project, while other use cases are based on decision support systems developed specifically for the project. Open source code for many of these components is available, and an open source reference parser is also available for comparison and testing of other clinical information systems and clinical decision support systems that wish to implement the SANDS architecture. The SANDS architecture for decision support has several significant advantages over other architectures for clinical decision support. The most salient of these are:

Approach to risk identification in undifferentiated mental disorders

PubMed Central

Silveira, José; Rockman, Patricia; Fulford, Casey; Hunter, Jon

2016-01-01

Abstract Objective To provide primary care physicians with a novel approach to risk identification and related clinical decision making in the management of undifferentiated mental disorders. Sources of information We conducted a review of the literature in PubMed, CINAHL, PsycINFO, and Google Scholar using the search terms diagnostic uncertainty, diagnosis, risk identification, risk assessment/methods, risk, risk factors, risk management/methods, cognitive biases and psychiatry, decision making, mental disorders/diagnosis, clinical competence, evidence-based medicine, interviews as topic, psychiatry/education, psychiatry/methods, documentation/methods, forensic psychiatry/education, forensic psychiatry/methods, mental disorders/classification, mental disorders/psychology, violence/prevention and control, and violence/psychology. Main message Mental disorders are a large component of practice in primary care and often present in an undifferentiated manner, remaining so for prolonged periods. The challenging search for a diagnosis can divert attention from risk identification, as diagnosis is commonly presumed to be necessary before treatment can begin. This might inadvertently contribute to preventable adverse events. Focusing on salient aspects of the patient presentation related to risk should be prioritized. This article presents a novel approach to organizing patient information to assist risk identification and decision making in the management of patients with undifferentiated mental disorders. Conclusion A structured approach can help physicians to manage the clinical uncertainty common to risk identification in patients with mental disorders and cope with the common anxiety and cognitive biases that affect priorities in risk-related decision making. By focusing on risk, functional impairments, and related symptoms using a novel framework, physicians can meet their patients’ immediate needs while continuing the search for diagnostic clarity and long-term treatment. PMID:27965330

Approach to risk identification in undifferentiated mental disorders.

PubMed

Silveira, José; Rockman, Patricia; Fulford, Casey; Hunter, Jon

2016-12-01

To provide primary care physicians with a novel approach to risk identification and related clinical decision making in the management of undifferentiated mental disorders. We conducted a review of the literature in PubMed, CINAHL, PsycINFO, and Google Scholar using the search terms diagnostic uncertainty, diagnosis, risk identification, risk assessment/methods, risk, risk factors, risk management/methods, cognitive biases and psychiatry, decision making, mental disorders/diagnosis, clinical competence, evidence-based medicine, interviews as topic, psychiatry/education, psychiatry/methods, documentation/methods, forensic psychiatry/education, forensic psychiatry/methods, mental disorders/classification, mental disorders/psychology, violence/prevention and control, and violence/psychology. Mental disorders are a large component of practice in primary care and often present in an undifferentiated manner, remaining so for prolonged periods. The challenging search for a diagnosis can divert attention from risk identification, as diagnosis is commonly presumed to be necessary before treatment can begin. This might inadvertently contribute to preventable adverse events. Focusing on salient aspects of the patient presentation related to risk should be prioritized. This article presents a novel approach to organizing patient information to assist risk identification and decision making in the management of patients with undifferentiated mental disorders. A structured approach can help physicians to manage the clinical uncertainty common to risk identification in patients with mental disorders and cope with the common anxiety and cognitive biases that affect priorities in risk-related decision making. By focusing on risk, functional impairments, and related symptoms using a novel framework, physicians can meet their patients' immediate needs while continuing the search for diagnostic clarity and long-term treatment. Copyright© the College of Family Physicians of Canada.

An Internationally Consented Standard for Nursing Process-Clinical Decision Support Systems in Electronic Health Records.

PubMed

Müller-Staub, Maria; de Graaf-Waar, Helen; Paans, Wolter

2016-11-01

Nurses are accountable to apply the nursing process, which is key for patient care: It is a problem-solving process providing the structure for care plans and documentation. The state-of-the art nursing process is based on classifications that contain standardized concepts, and therefore, it is named Advanced Nursing Process. It contains valid assessments, nursing diagnoses, interventions, and nursing-sensitive patient outcomes. Electronic decision support systems can assist nurses to apply the Advanced Nursing Process. However, nursing decision support systems are missing, and no "gold standard" is available. The study aim is to develop a valid Nursing Process-Clinical Decision Support System Standard to guide future developments of clinical decision support systems. In a multistep approach, a Nursing Process-Clinical Decision Support System Standard with 28 criteria was developed. After pilot testing (N = 29 nurses), the criteria were reduced to 25. The Nursing Process-Clinical Decision Support System Standard was then presented to eight internationally known experts, who performed qualitative interviews according to Mayring. Fourteen categories demonstrate expert consensus on the Nursing Process-Clinical Decision Support System Standard and its content validity. All experts agreed the Advanced Nursing Process should be the centerpiece for the Nursing Process-Clinical Decision Support System and should suggest research-based, predefined nursing diagnoses and correct linkages between diagnoses, evidence-based interventions, and patient outcomes.

Development of cognitive and affective control networks and decision making.

PubMed

Kar, Bhoomika R; Vijay, Nivita; Mishra, Shreyasi

2013-01-01

Cognitive control and decision making are two important research areas in the realm of higher-order cognition. Control processes such as interference control and monitoring in cognitive and affective contexts have been found to influence the process of decision making. Development of control processes follows a gradual growth pattern associated with the prolonged maturation of underlying neural circuits including the lateral prefrontal cortex, anterior cingulate, and the medial prefrontal cortex. These circuits are also involved in the control of processes that influences decision making, particularly with respect to choice behavior. Developmental studies on affective control have shown distinct patterns of brain activity with adolescents showing greater activation of amygdala whereas adults showing greater activity in ventral prefrontal cortex. Conflict detection, monitoring, and adaptation involve anticipation and subsequent performance adjustments which are also critical to complex decision making. We discuss the gradual developmental patterns observed in two of our studies on conflict monitoring and adaptation in affective and nonaffective contexts. Findings of these studies indicate the need to look at the differences in the effects of the development of cognitive and affective control on decision making in children and particularly adolescents. Neuroimaging studies have shown the involvement of separable neural networks for cognitive (medial prefrontal cortex and anterior cingulate) and affective control (amygdala, ventral medial prefrontal cortex) shows that one system can affect the other also at the neural level. Hence, an understanding of the interaction and balance between the cognitive and affective brain networks may be crucial for self-regulation and decision making during the developmental period, particularly late childhood and adolescence. The chapter highlights the need for empirical investigation on the interaction between the different aspects of cognitive control and decision making from a developmental perspective. Copyright © 2013 Elsevier B.V. All rights reserved.

Lessons learned from implementing service-oriented clinical decision support at four sites: A qualitative study.

PubMed

Wright, Adam; Sittig, Dean F; Ash, Joan S; Erickson, Jessica L; Hickman, Trang T; Paterno, Marilyn; Gebhardt, Eric; McMullen, Carmit; Tsurikova, Ruslana; Dixon, Brian E; Fraser, Greg; Simonaitis, Linas; Sonnenberg, Frank A; Middleton, Blackford

2015-11-01

To identify challenges, lessons learned and best practices for service-oriented clinical decision support, based on the results of the Clinical Decision Support Consortium, a multi-site study which developed, implemented and evaluated clinical decision support services in a diverse range of electronic health records. Ethnographic investigation using the rapid assessment process, a procedure for agile qualitative data collection and analysis, including clinical observation, system demonstrations and analysis and 91 interviews. We identified challenges and lessons learned in eight dimensions: (1) hardware and software computing infrastructure, (2) clinical content, (3) human-computer interface, (4) people, (5) workflow and communication, (6) internal organizational policies, procedures, environment and culture, (7) external rules, regulations, and pressures and (8) system measurement and monitoring. Key challenges included performance issues (particularly related to data retrieval), differences in terminologies used across sites, workflow variability and the need for a legal framework. Based on the challenges and lessons learned, we identified eight best practices for developers and implementers of service-oriented clinical decision support: (1) optimize performance, or make asynchronous calls, (2) be liberal in what you accept (particularly for terminology), (3) foster clinical transparency, (4) develop a legal framework, (5) support a flexible front-end, (6) dedicate human resources, (7) support peer-to-peer communication, (8) improve standards. The Clinical Decision Support Consortium successfully developed a clinical decision support service and implemented it in four different electronic health records and four diverse clinical sites; however, the process was arduous. The lessons identified by the Consortium may be useful for other developers and implementers of clinical decision support services. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Error affect inoculation for a complex decision-making task.

PubMed

Tabernero, Carmen; Wood, Robert E

2009-05-01

Individuals bring knowledge, implicit theories, and goal orientations to group meetings. Group decisions arise out of the exchange of these orientations. This research explores how a trainee's exploratory and deliberate process (an incremental theory and learning goal orientation) impacts the effectiveness of individual and group decision-making processes. The effectiveness of this training program is compared with another program that included error affect inoculation (EAI). Subjects were 40 Spanish Policemen in a training course. They were distributed in two training conditions for an individual and group decision-making task. In one condition, individuals received the Self-Guided Exploration plus Deliberation Process instructions, which emphasised exploring the options and testing hypotheses. In the other condition, individuals also received instructions based on Error Affect Inoculation (EAI), which emphasised positive affective reactions to errors and mistakes when making decisions. Results show that the quality of decisions increases when the groups share their reasoning. The AIE intervention promotes sharing information, flexible initial viewpoints, and improving the quality of group decisions. Implications and future directions are discussed.

Recruitment of subjects into clinical trials for Alzheimer disease.

PubMed

Knebl, Janice A; Patki, Deepti

2010-09-01

Alzheimer disease is a devastating neurodegenerative disorder affecting millions of Americans. It reduces the ability of the individual to remain independent, places a burden on caregivers, and substantially increases healthcare costs. New treatments are being tested in numerous clinical trials with the goal of preventing or delaying the onset of Alzheimer disease, slowing or modifying the disease's course, or finding a cure for patients with the disease. Alzheimer disease research can successfully proceed only if individuals who have this illness are willing to participate in clinical trials. However, recruitment and retention of subjects in clinical trials for Alzheimer disease is a challenging task. Furthermore, because of reductions in decision-making capacities of individuals with Alzheimer disease, clinical trials also need to involve caregivers. The present article delineates unique hurdles encountered in the recruitment process for Alzheimer disease clinical trials. The article also identifies strategies for effective recruitment of subjects in Alzheimer disease clinical trials, including guidelines to help principal investigators and clinical research coordinators reach recruitment goals.

Affective and cognitive decision-making in adolescents.

PubMed

van Duijvenvoorde, Anna C K; Jansen, Brenda R J; Visser, Ingmar; Huizenga, Hilde M

2010-01-01

Adolescents demonstrate impaired decision-making in emotionally arousing situations, yet they appear to exhibit relatively mature decision-making skills in predominantly cognitive, low-arousal situations. In this study we compared adolescents' (13-15 years) performance on matched affective and cognitive decision-making tasks, in order to determine (1) their performance level on each task and (2) whether performance on the cognitive task was associated with performance on the affective task. Both tasks required a comparison of choice dimensions characterized by frequency of loss, amount of loss, and constant gain. Results indicated that in the affective task, adolescents performed sub-optimally by considering only the frequency of loss, whereas in the cognitive task adolescents used relatively mature decision rules by considering two or all three choice dimensions. Performance on the affective task was not related to performance on the cognitive task. These results are discussed in light of neural developmental trajectories observed in adolescence.

Attunement and alignment of people with schizophrenia and their preferred alternative decision-makers: An exploratory pilot study comparing treatment and research decisions.

PubMed

Roberts, Laura Weiss; Kim, Jane Paik

2015-12-01

Schizophrenia is a serious mental disorder that may affect the decisional capacity, and as a consequence, preferred alternative decision-makers may be engaged to help with clinical care and research-related choices. Ideally, alternative decision-makers will seek to make decisions that fit with the views and preferences of the ill individual. Few data exist, however, comparing the views of alternative decision-makers to those of individuals with schizophrenia. We conducted a written survey with individuals with schizophrenia living in a community setting, and a parallel survey with the person whom the ill individual identified as being a preferred alternative decision-maker. Complete data were obtained on 20 pairs (n = 40, total). Domains queried included (a) burden, happiness, and safety of the ill individual and of his or her family in treatment and research decisions and (b) importance of ethical principles in every day life. Two-sided paired t-tests and graphical summaries were used to compare responses. Individuals with schizophrenia and their linked preferred alternative decision-makers were attuned on four of six aspects of treatment decision-making and on all six aspects of research decision-making that we queried. The preferred alternative decision-makers overall demonstrated attunement to the views of the ill individuals in this small study. Ill individuals and their preferred alternative decision-makers were aligned in their views of ethically-salient aspects of every day life. These novel findings suggest that alternative decision-makers identified by ill individuals may be able to guide choices based on an accurate understanding of the ill individuals' views and values. Copyright © 2015 Elsevier Ltd. All rights reserved.

The Neural Basis of Risky Choice with Affective Outcomes

PubMed Central

Suter, Renata S.; Pachur, Thorsten; Hertwig, Ralph; Endestad, Tor; Biele, Guido

2015-01-01

Both normative and many descriptive theories of decision making under risk are based on the notion that outcomes are weighted by their probability, with subsequent maximization of the (subjective) expected outcome. Numerous investigations from psychology, economics, and neuroscience have produced evidence consistent with this notion. However, this research has typically investigated choices involving relatively affect-poor, monetary outcomes. We compared choice in relatively affect-poor, monetary lottery problems with choice in relatively affect-rich medical decision problems. Computational modeling of behavioral data and model-based neuroimaging analyses provide converging evidence for substantial differences in the respective decision mechanisms. Relative to affect-poor choices, affect-rich choices yielded a more strongly curved probability weighting function of cumulative prospect theory, thus signaling that the psychological impact of probabilities is strongly diminished for affect-rich outcomes. Examining task-dependent brain activation, we identified a region-by-condition interaction indicating qualitative differences of activation between affect-rich and affect-poor choices. Moreover, brain activation in regions that were more active during affect-poor choices (e.g., the supramarginal gyrus) correlated with individual trial-by-trial decision weights, indicating that these regions reflect processing of probabilities. Formal reverse inference Neurosynth meta-analyses suggested that whereas affect-poor choices seem to be based on brain mechanisms for calculative processes, affect-rich choices are driven by the representation of outcomes’ emotional value and autobiographical memories associated with them. These results provide evidence that the traditional notion of expectation maximization may not apply in the context of outcomes laden with affective responses, and that understanding the brain mechanisms of decision making requires the domain of the decision to be taken into account. PMID:25830918

The neural basis of risky choice with affective outcomes.

PubMed

Suter, Renata S; Pachur, Thorsten; Hertwig, Ralph; Endestad, Tor; Biele, Guido

2015-01-01

Both normative and many descriptive theories of decision making under risk are based on the notion that outcomes are weighted by their probability, with subsequent maximization of the (subjective) expected outcome. Numerous investigations from psychology, economics, and neuroscience have produced evidence consistent with this notion. However, this research has typically investigated choices involving relatively affect-poor, monetary outcomes. We compared choice in relatively affect-poor, monetary lottery problems with choice in relatively affect-rich medical decision problems. Computational modeling of behavioral data and model-based neuroimaging analyses provide converging evidence for substantial differences in the respective decision mechanisms. Relative to affect-poor choices, affect-rich choices yielded a more strongly curved probability weighting function of cumulative prospect theory, thus signaling that the psychological impact of probabilities is strongly diminished for affect-rich outcomes. Examining task-dependent brain activation, we identified a region-by-condition interaction indicating qualitative differences of activation between affect-rich and affect-poor choices. Moreover, brain activation in regions that were more active during affect-poor choices (e.g., the supramarginal gyrus) correlated with individual trial-by-trial decision weights, indicating that these regions reflect processing of probabilities. Formal reverse inference Neurosynth meta-analyses suggested that whereas affect-poor choices seem to be based on brain mechanisms for calculative processes, affect-rich choices are driven by the representation of outcomes' emotional value and autobiographical memories associated with them. These results provide evidence that the traditional notion of expectation maximization may not apply in the context of outcomes laden with affective responses, and that understanding the brain mechanisms of decision making requires the domain of the decision to be taken into account.

The role of law in decisions to withhold and withdraw life-sustaining treatment from adults who lack capacity: a cross-sectional study.

PubMed

White, Benjamin P; Willmott, Lindy; Williams, Gail; Cartwright, Colleen; Parker, Malcolm

2017-05-01

To determine the role played by law in medical specialists' decision-making about withholding and withdrawing life-sustaining treatment from adults who lack capacity, and the extent to which legal knowledge affects whether law is followed. Cross-sectional postal survey of medical specialists. The two largest Australian states by population. 649 medical specialists from seven specialties most likely to be involved in end-of-life decision-making in the acute setting. Compliance with law and the impact of legal knowledge on compliance. 649 medical specialists (of 2104 potential participants) completed the survey (response rate 31%). Responses to a hypothetical scenario found a potential low rate of legal compliance, 32% (95% CI 28% to 36%). Knowledge of the law and legal compliance were associated: within compliers, 86% (95% CI 83% to 91%) had specific knowledge of the relevant aspect of the law, compared with 60% (95% CI 55% to 65%) within non-compliers. However, the reasons medical specialists gave for making decisions did not vary according to legal knowledge. Medical specialists prioritise patient-related clinical factors over law when confronted with a scenario where legal compliance is inconsistent with what they believe is clinically indicated. Although legally knowledgeable specialists were more likely to comply with the law, compliance in the scenario was not motivated by an intention to follow law. Ethical considerations (which are different from, but often align with, law) are suggested as a more important influence in clinical decision-making. More education and training of doctors is needed to demonstrate the role, relevance and utility of law in end-of-life care. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Identification of Patient Characteristics Influencing Setting of Care Decisions for Patients With Acute Bacterial Skin and Skin Structure Infections: Results of a Discrete Choice Experiment.

PubMed

Lane, Suzanne; Johnston, Karissa; Sulham, Katherine A; Syed, Iqra; Pollack, Charles V; Holland, Thomas; Nathwani, Dilip

2016-03-01

Rates of acute bacterial skin and skin structure infections (ABSSSI) have sharply increased since 2000. Treatment may be administered in the inpatient or outpatient setting; clinical decision-making regarding hospitalization is inconsistent, often leading to hospitalization of some patients with ABSSSI who qualify for outpatient parenteral antimicrobial therapy, which leads to increased overall care costs. New antibiotics such as oritavancin are hypothesized to be a cost-effective option improving accessibility to ambulatory treatment of ABSSSI. The goal of this study was to understand the patient attributes that affect clinical decision-making regarding the setting of care for ABSSSI treatment. An observational, cross-sectional study was conducted that surveyed clinicians of various specialties from the United States and the United Kingdom. The survey collected quantitative responses and used a series of choice-based experimental designs to evaluate patient attributes influencing clinical treatment decisions. Infection severity, severe comorbidities, and age ≥ 75 years were observed to have the greatest impact on treatment location decisions (odds ratio [OR], 0.000-0.004 [95% CI, 0.000-0.011], vs mild ABSSSI; OR, 0.246-0.484 [95% CI, 0.154-0.788], vs no active comorbidities; OR, 0.136-0.523 [95% CI, 0.070-0.888], vs ≤ 18 years, respectively). The majority of respondents indicated they would consider oritavancin to avoid postdischarge outpatient parenteral antimicrobial therapy or oral therapy, regardless of the pathogen (63.5%-83.5%). Key factors influencing ABSSSI treatment setting were severity of infection, severity of comorbidities, and age. Clinicians surveyed identified patient profiles in which single-dose oritavancin might enable wholly outpatient or shortened inpatient management. Additional studies to elucidate the ABSSSI care pathways that include oritavancin and other novel antibiotics are needed. Copyright © 2016 Elsevier HS Journals, Inc. All rights reserved.

Affective biasing of choices in gambling task decision making.

PubMed

Hinson, John M; Whitney, Paul; Holben, Heather; Wirick, Aaron K

2006-09-01

The proponents of the somatic marker hypothesis presume that rational decision making is guided by emotional reactions that are developed from prior experience. Supporting evidence for the hypothesis comes almost exclusively from the short-term affective reactions that are learned during the course of a hypothetical decision-making task--the gambling task (GT). We examined GT performance and affective reactions to choices when those choices were biased by words that had preexisting affective value. In one experiment, affectively valued words directly signaled good and bad choices. A congruent relation between affective value of word and choice outcome improved GT performance, whereas an incongruent relation greatly interfered with performance. In another experiment, affectively valued words were maintained as a working memory (WM) load between GT choices. A WM load with affectively positive words somewhat improved GT performance, whereas affectively negative words interfered with performance. Somatic markers-indicated by differential anticipatory skin conductance response (SCR) amplitude for good and bad choices-appeared at a point in the GT session when choice performance was superior. However, differential SCR developed during the session after good choice performance was already established. These results indicate that preexisting affective biases can influence GT decision making. In addition, the somatic markers that are regular accompaniments of GT decision making appeared to be temporally lagging indicators of choice performance.

Bits and bytes: the future of radiology lies in informatics and information technology.

PubMed

Brink, James A; Arenson, Ronald L; Grist, Thomas M; Lewin, Jonathan S; Enzmann, Dieter

2017-09-01

Advances in informatics and information technology are sure to alter the practice of medical imaging and image-guided therapies substantially over the next decade. Each element of the imaging continuum will be affected by substantial increases in computing capacity coincident with the seamless integration of digital technology into our society at large. This article focuses primarily on areas where this IT transformation is likely to have a profound effect on the practice of radiology. • Clinical decision support ensures consistent and appropriate resource utilization. • Big data enables correlation of health information across multiple domains. • Data mining advances the quality of medical decision-making. • Business analytics allow radiologists to maximize the benefits of imaging resources.

Considerations in pharmaceutical conversion: focus on antihistamines.

PubMed

Garbus, S B; Moulton, B W; Meltzer, E O; Reich, P R; Weinreb, L F; Friedman, J A; Orland, B I

1997-04-01

The practice of pharmaceutical conversion, which encompasses three types of drug interchange (generic, brand, and therapeutic substitution), is increasing in managed care settings. Pharmaceutical conversion has numerous implications for managed care organizations, their healthcare providers, and their customers. Although drug cost may be a driving consideration in pharmaceutical conversion, a number of other considerations are of equal or greater importance in the decision-making process may affect the overall cost of patient care. Among these considerations are clinical, psychosocial, and safety issues; patient adherence; patient satisfaction; and legal implications of pharmaceutical conversion. Patient-centered care must always remain central to decisions about pharmaceutical conversion. This article discusses the issues related to, and implications of, pharmaceutical conversion utilizing the antihistamines class of drugs as the case situation.

Investigating the influence of African American and African Caribbean race on primary care doctors' decision making about depression.

PubMed

Adams, A; Vail, L; Buckingham, C D; Kidd, J; Weich, S; Roter, D

2014-09-01

This paper explores differences in how primary care doctors process the clinical presentation of depression by African American and African-Caribbean patients compared with white patients in the US and the UK. The aim is to gain a better understanding of possible pathways by which racial disparities arise in depression care. One hundred and eight doctors described their thought processes after viewing video recorded simulated patients presenting with identical symptoms strongly suggestive of depression. These descriptions were analysed using the CliniClass system, which captures information about micro-components of clinical decision making and permits a systematic, structured and detailed analysis of how doctors arrive at diagnostic, intervention and management decisions. Video recordings of actors portraying black (both African American and African-Caribbean) and white (both White American and White British) male and female patients (aged 55 years and 75 years) were presented to doctors randomly selected from the Massachusetts Medical Society list and from Surrey/South West London and West Midlands National Health Service lists, stratified by country (US v.UK), gender, and years of clinical experience (less v. very experienced). Findings demonstrated little evidence of bias affecting doctors' decision making processes, with the exception of less attention being paid to the potential outcomes associated with different treatment options for African American compared with White American patients in the US. Instead, findings suggest greater clinical uncertainty in diagnosing depression amongst black compared with white patients, particularly in the UK. This was evident in more potential diagnoses. There was also a tendency for doctors in both countries to focus more on black patients' physical rather than psychological symptoms and to identify endocrine problems, most often diabetes, as a presenting complaint for them. This suggests that doctors in both countries have a less well developed mental model of depression for black compared with white patients. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.

Development, deployment and usability of a point-of-care decision support system for chronic disease management using the recently-approved HL7 decision support service standard.

PubMed

Lobach, David F; Kawamoto, Kensaku; Anstrom, Kevin J; Russell, Michael L; Woods, Peter; Smith, Dwight

2007-01-01

Clinical decision support is recognized as one potential remedy for the growing crisis in healthcare quality in the United States and other industrialized nations. While decision support systems have been shown to improve care quality and reduce errors, these systems are not widely available. This lack of availability arises in part because most decision support systems are not portable or scalable. The Health Level 7 international standard development organization recently adopted a draft standard known as the Decision Support Service standard to facilitate the implementation of clinical decision support systems using software services. In this paper, we report the first implementation of a clinical decision support system using this new standard. This system provides point-of-care chronic disease management for diabetes and other conditions and is deployed throughout a large regional health system. We also report process measures and usability data concerning the system. Use of the Decision Support Service standard provides a portable and scalable approach to clinical decision support that could facilitate the more extensive use of decision support systems.

SANDS: an architecture for clinical decision support in a National Health Information Network.

PubMed

Wright, Adam; Sittig, Dean F

2007-10-11

A new architecture for clinical decision support called SANDS (Service-oriented Architecture for NHIN Decision Support) is introduced and its performance evaluated. The architecture provides a method for performing clinical decision support across a network, as in a health information exchange. Using the prototype we demonstrated that, first, a number of useful types of decision support can be carried out using our architecture; and, second, that the architecture exhibits desirable reliability and performance characteristics.

Healthcare resource allocation decisions affecting uninsured services

PubMed Central

Harrison, Krista Lyn; Taylor, Holly A.

2017-01-01

Purpose Using the example of community access programs (CAPs), the purpose of this paper is to describe resource allocation and policy decisions related to providing health services for the uninsured in the USA and the organizational values affecting these decisions. Design/methodology/approach The study used comparative case study methodology at two geographically diverse sites. Researchers collected data from program documents, meeting observations, and interviews with program stakeholders. Findings Five resource allocation or policy decisions relevant to providing healthcare services were described at each site across three categories: designing the health plan, reacting to funding changes, and revising policies. Organizational values of access to care and stewardship most frequently affected resource allocation and policy decisions, while economic and political pressures affect the relative prioritization of values. Research limitations/implications Small sample size, the potential for social desirability or recall bias, and the exclusion of provider, member or community perspectives beyond those represented among participating board members. Practical implications Program directors or researchers can use this study to assess the extent to which resource allocation and policy decisions align with organizational values and mission statements. Social implications The description of how healthcare decisions are actually made can be matched with literature that describes how healthcare resource decisions ought to be made, in order to provide a normative grounding for future decisions. Originality/value This study addresses a gap in literature regarding how CAPs actually make resource allocation decisions that affect access to healthcare services. PMID:27934550

Patients' Values in Clinical Decision-Making.

PubMed

Faggion, Clovis Mariano; Pachur, Thorsten; Giannakopoulos, Nikolaos Nikitas

2017-09-01

Shared decision-making involves the participation of patient and dental practitioner. Well-informed decision-making requires that both parties understand important concepts that may influence the decision. This fourth article in a series of 4 aims to discuss the importance of patients' values when a clinical decision is made. We report on how to incorporate important concepts for well-informed, shared decision-making. Here, we present patient values as an important issue, in addition to previously established topics such as the risk of bias of a study, cost-effectiveness of treatment approaches, and a comparison of therapeutic benefit with potential side effects. We provide 2 clinical examples and suggestions for a decision tree, based on the available evidence. The information reported in this article may improve the relationship between patient and dental practitioner, resulting in more well-informed clinical decisions. Copyright © 2017 Elsevier Inc. All rights reserved.

An exploration of clinical decision making in mental health triage.

PubMed

Sands, Natisha

2009-08-01

Mental health (MH) triage is a specialist area of clinical nursing practice that involves complex decision making. The discussion in this article draws on the findings of a Ph.D. study that involved a statewide investigation of the scope of MH triage nursing practice in Victoria, Australia. Although the original Ph.D. study investigated a number of core practices in MH triage, the focus of the discussion in this article is specifically on the findings related to clinical decision making in MH triage, which have not previously been published. The study employed an exploratory descriptive research design that used mixed data collection methods including a survey questionnaire (n = 139) and semistructured interviews (n = 21). The study findings related to decision making revealed a lack of empirically tested evidence-based decision-making frameworks currently in use to support MH triage nursing practice. MH triage clinicians in Australia rely heavily on clinical experience to underpin decision making and have little of knowledge of theoretical models for practice, such as methodologies for rating urgency. A key recommendation arising from the study is the need to develop evidence-based decision-making frameworks such as clinical guidelines to inform and support MH triage clinical decision making.

Offering a Treatment Choice in the Irradiation of Prostate Cancer Leads to Better Informed and More Active Patients, Without Harm to Well-Being

DOE Office of Scientific and Technical Information (OSTI.GOV)

Tol-Geerdink, Julia J. van; Leer, Jan Willem; Lin, Emile N. J. Th. van

2008-02-01

Purpose: To examine, in prostate cancer patients, the effect of (1) being offered a choice between radiation doses in three-dimensional conformal radiotherapy, and of (2) accepting or declining the possibility to choose. Methods and Materials: A total of 150 patients with localized prostate cancer (T1-3N0M0) were offered a choice with a decision aid between two radiation doses (70 and 74 Gy). A control group of 144 patients received a fixed radiation dose without being offered a choice. Data were collected at baseline (before choice), before treatment (after choice), and 2 weeks and 6 months after treatment completion. Results: Compared withmore » the control group, the involvement group, receiving the decision aid, showed increased participation in decision making (p < 0.001), increased knowledge (p < 0.001), and improved risk perception (p < 0.001); they were more satisfied with the quality of information (p = 0.002) and considered their treatment a more appropriate treatment (p = 0.01). No group differences were found in well-being (e.g., general health, European Organization for Research and Treatment of Cancer quality of life, anxiety). Within the involvement group, accepting or declining the option to choose did not affect well-being either. Conclusions: Offering a choice of radiation dose, with a decision aid, increased involvement in decision making and led to a better-informed patient. In contrast to earlier suggestions, a strong increase in involvement did not result in improved well-being; and in contrast to clinical concerns, well-being was not negatively affected either, not even in those patients who preferred to leave the decision to their physician. This study shows that older patients, such as prostate cancer patients, can be informed and involved in decision making.« less

New perspectives for motivating better decisions in older adults

PubMed Central

Strough, JoNell; de Bruin, Wändi Bruine; Peters, Ellen

2015-01-01

Decision-making competence in later adulthood is affected by declines in cognitive skills, and age-related changes in affect and experience can sometimes compensate. However, recent findings suggest that age-related changes in motivation also affect the extent to which adults draw from experience, affect, and deliberative skills when making decisions. To date, relatively little attention has been given to strategies for addressing age-related changes in motivation to promote better decisions in older adults. To address this limitation, we draw from diverse literatures to suggest promising intervention strategies for motivating older recipients’ motivation to make better decisions. We start by reviewing the life-span developmental literature, which suggests that older adults’ motivation to put effort into decisions depends on the perceived personal relevance of decisions as well as their self-efficacy (i.e., confidence in applying their ability and knowledge). Next, we discuss two approaches from the health intervention design literature, the mental models approach and the patient activation approach, which aim to improve motivation for decision making by improving personal relevance or by building self-efficacy or confidence to use new information and skills. Using examples from these literatures, we discuss how to construct interventions to motivate good decisions in later adulthood. PMID:26157398

Emotional influences in patient safety.

PubMed

Croskerry, Pat; Abbass, Allan; Wu, Albert W

2010-12-01

The way that health care providers feel, both within themselves and toward their patients, may influence their clinical performance and impact patient safety, yet this aspect of provider behavior has received relatively little attention. How providers feel, their emotional or affective state, may exert a significant, unintended influence on their patients, and may compromise safety. We examined a broad literature across multiple disciplines to review the interrelationships between emotion, decision making, and behavior, and to assess their potential impact on patient safety. There is abundant evidence that the emotional state of the health care provider may be influenced by factors including characteristics of the patient, ambient conditions in the health care setting, diurnal, circadian, infradian, and seasonal variables, as well as endogenous disorders of the individual provider. These influences may lead to affective biases in decision making, resulting in errors and adverse events. Clinical reasoning and judgment may be particularly susceptible to emotional influence, especially those processes that rely on intuitive judgments. There are many ways that the emotional state of the health care provider can influence patient care. To reduce emotional errors, the level of awareness of these factors should be raised. Emotional skills training should be incorporated into the education of health care professionals. Specifically, clinical teaching should promote more openness and discussion about the provider's feelings toward patients. Strategies should be developed to help providers identify and de-bias themselves against emotional influences that may impact care, particularly in the emotionally evocative patient. Psychiatric conditions within the provider, which may compromise patient safety, need to be promptly detected, diagnosed, and managed.

Perceived Barriers Affecting Access to Preventive Dental Services: Application of DEMATEL Method.

PubMed

Bahadori, Mohammadkarim; Ravangard, Ramin; Asghari, Baratali

2013-08-01

Identifying perceived access barriers to preventive dental services is one of the basic steps to improve the public health. This study aimed to determine the perceived barriers affecting access to preventive dental services in one of Tehran dental clinics in 2012. This research was a cross-sectional descriptive-analytical study conducted in one of Tehran dental clinics in 2012 using decision-making trial and evaluation laboratory (DEMATEL) method. The study sample included all patients (100 patients) who had referred to the endodontic treatment department from 26 - 31 May, 2012. The required data were collected using a questionnaire. Collected data were analyzed using SPSS 18.0 and MATLAB 7.9.0 SPSSS 18.0, as well as, some descriptive and analytical tests including Mean, Standard Deviation (SD), and Independent T- Test. The five determinants of cost, inconvenience, fear, organization, and patient-dentist relationship were determined as barriers to access to dental services among which the cost and patient-dentist relationship were identified as the first and last priorities with the coordinates (1.4 and 1.4) and (1.25 and -0.65), respectively. High cost of dental care has led to not referring patients to the clinic. Oral health costs are too high; however insurance organizations have no commitment to support such services. Policymakers, administrators, and insurance organizations have a major role in improving access to dental services. These decision-makers in making their policies can provide the required financial resources, shift the available resources towards preventive care and periodic checkups, and consider providing proper and sufficient places for dental care facilities.

Probability or Reasoning: Current Thinking and Realistic Strategies for Improved Medical Decisions

PubMed Central

2017-01-01

A prescriptive model approach in decision making could help achieve better diagnostic accuracy in clinical practice through methods that are less reliant on probabilistic assessments. Various prescriptive measures aimed at regulating factors that influence heuristics and clinical reasoning could support clinical decision-making process. Clinicians could avoid time-consuming decision-making methods that require probabilistic calculations. Intuitively, they could rely on heuristics to obtain an accurate diagnosis in a given clinical setting. An extensive literature review of cognitive psychology and medical decision-making theory was performed to illustrate how heuristics could be effectively utilized in daily practice. Since physicians often rely on heuristics in realistic situations, probabilistic estimation might not be a useful tool in everyday clinical practice. Improvements in the descriptive model of decision making (heuristics) may allow for greater diagnostic accuracy. PMID:29209469

Probability or Reasoning: Current Thinking and Realistic Strategies for Improved Medical Decisions.

PubMed

Nantha, Yogarabindranath Swarna

2017-11-01

A prescriptive model approach in decision making could help achieve better diagnostic accuracy in clinical practice through methods that are less reliant on probabilistic assessments. Various prescriptive measures aimed at regulating factors that influence heuristics and clinical reasoning could support clinical decision-making process. Clinicians could avoid time-consuming decision-making methods that require probabilistic calculations. Intuitively, they could rely on heuristics to obtain an accurate diagnosis in a given clinical setting. An extensive literature review of cognitive psychology and medical decision-making theory was performed to illustrate how heuristics could be effectively utilized in daily practice. Since physicians often rely on heuristics in realistic situations, probabilistic estimation might not be a useful tool in everyday clinical practice. Improvements in the descriptive model of decision making (heuristics) may allow for greater diagnostic accuracy.

Psychological factors associated with the intention to choose for risk-reducing mastectomy in family cancer clinic attendees.

PubMed

van Driel, C M G; Oosterwijk, J C; Meijers-Heijboer, E J; van Asperen, C J; Zeijlmans van Emmichoven, I A; de Vries, J; Mourits, M J E; Henneman, L; Timmermans, D R M; de Bock, G H

2016-12-01

Women seeking counseling because of familial breast cancer occurrence face difficult decisions, such as whether and when to opt for risk-reducing mastectomy (RRM) in case of BRCA1/2 mutation. Only limited research has been done to identify the psychological factors associated with the decision for RRM. This study investigated which psychological factors are related to the intention to choose for RRM. A cohort of 486 cancer-unaffected women with a family history of breast cancer completed the following questionnaires prior to genetic counseling: the Cancer Worry Scale, Positive And Negative Affect Scale, Perceived Personal Control Scale, Hospital Anxiety and Depression Scale and State Anxiety Scale and questions regarding socio-demographic characteristics, family history, risk perception and RRM intention. Multivariate logistic regression was used to analyze the relation between psychological factors and women's intention to choose for RRM. Factors associated with RRM intention were high positive affect (OR = 1.86, 95%CI = 1.12-3.08), high negative affect (OR = 2.52, 95%CI = 1.44-4.43), high cancer worry (OR = 1.65, 95%CI = 1.00-2.72), high perceived personal control (OR = 3.58, 95%CI = 2.18-5.89), high risk-perception (OR = 1.85, 95%CI = 1.15-2.95) and having children (OR = 2.06, 95%CI = 1.21-3.50). Negative and positive affects play an important role in the intention for RRM. Furthermore, perceived personal control over the situation is associated with an intention for RRM. In addition to focusing on accurate risk communication, counseling should pay attention to the influence of perceived control and emotions to facilitate decision-making. Copyright © 2016 Elsevier Ltd. All rights reserved.

Productivity and turnover in PCPs: the role of staff participation in decision-making.

PubMed

Hung, Dorothy Y; Rundall, Thomas G; Cohen, Deborah J; Tallia, Alfred F; Crabtree, Benjamin F

2006-10-01

Efforts to redesign primary care practices are beginning to address how decisions are made in the practice setting. This study contributes to these efforts by examining associations between staff participation in decision-making, productivity, and turnover in primary care practices. The study is informed by organizational theories of participation that emphasize cognitive and affective influences on employee output and behavior. This research used data collected from primary care practices involved in a national initiative sponsored by the Robert Wood Johnson Foundation. Cross-sectional survey data on organizational structures and attributes among 49 practices were analyzed. Regression analysis was used to examine associations among practice productivity, staff participation in decision-making, and formal structures such as staff meetings. Associations between staff turnover and participative decision-making were also examined. Staff participation in decisions regarding quality improvement, practice change, and clinical operations was positively associated with practice productivity, whereas formal structures such as staff meetings were not. In addition, higher levels of participation in decision-making were associated with reduced turnover among nonclinicians and administrative staff. Examination of organizational features is increasingly recognized as a key to improving primary care performance. Study findings suggest that one important strategy may be implementation of a participative model emphasizing greater staff involvement in practice decisions. This may enhance information-sharing, work satisfaction, and commitment to organizational decisions, all of which can lead to beneficial outcomes such as increased productivity and stability in primary care practices.

Effect of experience on clinical decision making by cardiorespiratory physiotherapists in acute care settings.

PubMed

Smith, Megan; Higgs, Joy; Ellis, Elizabeth

2010-02-01

This article investigates clinical decision making in acute care hospitals by cardiorespiratory physiotherapists with differing degrees of clinical experience. Participants were observed as they engaged in their everyday practice and were interviewed about their decision making. Texts of the data were interpreted by using a hermeneutic approach that involved repeated reading and analysis of fieldnotes and interview transcripts to develop an understanding of the effect of experience on clinical decision making. Participants were classified into categories of cardiorespiratory physiotherapy experience: less experienced (<2 years), intermediate experience (2.5-4 years), and more experienced (>7 years). Four dimensions characteristic of increasing experience in cardiorespiratory physiotherapy clinical decision making were identified: 1) an individual practice model, 2) refined approaches to clinical decision making, 3) working in context, and 4) social and emotional capability. Underpinning these dimensions was evidence of reflection on practice, motivation to achieve best practice, critique of new knowledge, increasing confidence, and relationships with knowledgeable colleagues. These findings reflect characteristics of physiotherapy expertise that have been described in the literature. This study adds knowledge about the field of cardiorespiratory physiotherapy to the existing body of research on clinical decision making and broadens the existing understanding of characteristics of physiotherapy expertise.

Nurses' Clinical Decision Making on Adopting a Wound Clinical Decision Support System.

PubMed

Khong, Peck Chui Betty; Hoi, Shu Yin; Holroyd, Eleanor; Wang, Wenru

2015-07-01

Healthcare information technology systems are considered the ideal tool to inculcate evidence-based nursing practices. The wound clinical decision support system was built locally to support nurses to manage pressure ulcer wounds in their daily practice. However, its adoption rate is not optimal. The study's objective was to discover the concepts that informed the RNs' decisions to adopt the wound clinical decision support system as an evidence-based technology in their nursing practice. This was an exploratory, descriptive, and qualitative design using face-to-face interviews, individual interviews, and active participatory observation. A purposive, theoretical sample of 14 RNs was recruited from one of the largest public tertiary hospitals in Singapore after obtaining ethics approval. After consenting, the nurses were interviewed and observed separately. Recruitment stopped when data saturation was reached. All transcribed interview data underwent a concurrent thematic analysis, whereas observational data were content analyzed independently and subsequently triangulated with the interview data. Eight emerging themes were identified, namely, use of the wound clinical decision support system, beliefs in the wound clinical decision support system, influences of the workplace culture, extent of the benefits, professional control over nursing practices, use of knowledge, gut feelings, and emotions (fear, doubt, and frustration). These themes represented the nurses' mental outlook as they made decisions on adopting the wound clinical decision support system in light of the complexities of their roles and workloads. This research has provided insight on the nurses' thoughts regarding their decision to interact with the computer environment in a Singapore context. It captured the nurses' complex thoughts when deciding whether to adopt or reject information technology as they practice in a clinical setting.

Predictive Modeling of Physician-Patient Dynamics That Influence Sleep Medication Prescriptions and Clinical Decision-Making

NASA Astrophysics Data System (ADS)

Beam, Andrew L.; Kartoun, Uri; Pai, Jennifer K.; Chatterjee, Arnaub K.; Fitzgerald, Timothy P.; Shaw, Stanley Y.; Kohane, Isaac S.

2017-02-01

Insomnia remains under-diagnosed and poorly treated despite its high economic and social costs. Though previous work has examined how patient characteristics affect sleep medication prescriptions, the role of physician characteristics that influence this clinical decision remains unclear. We sought to understand patient and physician factors that influence sleep medication prescribing patterns by analyzing Electronic Medical Records (EMRs) including the narrative clinical notes as well as codified data. Zolpidem and trazodone were the most widely prescribed initial sleep medication in a cohort of 1,105 patients. Some providers showed a historical preference for one medication, which was highly predictive of their future prescribing behavior. Using a predictive model (AUC = 0.77), physician preference largely determined which medication a patient received (OR = 3.13 p = 3 × 10-37). In addition to the dominant effect of empirically determined physician preference, discussion of depression in a patient’s note was found to have a statistically significant association with receiving a prescription for trazodone (OR = 1.38, p = 0.04). EMR data can yield insights into physician prescribing behavior based on real-world physician-patient interactions.

The role of emotion in patient safety: Are we brave enough to scratch beneath the surface?

PubMed

Heyhoe, Jane; Birks, Yvonne; Harrison, Reema; O'Hara, Jane K; Cracknell, Alison; Lawton, Rebecca

2016-02-01

Healthcare professionals work in emotionally charged settings; yet, little is known about the role of emotion in ensuring safe patient care. This article presents current knowledge in this field, drawing upon psychological approaches and evidence from clinical settings. We explore the emotions that health professionals experience in relation to making a medical error and describe the impact on healthcare professionals and on their professional and patient relationships. We also explore how positive and negative emotions can contribute to clinical decision making and affect responses to clinical situations. Evidence to date suggests that emotion plays an integral role in patient safety. Implications for training, practice and research are discussed in addition to strategies to facilitate health services to understand and respond to the influence of emotion in clinical practice. © The Royal Society of Medicine.

High-Value Consults: A Curriculum to Promote Point-of-Care, Evidence-Based Recommendations.

PubMed

Nandiwada, Deepa Rani; Kohli, Amar; McNamara, Megan; Smith, Kenneth J; Zimmer, Shanta; McNeil, Melissa; Spagnoletti, Carla; Rubio, Doris; Berlacher, Kathryn

2017-10-01

In an era when value-based care is paramount, teaching trainees to explicitly communicate the evidence behind recommendations fosters high-value care (HVC) in the consultation process. To implement an HVC consult curriculum highlighting the need for clear consult questions, evidence-based recommendations to improve consult teaching, clinical decision-making, and the educational value of consults. A pilot curriculum was implemented for residents on cardiology consult electives utilizing faculty and fellows as evidence-based medicine (EBM) coaches. The curriculum included an online module, an EBM teaching point template, EBM presentations on rounds, and "coach" feedback on notes. A total of 15 residents and 4 fellows on cardiology consults participated, and 87% (13 of 15) of residents on consults felt the curriculum was educationally valuable. A total of 80% (72 of 90) of residents on general medicine rotations responded to the survey, and 25 of 72 residents (35%) had a consult with the EBM template. General medicine teams felt the EBM teaching points affected clinical decision-making (48%, 12 of 25) and favored dissemination of the curriculum (90%, 72 of 80). Checklist-guided chart review showed a 22% improvement in evidence-based summaries behind recommendations (7 of 36 precurriculum to 70 of 146 charts postcurriculum, P  = .015). The HVC consult curriculum during a cardiology elective was perceived by residents to influence clinical decision-making and evidence-based recommendations, and was found to be educationally valuable on both parties in the consult process.

Assessment of the sunk-cost effect in clinical decision-making.

PubMed

Braverman, Jennifer A; Blumenthal-Barby, J S

2012-07-01

Despite the current push toward the practice of evidence-based medicine and comparative effectiveness research, clinicians' decisions may be influenced not only by evidence, but also by cognitive biases. A cognitive bias describes a tendency to make systematic errors in certain circumstances based on cognitive factors rather than evidence. Though health care providers have been shown in several studies to be susceptible to a variety of types of cognitive biases, research on the role of the sunk-cost bias in clinical decision-making is extremely limited. The sunk-cost bias is the tendency to pursue a course of action, even after it has proved to be suboptimal, because resources have been invested in that course of action. This study explores whether health care providers' medical treatment recommendations are affected by prior investments in a course of treatment. Specifically, we surveyed 389 health care providers in a large urban medical center in the United States during August 2009. We asked participants to make a treatment recommendation based on one of four hypothetical clinical scenarios that varied in the source and type of prior investment described. By comparing recommendations across scenarios, we found that providers did not demonstrate a sunk-cost effect; rather, they demonstrated a significant tendency to over-compensate for the effect. In addition, we found that more than one in ten health care providers recommended continuation of an ineffective treatment. Copyright © 2012 Elsevier Ltd. All rights reserved.

Multi-criteria clinical decision support: A primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare.

PubMed

Dolan, James G

2010-01-01

Current models of healthcare quality recommend that patient management decisions be evidence-based and patient-centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances into the decision making process and actively involve both patients along with health care providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers.Advances in the decision sciences have led to the development of a number of multiple criteria decision making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine "hard data" with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision support systems based on multi-criteria decision making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings.The goal of this paper is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision-making. Methods discussed include the balance sheet, the even swap method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process (AHP).

Multi-criteria clinical decision support: A primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare

PubMed Central

Dolan, James G.

2010-01-01

Current models of healthcare quality recommend that patient management decisions be evidence-based and patient-centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances into the decision making process and actively involve both patients along with health care providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers. Advances in the decision sciences have led to the development of a number of multiple criteria decision making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine “hard data” with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision support systems based on multi-criteria decision making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings. The goal of this paper is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision-making. Methods discussed include the balance sheet, the even swap method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process (AHP) PMID:21394218

Shared decision-making – transferring research into practice: the Analytic Hierarchy Process (AHP)

PubMed Central

Dolan, James G.

2008-01-01

Objective To illustrate how the Analytic Hierarchy Process (AHP) can be used to promote shared decision-making and enhance clinician-patient communication. Methods Tutorial review. Results The AHP promotes shared decision making by creating a framework that is used to define the decision, summarize the information available, prioritize information needs, elicit preferences and values, and foster meaningful communication among decision stakeholders. Conclusions The AHP and related multi-criteria methods have the potential for improving the quality of clinical decisions and overcoming current barriers to implementing shared decision making in busy clinical settings. Further research is needed to determine the best way to implement these tools and to determine their effectiveness. Practice Implications Many clinical decisions involve preference-based trade-offs between competing risks and benefits. The AHP is a well-developed method that provides a practical approach for improving patient-provider communication, clinical decision-making, and the quality of patient care in these situations. PMID:18760559

Effect of patient decision aid was influenced by presurgical evaluation among patients with osteoarthritis of the knee.

PubMed

Boland, Laura; Taljaard, Monica; Dervin, Geoffrey; Trenaman, Logan; Tugwell, Peter; Pomey, Marie-Pascale; Stacey, Dawn

2017-12-01

Decision aids help patients make total joint arthroplasty decisions, but presurgical evaluation might influence the effects of a decision aid. We compared the effects of a decision aid among patients considering total knee arthroplasty at 2 surgical screening clinics with different evaluation processes. We performed a subgroup analysis of a randomized controlled trial. Patients were recruited from 2 surgical screening clinics: an academic clinic providing 20-minute physician consultations and a community clinic providing 45-minute physiotherapist/nurse consultations with education. We compared the effects of decision quality, decisional conflict and surgery rate using Cochran-Mantel-Haenszel χ 2 tests and the Breslow-Day test. We evaluated 242 patients: 123 from the academic clinic (61 who used the decision aid and 62 controls) and 119 from the community clinic (59 who used the decision aid and 60 controls). Results suggested a between-site difference in the effect of the decision aid on the patients' decision quality ( p = 0.09): at the academic site, patients who used the decision were more likely to make better-quality decisions than controls (54% v. 35%, p = 0.044), but not at the community site (47% v. 51%, p = 0.71). Fewer patients who used decision aids at the academic site than at the community site experienced decisional conflict ( p = 0.007) (33% v. 52%, p = 0.05 at the academic site and 40% v. 24%, p = 0.08 at the community site). The effect of the decision aid on surgery rates did not differ between sites ( p = 0.65). The decision aid had a greater effect at the academic site than at the community site, which provided longer consultations with more verbal education. Hence, decision aids might be of greater value when more extensive total knee arthroplasty presurgical assessment and counselling are either impractical or unavailable.

Effect of patient decision aid was influenced by presurgical evaluation among patients with osteoarthritis of the knee.

PubMed

Boland, Laura; Taljaard, Monica; Dervin, Geoffrey; Trenaman, Logan; Tugwell, Peter; Pomey, Marie-Pascale; Stacey, Dawn

2018-02-01

Decision aids help patients make total joint arthroplasty decisions, but presurgical evaluation might influence the effects of a decision aid. We compared the effects of a decision aid among patients considering total knee arthroplasty at 2 surgical screening clinics with different evaluation processes. We performed a subgroup analysis of a randomized controlled trial. Patients were recruited from 2 surgical screening clinics: an academic clinic providing 20-minute physician consultations and a community clinic providing 45-minute physiotherapist/nurse consultations with education. We compared the effects of decision quality, decisional conflict and surgery rate using Cochran-Mantel-Haenszel χ 2 tests and the Breslow-Day test. We evaluated 242 patients: 123 from the academic clinic (61 who used the decision aid and 62 controls) and 119 from the community clinic (59 who used the decision aid and 60 controls). Results suggested a between-site difference in the effect of the decision aid on the patients' decision quality ( p = 0.09): at the academic site, patients who used the decision aid were more likely to make better-quality decisions than controls (54% v. 35%, p = 0.044), but not at the community site (47% v. 51%, p = 0.71). Fewer patients who used decision aids at the academic site than at the community site experienced decisional conflict ( p = 0.007) (33% v. 52%, p = 0.05 at the academic site and 40% v. 24%, p = 0.08 at the community site). The effect of the decision aid on surgery rates did not differ between sites ( p = 0.65). The decision aid had a greater effect at the academic site than at the community site, which provided longer consultations with more verbal education. Hence, decision aids might be of greater value when more extensive total knee arthroplasty presurgical assessment and counselling are either impractical or unavailable.

Shared Decision Making and Autonomy Among US Participants with Multiple Sclerosis in the NARCOMS Registry

PubMed Central

Thomas, Nina; Tyry, Tuula; Fox, Robert J.; Salter, Amber

2017-01-01

Background: Treatment decisions in multiple sclerosis (MS) are affected by many factors and are made by the patient, doctor, or both. With new disease-modifying therapies (DMTs) emerging, the complexity surrounding treatment decisions is increasing, further emphasizing the importance of understanding decision-making preferences. Methods: North American Research Committee on Multiple Sclerosis (NARCOMS) Registry participants completed the Fall 2014 Update survey, which included the Control Preferences Scale (CPS). The CPS consists of five images showing different patient/doctor roles in treatment decision making. The images were collapsed to three categories: patient-centered, shared, and physician-centered decision-making preferences. Associations between decision-making preferences and demographic and clinical factors were evaluated using multivariable logistic regression. Results: Of 7009 participants, 79.3% were women and 93.5% were white (mean [SD] age, 57.6 [10.3] years); 56.7% reported a history of relapses. Patient-centered decision making was most commonly preferred by participants (47.9%), followed by shared decision making (SDM; 42.8%). SDM preference was higher for women and those taking DMTs and increased with age and disease duration (all P < .05). Patient-centered decisions were most common for respondents not taking a DMT at the time of the survey and were preferred by those who had no DMT history compared with those who had previously taken a DMT (P < .0001). There was no difference in SDM preference by current MS disease course after adjusting for other disease-related factors. Conclusions: Responders reported most commonly considering their doctor's opinion before making a treatment decision and making decisions jointly with their doctor. DMT use, gender, and age were associated with decision-making preference. PMID:29270088

The clinical utility index as a practical multiattribute approach to drug development decisions.

PubMed

Poland, B; Hodge, F L; Khan, A; Clemen, R T; Wagner, J A; Dykstra, K; Krishna, R

2009-07-01

We identify some innovative approaches to predicting overall patient benefit from investigational drugs to support development decisions. We then illustrate calculation of a probabilistic clinical utility index (CUI), an implementation of multiattribute utility that focuses on clinical attributes. We recommend use of the CUI for the support of early drug development decisions because of its practicality, reasonable accuracy, and transparency to decision makers, at stages in which financial factors that may dominate later-phase decisions are less critical.

Psychological Factors Associated with Genetic Test Decision-Making among Parents of Children with Autism Spectrum Disorders in Taiwan

ERIC Educational Resources Information Center

Xu, Lei; Richman, Alice R.

2015-01-01

Making decisions to undergo Autism Spectrum Disorders (ASD) genetic testing can be challenging. It is important to understand how the perceptions of affected individuals might influence testing decision-making. Although evidence has shown that psychological factors are important in predicting testing decisions, affect-type variables have been…

Driving with roadmaps and dashboards: using information resources to structure the decision models in service organizations.

PubMed

Chorpita, Bruce F; Bernstein, Adam; Daleiden, Eric L

2008-03-01

This paper illustrates the application of design principles for tools that structure clinical decision-making. If the effort to implement evidence-based practices in community services organizations is to be effective, attention must be paid to the decision-making context in which such treatments are delivered. Clinical research trials commonly occur in an environment characterized by structured decision making and expert supports. Technology has great potential to serve mental health organizations by supporting these potentially important contextual features of the research environment, through organization and reporting of clinical data into interpretable information to support decisions and anchor decision-making procedures. This article describes one example of a behavioral health reporting system designed to facilitate clinical and administrative use of evidence-based practices. The design processes underlying this system-mapping of decision points and distillation of performance information at the individual, caseload, and organizational levels-can be implemented to support clinical practice in a wide variety of settings.

When four principles are too many: bloodgate, integrity and an action-guiding model of ethical decision making in clinical practice.

PubMed

Muirhead, William

2012-04-01

Medical ethical analysis remains dominated by the principlist account first proposed by Beauchamp and Childress. This paper argues that the principlist model is unreflective of how ethical decisions are taken in clinical practice. Two kinds of medical ethical decisions are distinguished: biosocial ethics and clinical ethics. It is argued that principlism is an inappropriate model for clinical ethics as it is neither sufficiently action-guiding nor does it emphasise the professional integrity of the clinician. An alternative model is proposed for decision making in the realm of clinical ethics.

Resisting Prescribed Opioids: A Qualitative Study of Decision Making in Patients Taking Opioids for Chronic Noncancer Pain.

PubMed

Paterson, Charlotte; Ledgerwood, Kay; Arnold, Carolyn; Hogg, Malcolm; Xue, Charlie; Zheng, Zhen

2016-04-01

Opioids are increasingly prescribed for chronic noncancer pain across the developed world. Clinical guidelines for management of these patients focus on over-use. However, research into other types of long-term medication indicates that many patients minimize drug use whenever possible. To identify the varying influences on patients' decisions about their use of prescribed opioids and explore whether concepts of resistance and minimization of intake apply to these patients. A multiprofessional team performed a qualitative interview study using the constant-comparative method. Patient's decision making was explored in depth and with a thematic analysis utilizing a published "Model of medicine-taking." A purposive sample of 20 participants drawn from two pain clinics in Melbourne, Australia. The sample was biased toward patients interested in nonmedication pain management options. Patients' needs to obtain relief from severe pain, maintain function, and minimize side effects could lead to under-use as well as over-use of prescribed opioids. In keeping with the published Model of medicine-taking, resistance to taking opioids was a common and important influence on behavior. In the face of severe chronic pain, many participants used a variety of strategies to evaluate, avoid, reduce, self-regulate, and replace opioids. Furthermore, participants perceived a resistance to opioids within the system and among some healthcare professionals. This sometimes adversely affected their adherence. Both patients and doctors exhibit aspects of resistance to the use of prescribed opioids for chronic noncancer pain, suggesting that this shared concern could be the basis of a productive therapeutic alliance to improve communication and shared decision making. Clinical guidelines for opioids use for chronic noncancer pain focus on over-use. Our qualitative interview study found that many patients resisted and minimized the use of opioids. Using a published "Model of medicine-taking," we identified various influences on patient decision making. Both patients and doctors had concerns about using opioids for chronic noncancer pain. These could be the basis of a productive therapeutic alliance to improve communication and shared decision making. © 2015 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Free software to analyse the clinical relevance of drug interactions with antiretroviral agents (SIMARV®) in patients with HIV/AIDS.

PubMed

Giraldo, N A; Amariles, P; Monsalve, M; Faus, M J

Highly active antiretroviral therapy has extended the expected lifespan of patients with HIV/AIDS. However, the therapeutic benefits of some drugs used simultaneously with highly active antiretroviral therapy may be adversely affected by drug interactions. The goal was to design and develop a free software to facilitate analysis, assessment, and clinical decision making according to the clinical relevance of drug interactions in patients with HIV/AIDS. A comprehensive Medline/PubMed database search of drug interactions was performed. Articles that recognized any drug interactions in HIV disease were selected. The publications accessed were limited to human studies in English or Spanish, with full texts retrieved. Drug interactions were analyzed, assessed, and grouped into four levels of clinical relevance according to gravity and probability. Software to systematize the information regarding drug interactions and their clinical relevance was designed and developed. Overall, 952 different references were retrieved and 446 selected; in addition, 67 articles were selected from the citation lists of identified articles. A total of 2119 pairs of drug interactions were identified; of this group, 2006 (94.7%) were drug-drug interactions, 1982 (93.5%) had an identified pharmacokinetic mechanism, and 1409 (66.5%) were mediated by enzyme inhibition. In terms of clinical relevance, 1285 (60.6%) drug interactions were clinically significant in patients with HIV (levels 1 and 2). With this information, a software program that facilitates identification and assessment of the clinical relevance of antiretroviral drug interactions (SIMARV ® ) was developed. A free software package with information on 2119 pairs of antiretroviral drug interactions was designed and developed that could facilitate analysis, assessment, and clinical decision making according to the clinical relevance of drug interactions in patients with HIV/AIDS. Copyright © 2016 Elsevier Inc. All rights reserved.

Factors affecting receipt of chemotherapy in women with breast cancer

PubMed Central

Morimoto, Libby; Coalson, Jenna; Mowat, Fionna; O’Malley, Cynthia

2010-01-01

Aims: To review literature describing factors associated with receipt of chemotherapy for breast cancer, to better understand what factors are most relevant to women’s health and whether health disparities are apparent, and to assess how these factors might affect observational studies and outcomes research. Patterns of care for metastatic breast cancer, for which no standard-of-care exists, were of particular interest. Methods: Relevant studies written in English, Italian, French, or Spanish, published in 2000 or later, were identified through MEDLINE and reviewed. Review articles and clinical trials were excluded; all observational studies and surveys were considered. Articles were reviewed for any discussion of patient characteristics, hospital/physician/insurance characteristics, psychosocial characteristics, and clinical characteristics affecting receipt of chemotherapy by breast cancer patients. Results: In general, factors associated with increased likelihood of receiving chemotherapy included younger age, being Caucasian, having good general health and few co-morbidities, having more severe clinical disease, having responded well to previous treatment, and having breast cancer that is estrogen- or progesterone-receptor-negative. Many of the clinical factors found to increase the likelihood of receiving chemotherapy were consistent with current oncology guidelines. Of the relevant 19 studies identified, only six (32%) reported data specific to metastatic cancer; most studies aggregated women with stage I–IV for purposes of analysis. Conclusion: Studies of patterns of care in breast cancer treatment can help identify challenges in health care provided to particular subgroups of women and can aid researchers in designing studies that account for such factors in clinical and outcomes research. Although scarce, studies evaluating only women with metastatic breast cancer indicate that factors affecting decisions related to receipt of chemotherapy are similar across stage for this disease. PMID:21072304

Navigating Decisional Discord: The Pediatrician’s Role When Child and Parents Disagree

PubMed Central

DuBois, James; Kodish, Eric; Wolfe, Joanne; Feudtner, Chris

2017-01-01

From the time when children enter the preteen years onward, pediatric medical decision-making can entail a complex interaction between child, parents, and pediatrician. When the child and parents disagree regarding medical decisions, the pediatrician has the challenging task of guiding the family to a final decision. Unresolved discord can affect family cohesiveness, patient adherence, and patient self-management. In this article, we outline 3 models for the pediatrician’s role in the setting of decisional discord: deference, advocative, and arbitrative. In the deference model, the pediatrician prioritizes parental decision-making authority. In the advocative model, the pediatrician advocates for the child’s preference in decision-making so long as the child’s decision is medically reasonable. In the arbitrative model, the pediatrician works to resolve the conflict in a balanced fashion. Although each model has advantages and disadvantages, the arbitrative model should serve as the initial model in nearly all settings. The arbitrative model is likely to reach the most beneficial decision in a manner that maintains family cohesiveness by respecting the authority of parents and the developing autonomy of children. We also highlight, however, occasions when the deference or advocative models may be more appropriate. Physicians should keep all 3 models available in their professional toolkit and develop the wisdom to deploy the right model for each particular clinical situation. PMID:28562285

Navigating Decisional Discord: The Pediatrician's Role When Child and Parents Disagree.

PubMed

Sisk, Bryan A; DuBois, James; Kodish, Eric; Wolfe, Joanne; Feudtner, Chris

2017-06-01

From the time when children enter the preteen years onward, pediatric medical decision-making can entail a complex interaction between child, parents, and pediatrician. When the child and parents disagree regarding medical decisions, the pediatrician has the challenging task of guiding the family to a final decision. Unresolved discord can affect family cohesiveness, patient adherence, and patient self-management. In this article, we outline 3 models for the pediatrician's role in the setting of decisional discord: deference, advocative, and arbitrative. In the deference model, the pediatrician prioritizes parental decision-making authority. In the advocative model, the pediatrician advocates for the child's preference in decision-making so long as the child's decision is medically reasonable. In the arbitrative model, the pediatrician works to resolve the conflict in a balanced fashion. Although each model has advantages and disadvantages, the arbitrative model should serve as the initial model in nearly all settings. The arbitrative model is likely to reach the most beneficial decision in a manner that maintains family cohesiveness by respecting the authority of parents and the developing autonomy of children. We also highlight, however, occasions when the deference or advocative models may be more appropriate. Physicians should keep all 3 models available in their professional toolkit and develop the wisdom to deploy the right model for each particular clinical situation. Copyright © 2017 by the American Academy of Pediatrics.

Rationality, practice variation and person-centred health policy: a threshold hypothesis.

PubMed

Djulbegovic, Benjamin; Hamm, Robert M; Mayrhofer, Thomas; Hozo, Iztok; Van den Ende, Jef

2015-12-01

Variation in practice of medicine is one of the major health policy issues of today. Ultimately, it is related to physicians' decision making. Similar patients with similar likelihood of having disease are often managed by different doctors differently: some doctors may elect to observe the patient, others decide to act based on diagnostic testing and yet others may elect to treat without testing. We explain these differences in practice by differences in disease probability thresholds at which physicians decide to act: contextual social and clinical factors and emotions such as regret affect the threshold by influencing the way doctors integrate objective data related to treatment and testing. However, depending on a theoretical construct each of the physician's behaviour can be considered rational. In fact, we showed that the current regulatory policies lead to predictably low thresholds for most decisions in contemporary practice. As a result, we may expect continuing motivation for overuse of treatment and diagnostic tests. We argue that rationality should take into account both formal principles of rationality and human intuitions about good decisions along the lines of Rawls' 'reflective equilibrium/considered judgment'. In turn, this can help define a threshold model that is empirically testable. © 2015 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.

Clinical decision making in dermatology: observation of consultations and the patients' perspectives.

PubMed

Hajjaj, F M; Salek, M S; Basra, M K A; Finlay, A Y

2010-01-01

Clinical decision making is a complex process and might be influenced by a wide range of clinical and non-clinical factors. Little is known about this process in dermatology. The aim of this study was to explore the different types of management decisions made in dermatology and to identify factors influencing those decisions from observation of consultations and interviews with the patients. 61 patient consultations were observed by a physician with experience in dermatology. The patients were interviewed immediately after each consultation. Consultations and interviews were audio recorded, transcribed and their content analysed using thematic content analysis. The most common management decisions made during the consultations included: follow-up, carrying out laboratory investigation, starting new topical treatment, renewal of systemic treatment, renewal of topical treatment, discharging patients and starting new systemic treatment. Common influences on those decisions included: clinical factors such as ineffectiveness of previous therapy, adherence to prescribing guidelines, side-effects of medications, previous experience with the treatment, deterioration or improvement in the skin condition, and chronicity of skin condition. Non-clinical factors included: patient's quality of life, patient's friends or relatives, patient's time commitment, travel or transportation difficulties, treatment-related costs, availability of consultant, and availability of treatment. The study has shown that patients are aware that management decisions in dermatology are influenced by a wide range of clinical and non-clinical factors. Education programmes should be developed to improve the quality of decision making. Copyright © 2010 S. Karger AG, Basel.

Adoption of clinical decision support systems in a developing country: Antecedents and outcomes of physician's threat to perceived professional autonomy.

PubMed

Esmaeilzadeh, Pouyan; Sambasivan, Murali; Kumar, Naresh; Nezakati, Hossein

2015-08-01

The basic objective of this research is to study the antecedents and outcomes of professional autonomy which is a central construct that affects physicians' intention to adopt clinical decision support systems (CDSS). The antecedents are physicians' attitude toward knowledge sharing and interactivity perception (about CDSS) and the outcomes are performance expectancy and intention to adopt CDSS. Besides, we include (1) the antecedents of attitude toward knowledge sharing-subjective norms, social factors and OCB (helping behavior) and (2) roles of physicians' involvement in decision making, computer self-efficacy and effort expectancy in our framework. Data from a stratified sample of 335 Malaysian physicians working in 12 public and private hospitals in Malaysia were collected to test the hypotheses using Structural Equation Modeling (SEM). The important findings of our research are: (1) factors such as perceived threat to professional autonomy, performance expectancy, and physicians' involvement in making decision about CDSS have significant impact on physicians' intention to adopt CDSS; (2) physicians' attitude toward knowledge sharing, interactivity perception and computer self-efficacy of physicians play a crucial role in influencing their perceived threat to professional autonomy; and (3) social network, shared goals and OCB (helping behavior) impact physicians' attitude toward knowledge sharing. The findings provide a comprehensive understanding of the factors that influence physicians' intention to adopt CDSS in a developing country. The results can help hospital managers manage CDSS implementation in an effective manner. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Health literacy in pregnant women facing prenatal screening may explain their intention to use a patient decision aid: a short report.

PubMed

Delanoë, Agathe; Lépine, Johanie; Leiva Portocarrero, Maria Esther; Robitaille, Hubert; Turcotte, Stéphane; Lévesque, Isabelle; Wilson, Brenda J; Giguère, Anik M C; Légaré, France

2016-07-11

It has been suggested that health literacy may impact the use of decision aids (DAs) among patients facing difficult decisions. Embedded in the pilot test of a questionnaire, this study aimed to measure the association between health literacy and pregnant women's intention to use a DA to decide about prenatal screening. We recruited a convenience sample of 45 pregnant women in three clinical sites (family practice teaching unit, birthing center and obstetrical ambulatory care clinic). We asked participating women to complete a self-administered questionnaire assessing their intention to use a DA to decide about prenatal screening and assessed their health literacy levels using one subjective and two objective scales. Two of the three scales discriminated between levels of health literacy (three numeracy questions and three health literacy questions). We found a positive correlation between pregnant women's intention to use a DA and subjective health literacy (Spearman coefficient, Rho 0.32, P = 0.04) but not objective health literacy (Spearman coefficient, Rho 0.07, P = 0.65). Hence subjective health literacy may affect the intention to use a DA among pregnant women facing a decision about prenatal screening. Special attention should be given to pregnant women with lower health literacy levels to increase their intention to use a DA and ensure that every pregnant women can give informed and value-based consent to prenatal screening.

Clinical factors affecting physicians' management decisions in cases of female partner abuse.

PubMed

Ferris, L E; Norton, P; Dunn, E V; Gort, E H

1999-06-01

This study determined which clinical factors influence Canadian primary care physicians' management decisions in cases of female partner abuse. We used a cross-sectional survey design and randomly sampled (n = 2,014) English-speaking Canadian physicians with a primary interest in family or general practice who were practicing in any of the 12 provinces and territories in Canada and who were active in private practice and registered to prescribe. Respondents completed a questionnaire that required them to score management decision plans in response to case scenarios illustrating typical office-based situations that might involve domestic violence. The response rate was 50.7% (n = 1,022). Using forward stepwise regression analysis, the strongest predictor of whether a physician endorsed a management plan in response to violence was whether the woman acknowledged or revealed the abuse. Male physicians were more likely than females to endorse talking with the suspected abuser if he was known to them, regardless of the quality of this patient-physician relationship with the abuser. Decisions about whether to deal with the abuse or the selection of a management plan are not dependent on the severity of the physical abuse and the emotional consequences. Whether a woman acknowledges or reveals the abuse, as well as whether both the male and female patients are in the physician's practice, are predictive of whether a physician's response to a case scenario involves dealing with spousal abuse and how he/she will address it.

Dual processing model of medical decision-making

PubMed Central

2012-01-01

Background Dual processing theory of human cognition postulates that reasoning and decision-making can be described as a function of both an intuitive, experiential, affective system (system I) and/or an analytical, deliberative (system II) processing system. To date no formal descriptive model of medical decision-making based on dual processing theory has been developed. Here we postulate such a model and apply it to a common clinical situation: whether treatment should be administered to the patient who may or may not have a disease. Methods We developed a mathematical model in which we linked a recently proposed descriptive psychological model of cognition with the threshold model of medical decision-making and show how this approach can be used to better understand decision-making at the bedside and explain the widespread variation in treatments observed in clinical practice. Results We show that physician’s beliefs about whether to treat at higher (lower) probability levels compared to the prescriptive therapeutic thresholds obtained via system II processing is moderated by system I and the ratio of benefit and harms as evaluated by both system I and II. Under some conditions, the system I decision maker’s threshold may dramatically drop below the expected utility threshold derived by system II. This can explain the overtreatment often seen in the contemporary practice. The opposite can also occur as in the situations where empirical evidence is considered unreliable, or when cognitive processes of decision-makers are biased through recent experience: the threshold will increase relative to the normative threshold value derived via system II using expected utility threshold. This inclination for the higher diagnostic certainty may, in turn, explain undertreatment that is also documented in the current medical practice. Conclusions We have developed the first dual processing model of medical decision-making that has potential to enrich the current medical decision-making field, which is still to the large extent dominated by expected utility theory. The model also provides a platform for reconciling two groups of competing dual processing theories (parallel competitive with default-interventionalist theories). PMID:22943520

Shared decision making and use of decision AIDS for localized prostate cancer : perceptions from radiation oncologists and urologists.

PubMed

Wang, Elyn H; Gross, Cary P; Tilburt, Jon C; Yu, James B; Nguyen, Paul L; Smaldone, Marc C; Shah, Nilay D; Abouassally, Robert; Sun, Maxine; Kim, Simon P

2015-05-01

The current attitudes of prostate cancer specialists toward decision aids and their use in clinical practice to facilitate shared decision making are poorly understood. To assess attitudes toward decision aids and their dissemination in clinical practice. A survey was mailed to a national random sample of 1422 specialists (711 radiation oncologists and 711 urologists) in the United States from November 1, 2011, through April 30, 2012. Respondents were asked about familiarity, perceptions, and use of decision aids for clinically localized prostate cancer and trust in various professional societies in developing decision aids. The Pearson χ2 test was used to test for bivariate associations between physician characteristics and outcomes. Similar response rates were observed for radiation oncologists and urologists (44.0% vs 46.1%; P=.46). Although most respondents had some familiarity with decision aids, only 35.5% currently use a decision aid in clinic practice. The most commonly cited barriers to decision aid use included the perception that their ability to estimate the risk of recurrence was superior to that of decision aids (7.7% in those not using decision aids and 26.2% in those using decision aids; P<.001) and the concern that patients could not process information from a decision aid (7.6% in those not using decision aids and 23.7% in those using decision aids; P<.001). In assessing trust in decision aids established by various professional medical societies, specialists consistently reported trust in favor of their respective organizations, with 9.2% being very confident and 59.2% being moderately confident (P=.01). Use of decision aids among specialists treating patients with prostate cancer is relatively low. Efforts to address barriers to clinical implementation of decision aids may facilitate greater shared decision making for patients diagnosed as having prostate cancer.

The affective regulation of cognitive priming.

PubMed

Storbeck, Justin; Clore, Gerald L

2008-04-01

Semantic and affective priming are classic effects observed in cognitive and social psychology, respectively. The authors discovered that affect regulates such priming effects. In Experiment 1, positive and negative moods were induced before one of three priming tasks; evaluation, categorization, or lexical decision. As predicted, positive affect led to both affective priming (evaluation task) and semantic priming (category and lexical decision tasks). However, negative affect inhibited such effects. In Experiment 2, participants in their natural affective state completed the same priming tasks as in Experiment 1. As expected, affective priming (evaluation task) and category priming (categorization and lexical decision tasks) were observed in such resting affective states. Hence, the authors conclude that negative affect inhibits semantic and affective priming. These results support recent theoretical models, which suggest that positive affect promotes associations among strong and weak concepts, and that negative affect impairs such associations (Clore & Storbeck, 2006; Kuhl, 2000). (Copyright) 2008 APA.

Midwives׳ clinical reasoning during second stage labour: Report on an interpretive study.

PubMed

Jefford, Elaine; Fahy, Kathleen

2015-05-01

clinical reasoning was once thought to be the exclusive domain of medicine - setting it apart from 'non-scientific' occupations like midwifery. Poor assessment, clinical reasoning and decision-making skills are well known contributors to adverse outcomes in maternity care. Midwifery decision-making models share a common deficit: they are insufficiently detailed to guide reasoning processes for midwives in practice. For these reasons we wanted to explore if midwives actively engaged in clinical reasoning processes within their clinical practice and if so to what extent. The study was conducted using post structural, feminist methodology. to what extent do midwives engage in clinical reasoning processes when making decisions in the second stage labour? twenty-six practising midwives were interviewed. Feminist interpretive analysis was conducted by two researchers guided by the steps of a model of clinical reasoning process. Six narratives were excluded from analysis because they did not sufficiently address the research question. The midwives narratives were prepared via data reduction. A theoretically informed analysis and interpretation was conducted. using a feminist, interpretive approach we created a model of midwifery clinical reasoning grounded in the literature and consistent with the data. Thirteen of the 20 participant narratives demonstrate analytical clinical reasoning abilities but only nine completed the process and implemented the decision. Seven midwives used non-analytical decision-making without adequately checking against assessment data. over half of the participants demonstrated the ability to use clinical reasoning skills. Less than half of the midwives demonstrated clinical reasoning as their way of making decisions. The new model of Midwifery Clinical Reasoning includes 'intuition' as a valued way of knowing. Using intuition, however, should not replace clinical reasoning which promotes through decision-making can be made transparent and be consensually validated. Copyright © 2015 Elsevier Ltd. All rights reserved.

Use of handheld computers in clinical practice: a systematic review.

PubMed

Mickan, Sharon; Atherton, Helen; Roberts, Nia Wyn; Heneghan, Carl; Tilson, Julie K

2014-07-06

Many healthcare professionals use smartphones and tablets to inform patient care. Contemporary research suggests that handheld computers may support aspects of clinical diagnosis and management. This systematic review was designed to synthesise high quality evidence to answer the question; Does healthcare professionals' use of handheld computers improve their access to information and support clinical decision making at the point of care? A detailed search was conducted using Cochrane, MEDLINE, EMBASE, PsycINFO, Science and Social Science Citation Indices since 2001. Interventions promoting healthcare professionals seeking information or making clinical decisions using handheld computers were included. Classroom learning and the use of laptop computers were excluded. Two authors independently selected studies, assessed quality using the Cochrane Risk of Bias tool and extracted data. High levels of data heterogeneity negated statistical synthesis. Instead, evidence for effectiveness was summarised narratively, according to each study's aim for assessing the impact of handheld computer use. We included seven randomised trials investigating medical or nursing staffs' use of Personal Digital Assistants. Effectiveness was demonstrated across three distinct functions that emerged from the data: accessing information for clinical knowledge, adherence to guidelines and diagnostic decision making. When healthcare professionals used handheld computers to access clinical information, their knowledge improved significantly more than peers who used paper resources. When clinical guideline recommendations were presented on handheld computers, clinicians made significantly safer prescribing decisions and adhered more closely to recommendations than peers using paper resources. Finally, healthcare professionals made significantly more appropriate diagnostic decisions using clinical decision making tools on handheld computers compared to colleagues who did not have access to these tools. For these clinical decisions, the numbers need to test/screen were all less than 11. Healthcare professionals' use of handheld computers may improve their information seeking, adherence to guidelines and clinical decision making. Handheld computers can provide real time access to and analysis of clinical information. The integration of clinical decision support systems within handheld computers offers clinicians the highest level of synthesised evidence at the point of care. Future research is needed to replicate these early results and to identify beneficial clinical outcomes.

Use of handheld computers in clinical practice: a systematic review

PubMed Central

2014-01-01

Background Many healthcare professionals use smartphones and tablets to inform patient care. Contemporary research suggests that handheld computers may support aspects of clinical diagnosis and management. This systematic review was designed to synthesise high quality evidence to answer the question; Does healthcare professionals’ use of handheld computers improve their access to information and support clinical decision making at the point of care? Methods A detailed search was conducted using Cochrane, MEDLINE, EMBASE, PsycINFO, Science and Social Science Citation Indices since 2001. Interventions promoting healthcare professionals seeking information or making clinical decisions using handheld computers were included. Classroom learning and the use of laptop computers were excluded. Two authors independently selected studies, assessed quality using the Cochrane Risk of Bias tool and extracted data. High levels of data heterogeneity negated statistical synthesis. Instead, evidence for effectiveness was summarised narratively, according to each study’s aim for assessing the impact of handheld computer use. Results We included seven randomised trials investigating medical or nursing staffs’ use of Personal Digital Assistants. Effectiveness was demonstrated across three distinct functions that emerged from the data: accessing information for clinical knowledge, adherence to guidelines and diagnostic decision making. When healthcare professionals used handheld computers to access clinical information, their knowledge improved significantly more than peers who used paper resources. When clinical guideline recommendations were presented on handheld computers, clinicians made significantly safer prescribing decisions and adhered more closely to recommendations than peers using paper resources. Finally, healthcare professionals made significantly more appropriate diagnostic decisions using clinical decision making tools on handheld computers compared to colleagues who did not have access to these tools. For these clinical decisions, the numbers need to test/screen were all less than 11. Conclusion Healthcare professionals’ use of handheld computers may improve their information seeking, adherence to guidelines and clinical decision making. Handheld computers can provide real time access to and analysis of clinical information. The integration of clinical decision support systems within handheld computers offers clinicians the highest level of synthesised evidence at the point of care. Future research is needed to replicate these early results and to identify beneficial clinical outcomes. PMID:24998515

A problem solving and decision making toolbox for approaching clinical problems and decisions.

PubMed

Margolis, C; Jotkowitz, A; Sitter, H

2004-08-01

In this paper, we begin by presenting three real patients and then review all the practical conceptual tools that have been suggested for systematically analyzing clinical problems. Each of these conceptual tools (e.g. Evidence-Based Medicine, Clinical Practice Guidelines, Decision Analysis) deals mainly with a different type or aspect of clinical problems. We suggest that all of these conceptual tools can be thought of as belonging in the clinician's toolbox for solving clinical problems and making clinical decisions. A heuristic for guiding the clinician in using the tools is proposed. The heuristic is then used to analyze management of the three patients presented at the outset. Copyright 2004 Birkhäuser Verlag, Basel

Improved genetic counseling in Alport syndrome by new variants of COL4A5 gene.

PubMed

Fernandez-Rosado, Francisco; Campos, Ana; Alvarez-Cubero, Maria Jesus; Ruiz, Ana; Entrala-Bernal, Carmen

2015-07-01

There are current requirements of using genetic databases for offering a better genetic assistance to patients of some syndromes, especially those with X-linked heredity patterns (like Alport Syndrome) for the high probability of having descendants affected by the disease. We describe the first reported case of COL4A5 gene missense c.1499 G>T mutation in a 16-year-old girl confirmed to be affected by Alport Syndrome after genetic counseling. Next Generation Sequencing procedures let discover this mutation and offer an accurate clinical treatment to this patient. Current scientific understanding of genetic syndromes suggests the high importance of updated databases and the inclusion of Variant of Unknown Significance related to clinical cases. All of this updating could enable patients to have a better opportunity of diagnosis and having genetic and clinical counseling. This event is even more important in women planning to start a family to have correct genetic counseling regarding the risk posed to offspring, and allowing the decision to undergo prenatal testing. © 2015 Asian Pacific Society of Nephrology.

Treatment modalities in children with teeth affected by molar-incisor enamel hypomineralisation (MIH): A systematic review.

PubMed

Lygidakis, N A

2010-04-01

This was to review the literature concerning the treatment of permanent teeth with molar-incisor hypomineralised enamel (MIH), comment about possible shortcomings and propose areas of future research. A search of MedLine, Scopus, ResearchGate, Isis and Google Scholar databases was conducted using all terms relevant to the subject. Relevant papers published in English were identified after a review of their titles, abstracts or full reading of the papers. Of 189 references initially found, 66 papers were included; 34 directly relevant to the subject. From the latter, only 14 concerned laboratory or clinical studies dealing with treatment for MIH. Since 2000 11 reviews evaluated, to a certain extent, treatment options for affected teeth. Analysis of the proposed treatment modalities indicated options for prevention, restorations, and adhesion to hypomineralised enamel, full coronal coverage and extraction followed by orthodontics. Based on these findings, a treatment decision plan is proposed. Although treatment approaches for MIH have started to be clearer, long-term clinical trials, supported by laboratory studies, should be conducted to further facilitate the clinical management of this dental defect.

Anchoring in Destination-Therapy Left Ventricular Assist Device Decision Making: A Mechanical Turk Survey.

PubMed

Paine, Arcadia M; Allen, Larry A; Thompson, Jocelyn S; McIlvennan, Colleen K; Jenkins, Amy; Hammes, Andrew; Kroehl, Miranda; Matlock, Daniel D

2016-11-01

People with end-stage heart failure may have to decide about destination-therapy left ventricular assist device (DT-LVAD). Individuals facing difficult decisions often rely on heuristics, such as anchoring, which predictably bias decision outcomes. We aimed to investigate whether showing a larger historical Heartmate XVE creates an anchoring effect, making the smaller Heartmate II (HMII) appear more favorable. With the use of Amazon Mechanical Turk, participants watched videos asking them to imagine themselves dying of end-stage heart failure, then were presented the option of LVAD as potentially life-prolonging therapy. Participants were randomized to a control group who were only shown the HMII device, and the intervention group who saw the XVE device before the HMII. Participants then completed surveys. A total of 487 participants completed the survey (control = 252; intervention = 235); 79% were <40 years of age, 84% were white, and 55% were male. The intervention group was not more likely to accept the LVAD therapy (68% vs 61%; P = .37). However, participants in the intervention group were more likely (51% vs 17%; P < .01) to agree or strongly agree with the statement that the HMII was "smaller than expected." Participants in the intervention group were also more likely to rate the size of the device as "important" or "very important" in their decision (61% vs 46%; P < .01). Although the XVE anchor did not affect likelihood of accepting the LVAD, it did affect device perception. This article highlights an important point with clinical implications: factors such as anchoring have the potential to inappropriately influence perceptions and decisions and should be carefully considered in research and practice. Copyright © 2016 Elsevier Inc. All rights reserved.

Evaluating effect of symptoms heterogeneity on decision-making ability in obsessive-compulsive disorder.

PubMed

Martoni, Riccardo Maria; Brombin, Chiara; Nonis, Alessandro; Salgari, Giulia Carlotta; Buongiorno, Angela; Cavallini, Maria Cristina; Galimberti, Elisa; Bellodi, Laura

2015-07-01

Despite having a univocal definition, obsessive-compulsive disorder (OCD) shows a remarkably phenotypic heterogeneity. The published reports show impaired decision-making in OCD patients, using tasks such as the Iowa Gambling Task (IGT). We wanted to verify the hypothesis of an IGT worse performance in a large sample of OCD patients and healthy control (HC) subjects and to examine the relation between neuropsychological performance in IGT and the OCD symptoms heterogeneity. Binary data from the Yale-Brown Obsessive Compulsive Scale collected on a large sample of OCD patients were analyzed using a multidimensional item response theory model to explore the underlying structure of data, thus revealing latent factors. Factor scores were categorized into quartiles. Then, for each factor, we identified patients respectively with the highest versus lowest score. We evaluated whether symptom dimensions affect the probability of a correct answer over time generalized, during IGT performance, fitting a generalized linear mixed model. We found a general deficit in ambiguous decision-making in OCD compared to HC. Moreover, our findings suggested that OCD symptoms heterogeneity affects decision-making learning abilities during IGT. In fact, while 'Symmetry' and 'Washing' patients showed a learning curve during the task, other subgroups did not. Our study confirmed previous findings suggesting that OCD is characterized by a deficit in decision-making under uncertainty. Moreover, our study gave evidence about biological specificity for each symptom dimension in OCD. Data were discussed in the context of the somatic marker hypothesis, which was hypothesized to be reduced in OCD patients. © 2014 The Authors. Psychiatry and Clinical Neurosciences © 2014 Japanese Society of Psychiatry and Neurology.

The impact of simulation sequencing on perceived clinical decision making.

PubMed

Woda, Aimee; Hansen, Jamie; Paquette, Mary; Topp, Robert

2017-09-01

An emerging nursing education trend is to utilize simulated learning experiences as a means to optimize competency and decision making skills. The purpose of this study was to examine differences in students' perception of clinical decision making and clinical decision making-related self-confidence and anxiety based on the sequence (order) in which they participated in a block of simulated versus hospital-based learning experiences. A quasi-experimental crossover design was used. Between and within group differences were found relative to self-confidence with the decision making process. When comparing groups, at baseline the simulation followed by hospital group had significantly higher self-confidence scores, however, at 14-weeks both groups were not significantly different. Significant within group differences were found in the simulation followed by hospital group only, demonstrating a significant decrease in clinical decision making related anxiety across the semester. Finally, there were no significant difference in; perceived clinical decision making within or between the groups at the two measurement points. Preliminary findings suggest that simulated learning experiences can be offered with alternating sequences without impacting the process, anxiety or confidence with clinical decision making. This study provides beginning evidence to guide curriculum development and allow flexibility based on student needs and available resources. Copyright © 2017. Published by Elsevier Ltd.

The Relationships of Self-Esteem, Future Time Perspective, Positive Affect, Social Support, and Career Decision: A Longitudinal Multilevel Study

PubMed Central

Park, In-Jo; Kim, Minhee; Kwon, Seungwoo; Lee, Hae-Gyoung

2018-01-01

This study aimed, first, to determine whether the intra-individual variability in positive affect was related to the intra-individual variability in career decision-making self-efficacy, and career choice anxiety. The second objective was to examine whether social support moderates the relationship between affect and these outcome variables. The third objective was to find out how career decision-making self-efficacy and career choice anxiety change according to self-esteem and future time perspective. We conducted a study using the daily diary method in which participants were asked to rate their affect or attitudes for 21 consecutive days. In total, 128 university students participated in this study. The main results were as follows. First, positive affect was associated positively with career decision-making self-efficacy and negatively with career choice anxiety. Second, social support had a synergy effect with positive affect to influence career choice anxiety. Third, self-esteem was related positively to career decision-making self-efficacy and negatively to career choice anxiety. We discuss theoretical and practical implications. PMID:29755381

The Relationships of Self-Esteem, Future Time Perspective, Positive Affect, Social Support, and Career Decision: A Longitudinal Multilevel Study.

PubMed

Park, In-Jo; Kim, Minhee; Kwon, Seungwoo; Lee, Hae-Gyoung

2018-01-01

This study aimed, first, to determine whether the intra-individual variability in positive affect was related to the intra-individual variability in career decision-making self-efficacy, and career choice anxiety. The second objective was to examine whether social support moderates the relationship between affect and these outcome variables. The third objective was to find out how career decision-making self-efficacy and career choice anxiety change according to self-esteem and future time perspective. We conducted a study using the daily diary method in which participants were asked to rate their affect or attitudes for 21 consecutive days. In total, 128 university students participated in this study. The main results were as follows. First, positive affect was associated positively with career decision-making self-efficacy and negatively with career choice anxiety. Second, social support had a synergy effect with positive affect to influence career choice anxiety. Third, self-esteem was related positively to career decision-making self-efficacy and negatively to career choice anxiety. We discuss theoretical and practical implications.

Factors affecting participation decision and amount of physical activity among urban dwellers in Malaysia.

PubMed

Cheah, Y K; Azahadi, M; Phang, S N; Hazilah, N

2017-05-01

The rapid rise in the prevalence of physical inactivity-related diseases has become a serious public health issue worldwide. The objective of the present study is to examine the factors affecting participation in physical activity among urban dwellers in Malaysia. This cross-sectional study measures physical activity using a rigorous regression model. Data are obtained from the National Health and Morbidity Survey 2011 (NHMS 2011). A lognormal hurdle model is used to analyse the participation decision and the amount decision of physical activity. The results show that income, gender, ethnicity, marital status and employment status are significantly associated with participation decision and amount decision. However, age, insurance and self-rated health only affect participation decision, whereas family size, education and smoking only affect amount decision. It can, thus, be concluded that sociodemographic, insurance, lifestyle and health factors play an important role in determining physical activity behaviour among urban dwellers. When formulating policies, special attention must be paid to these factors. Copyright © 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

How do patients choose private in vitro fertilization treatment? A customer survey in a tertiary fertility center in the United Kingdom.

PubMed

Lass, A; Brinsden, P

2001-05-01

To assess the relevant factors affecting patients' decision when choosing a clinic for private, self-funded IVF treatment. Prospective anonymous closed questionnaires. Single tertiary-care private IVF center. New patients attending primary consultation in a period of 7 months from September 1999 to March 2000. None. Primary knowledge about the clinic, source of referral, knowledge of, availability of information pack, and familiarity with the clinic's success rates and treatment's price. The last question assessed the relative importance of each factor in the decision-making process according to the SERVQUAL model, modified version. All items were measured as perceptions on a 5-point Likert scale. 1 = not important, 3 = neutral, and 5 = very important. One hundred seventy-five patients completed the questionnaire. They were well informed and investigated the market before making their final choice. Patients collect information from many sources, including new channels such as the Internet. Up to one third of patients do not consult their doctor before treatment. By far the most relevant factor in decision making is the success rate (i.e., delivery rates) of the clinic, followed by recommendation by general practitioner (GP) or consultant (respectively, Likert scale score, 4.6; 95% confidence interval [CI], 4.5-4.7; and Likert scale score, 4.0; 95% CI, 3.9-4.2; P<.01). Other factors, such as cost of the treatment, friends and relatives' opinions, and distance from home were not relevant. Units that wish to thrive and increase their market share should deliver high-quality service and concentrate their efforts on excelling in performance.

Theory of mind and decision-making processes are impaired in Parkinson's disease.

PubMed

Xi, Chunhua; Zhu, Youling; Mu, Yanfang; Chen, Bing; Dong, Bin; Cheng, Huaidong; Hu, Panpan; Zhu, Chunyan; Wang, Kai

2015-02-15

Prefrontal cortex plays a vital role in the theory of mind (ToM) and decision making, as shown in functional brain imaging and lesion studies. Considering the primary neuropathology of Parkinson's disease (PD) involving the frontal lobe system, patients with PD are expected to exhibit deficits in ToM and social decision making. The aim of this study was to investigate affective ToM and decision making in patients with PD and healthy controls (HC) in a task assessing affective ToM (Reading the Mind in the Eyes, RME) and two decision-making tasks (Iowa Gambling Task, IGT; Game of Dice Task, GDT). Consistent with previous findings, patients with PD were impaired in the affective ToM task, and when making decisions under ambiguity and in risk situations. The score of emotion recognition in the RME task was negatively correlated with the severity of the disease and positively correlated with the total number of advantageous cards chosen in the IGT. However, the final capital in the GDT was correlated with memory impairment. The present study implies that affective ToM and decision making under ambiguity may share similar neural mechanisms, while decision making under ambiguity and decision making under risk may involve processing within different neural networks. Copyright © 2014 Elsevier B.V. All rights reserved.

Legal Considerations in Clinical Decision Making.

ERIC Educational Resources Information Center

Ursu, Samuel C.

1992-01-01

Discussion of legal issues in dental clinical decision making looks at the nature and elements of applicable law, especially malpractice, locus of responsibility, and standards of care. Greater use of formal decision analysis in clinical dentistry and better research on diagnosis and treatment are recommended, particularly in light of increasing…

[The effects of case-based learning using video on clinical decision making and learning motivation in undergraduate nursing students].

PubMed

Yoo, Moon-Sook; Park, Jin-Hee; Lee, Si-Ra

2010-12-01

The purpose of this study was to examine the effects of case-base learning (CBL) using video on clinical decision-making and learning motivation. This research was conducted between June 2009 and April 2010 as a nonequivalent control group non-synchronized design. The study population was 44 third year nursing students who enrolled in a college of nursing, A University in Korea. The nursing students were divided into the CBL and the control group. The intervention was the CBL with three cases using video. The controls attended a traditional live lecture on the same topics. With questionnaires objective clinical decision-making, subjective clinical decision-making, and learning motivation were measured before the intervention, and 10 weeks after the intervention. Significant group differences were observed in clinical decision-making and learning motivation. The post-test scores of clinical decision-making in the CBL group were statistically higher than the control group. Learning motivation was also significantly higher in the CBL group than in the control group. These results indicate that CBL using video is effective in enhancing clinical decision-making and motivating students to learn by encouraging self-directed learning and creating more interest and curiosity in learning.

[Clinical reasoning in undergraduate nursing education: a scoping review].

PubMed

Menezes, Sáskia Sampaio Cipriano de; Corrêa, Consuelo Garcia; Silva, Rita de Cássia Gengo E; Cruz, Diná de Almeida Monteiro Lopes da

2015-12-01

This study aimed at analyzing the current state of knowledge on clinical reasoning in undergraduate nursing education. A systematic scoping review through a search strategy applied to the MEDLINE database, and an analysis of the material recovered by extracting data done by two independent reviewers. The extracted data were analyzed and synthesized in a narrative manner. From the 1380 citations retrieved in the search, 23 were kept for review and their contents were summarized into five categories: 1) the experience of developing critical thinking/clinical reasoning/decision-making process; 2) teaching strategies related to the development of critical thinking/clinical reasoning/decision-making process; 3) measurement of variables related to the critical thinking/clinical reasoning/decision-making process; 4) relationship of variables involved in the critical thinking/clinical reasoning/decision-making process; and 5) theoretical development models of critical thinking/clinical reasoning/decision-making process for students. The biggest challenge for developing knowledge on teaching clinical reasoning seems to be finding consistency between theoretical perspectives on the development of clinical reasoning and methodologies, methods, and procedures in research initiatives in this field.

The heart and potassium: a banana republic.

PubMed

Khan, Ehsan; Spiers, Christine; Khan, Maria

2013-03-01

The importance of potassium in maintaining stable cardiac function is a clinically understood phenomenon. Physiologically the importance of potassium in cardiac function is described by the large number of different kinds of potassium ions channels found in the heart compared to channels and membrane transport mechanisms for other ions such as sodium and calcium. Potassium is important in physiological homeostatic control of cardiac function, but is also of relevance to the diseased state, as potassium-related effects may stabilize or destabilize cardiac function. This article aims to provide a detailed understanding of potassium-mediated cardiac function. This will help the clinical practitioner evaluate how modulation of potassium ion channels by disease and pharmacological manipulation affect the cardiac patient, thus aiding in decision making when faced with clinical problems related to potassium.

How concerns for bisphosphonate-induced osteonecrosis of the jaw affect clinical practice among dentists: a study from the South Texas Oral Health Network

PubMed Central

Gonzales, Cara B.; Young, Veronica; Ketchum, Norma S.; Bone, Jamie; Oates, Thomas W.; Mungia, Rahma

2015-01-01

Bisphosphonate-induced osteonecrosis of the jaw (BONJ) represents a growing concern for dentists and patients, in that it may alter clinical care. This study assesses the knowledge and perceptions of practicing dentists in relation to the risk of BONJ and how their knowledge and perceptions influence their decisions when developing treatment plans. For this study, a sample of dentists (n = 93) in South Texas completed a 38-item survey about BONJ knowledge and perception and their current clinical practices for patients undergoing bisphosphonate therapy. Knowledge score groupings reflected differences between low-knowledge and high-knowledge dentists in terms of their behavior concerning medical history, alternative treatments offered, and routine blood testing for patients on bisphosphonate therapy. PMID:25734289

Goals of Care or Goals of Trust? How Family Members Perceive Goals for Dying Nursing Home Residents.

PubMed

Rosemond, Cherie; Hanson, Laura C; Zimmerman, Sheryl

2017-04-01

Dementia affects more than 5 million Americans, and is a leading cause of death. Family members of nursing home (NH) residents with advanced dementia report difficulty making decisions about care toward the end of life. As part of a randomized trial testing an intervention to improve decision making, this qualitative study aimed to understand how family decision makers experienced goal-based decision making in advance of the death of their relative. This qualitative study was conducted as part of the goals of care clinical trial. Study participants (n = 16) were family decision makers in North Carolina whose relative with advanced dementia died after participating in the goals of care intervention. Semi-structured interviews were analyzed using a qualitative description approach. Family members' experience of decision making and death differed based on the presence or absence of trusting relationships with NH staff. Family members who reported trust described a positive end-of-life experience and less need for prescribed goals of care discussions. In the absence of trust, family members reported that goals of care discussions were ignored by staff or created confusion. Among family members of persons who recently died from dementia in NHs, expressions of trust in staff were strongly related to perceptions of decision making about goals of care. Although goals of care discussions may potentially promote communication to earn trust, the presence of pre-existing trust ultimately influenced the decision making and end-of-life experiences of residents and families.

Characteristics of the postcounseling reproductive decision-making process: an explorative study.

PubMed

Frets, P G; Verhage, F; Niermeijer, M F

1991-09-01

An in-depth, recorded interview of 30 couples 2-3 years after genetic counseling explored the characteristics of the postcounseling decision-making process, including the role of guilt feelings towards the proband. The study concerned couples with an affected child, sib, or spouse. Results were evaluated by 2 to 4 judges. In contrast to other studies, a generally unstructured decision-making process was found whereby guilt feelings played a significant role in more than half the couples. Guilt feelings were more predominant in couples with an affected sib than in those with an affected spouse. Lack of structure did not seem to complicate the decision-making process. Therefore, authors do not advocate promotion of structuring the decision-making process. Genetic counselors might focus on understanding counselees' feelings concerning the reproductive decision. Acceptance of apparently irrational considerations is particularly important, because these feelings indicate the influence of unconscious motives. Another important aspect of supporting counselees is to understand the role played by guilt feelings toward parents or an affected sib.

Developmental and sex-related differences in preschoolers' affective decision making.

PubMed

Heilman, Renata M; Miu, Andrei C; Benga, Oana

2009-01-01

This study investigated developmental and sex-related differences in affective decision making, using a two-deck version of Children's Gambling Task administered to 3- and 4-year-old children. The main findings were that 4-year-old children displayed better decision-making performance than 3-year-olds. This effect was independent of developmental changes in inductive reasoning, language, and working memory. There were also sex differences in decision-making performance, which were apparent only in 3-year-old children and favored girls. Moreover, age predicted awareness of task and the correlation between the latter and decision-making performance was significant, but only in 4-year-old children. This study thus indicates that there is a remarkable developmental leap in affective decision making, whose effects are apparent around the age of 4, which according to our results, also marks the age when the correlation of declarative knowledge and decision-making performance becomes significant.

Different decision deficits impair response inhibition in progressive supranuclear palsy and Parkinson’s disease

PubMed Central

Rittman, Timothy; Nombela, Cristina; Fois, Alessandro; Coyle-Gilchrist, Ian; Barker, Roger A.; Hughes, Laura E.; Rowe, James B.

2016-01-01

Abstract Progressive supranuclear palsy and Parkinson’s disease have distinct underlying neuropathology, but both diseases affect cognitive function in addition to causing a movement disorder. They impair response inhibition and may lead to impulsivity, which can occur even in the presence of profound akinesia and rigidity. The current study examined the mechanisms of cognitive impairments underlying disinhibition, using horizontal saccadic latencies that obviate the impact of limb slowness on executing response decisions. Nineteen patients with clinically diagnosed progressive supranuclear palsy (Richardson’s syndrome), 24 patients with clinically diagnosed Parkinson’s disease and 26 healthy control subjects completed a saccadic Go/No-Go task with a head-mounted infrared saccadometer. Participants were cued on each trial to make a pro-saccade to a horizontal target or withhold their responses. Both patient groups had impaired behavioural performance, with more commission errors than controls. Mean saccadic latencies were similar between all three groups. We analysed behavioural responses as a binary decision between Go and No-Go choices. By using Bayesian parameter estimation, we fitted a hierarchical drift–diffusion model to individual participants’ single trial data. The model decomposes saccadic latencies into parameters for the decision process: decision boundary, drift rate of accumulation, decision bias, and non-decision time. In a leave-one-out three-way classification analysis, the model parameters provided better discrimination between patients and controls than raw behavioural measures. Furthermore, the model revealed disease-specific deficits in the Go/No-Go decision process. Both patient groups had slower drift rate of accumulation, and shorter non-decision time than controls. But patients with progressive supranuclear palsy were strongly biased towards a pro-saccade decision boundary compared to Parkinson’s patients and controls. This indicates a prepotency of responding in combination with a reduction in further accumulation of evidence, which provides a parsimonious explanation for the apparently paradoxical combination of disinhibition and severe akinesia. The combination of the well-tolerated oculomotor paradigm and the sensitivity of the model-based analysis provides a valuable approach for interrogating decision-making processes in neurodegenerative disorders. The mechanistic differences underlying participants’ poor performance were not observable from classical analysis of behavioural data, but were clearly revealed by modelling. These differences provide a rational basis on which to develop and assess new therapeutic strategies for cognition and behaviour in these disorders. PMID:26582559

Different decision deficits impair response inhibition in progressive supranuclear palsy and Parkinson's disease.

PubMed

Zhang, Jiaxiang; Rittman, Timothy; Nombela, Cristina; Fois, Alessandro; Coyle-Gilchrist, Ian; Barker, Roger A; Hughes, Laura E; Rowe, James B

2016-01-01

Progressive supranuclear palsy and Parkinson's disease have distinct underlying neuropathology, but both diseases affect cognitive function in addition to causing a movement disorder. They impair response inhibition and may lead to impulsivity, which can occur even in the presence of profound akinesia and rigidity. The current study examined the mechanisms of cognitive impairments underlying disinhibition, using horizontal saccadic latencies that obviate the impact of limb slowness on executing response decisions. Nineteen patients with clinically diagnosed progressive supranuclear palsy (Richardson's syndrome), 24 patients with clinically diagnosed Parkinson's disease and 26 healthy control subjects completed a saccadic Go/No-Go task with a head-mounted infrared saccadometer. Participants were cued on each trial to make a pro-saccade to a horizontal target or withhold their responses. Both patient groups had impaired behavioural performance, with more commission errors than controls. Mean saccadic latencies were similar between all three groups. We analysed behavioural responses as a binary decision between Go and No-Go choices. By using Bayesian parameter estimation, we fitted a hierarchical drift-diffusion model to individual participants' single trial data. The model decomposes saccadic latencies into parameters for the decision process: decision boundary, drift rate of accumulation, decision bias, and non-decision time. In a leave-one-out three-way classification analysis, the model parameters provided better discrimination between patients and controls than raw behavioural measures. Furthermore, the model revealed disease-specific deficits in the Go/No-Go decision process. Both patient groups had slower drift rate of accumulation, and shorter non-decision time than controls. But patients with progressive supranuclear palsy were strongly biased towards a pro-saccade decision boundary compared to Parkinson's patients and controls. This indicates a prepotency of responding in combination with a reduction in further accumulation of evidence, which provides a parsimonious explanation for the apparently paradoxical combination of disinhibition and severe akinesia. The combination of the well-tolerated oculomotor paradigm and the sensitivity of the model-based analysis provides a valuable approach for interrogating decision-making processes in neurodegenerative disorders. The mechanistic differences underlying participants' poor performance were not observable from classical analysis of behavioural data, but were clearly revealed by modelling. These differences provide a rational basis on which to develop and assess new therapeutic strategies for cognition and behaviour in these disorders. © The Author (2015). Published by Oxford University Press on behalf of the Guarantors of Brain.

Evaluating a mobile application for improving clinical laboratory test ordering and diagnosis.

PubMed

Meyer, Ashley N D; Thompson, Pamela J; Khanna, Arushi; Desai, Samir; Mathews, Benji K; Yousef, Elham; Kusnoor, Anita V; Singh, Hardeep

2018-04-20

Mobile applications for improving diagnostic decision making often lack clinical evaluation. We evaluated if a mobile application improves generalist physicians' appropriate laboratory test ordering and diagnosis decisions and assessed if physicians perceive it as useful for learning. In an experimental, vignette study, physicians diagnosed 8 patient vignettes with normal prothrombin times (PT) and abnormal partial thromboplastin times (PTT). Physicians made test ordering and diagnosis decisions for 4 vignettes using each resource: a mobile app, PTT Advisor, developed by the Centers for Disease Control and Prevention (CDC)'s Clinical Laboratory Integration into Healthcare Collaborative (CLIHC); and usual clinical decision support. Then, physicians answered questions regarding their perceptions of the app's usefulness for diagnostic decision making and learning using a modified Kirkpatrick Training Evaluation Framework. Data from 368 vignettes solved by 46 physicians at 7 US health care institutions show advantages for using PTT Advisor over usual clinical decision support on test ordering and diagnostic decision accuracy (82.6 vs 70.2% correct; P < .001), confidence in decisions (7.5 vs 6.3 out of 10; P < .001), and vignette completion time (3:02 vs 3:53 min.; P = .06). Physicians reported positive perceptions of the app's potential for improved clinical decision making, and recommended it be used to address broader diagnostic challenges. A mobile app, PTT Advisor, may contribute to better test ordering and diagnosis, serve as a learning tool for diagnostic evaluation of certain clinical disorders, and improve patient outcomes. Similar methods could be useful for evaluating apps aimed at improving testing and diagnosis for other conditions.

Advancing beyond the system: telemedicine nurses' clinical reasoning using a computerised decision support system for patients with COPD - an ethnographic study.

PubMed

Barken, Tina Lien; Thygesen, Elin; Söderhamn, Ulrika

2017-12-28

Telemedicine is changing traditional nursing care, and entails nurses performing advanced and complex care within a new clinical environment, and monitoring patients at a distance. Telemedicine practice requires complex disease management, advocating that the nurses' reasoning and decision-making processes are supported. Computerised decision support systems are being used increasingly to assist reasoning and decision-making in different situations. However, little research has focused on the clinical reasoning of nurses using a computerised decision support system in a telemedicine setting. Therefore, the objective of the study is to explore the process of telemedicine nurses' clinical reasoning when using a computerised decision support system for the management of patients with chronic obstructive pulmonary disease. The factors influencing the reasoning and decision-making processes were investigated. In this ethnographic study, a combination of data collection methods, including participatory observations, the think-aloud technique, and a focus group interview was employed. Collected data were analysed using qualitative content analysis. When telemedicine nurses used a computerised decision support system for the management of patients with complex, unstable chronic obstructive pulmonary disease, two categories emerged: "the process of telemedicine nurses' reasoning to assess health change" and "the influence of the telemedicine setting on nurses' reasoning and decision-making processes". An overall theme, termed "advancing beyond the system", represented the connection between the reasoning processes and the telemedicine work and setting, where being familiar with the patient functioned as a foundation for the nurses' clinical reasoning process. In the telemedicine setting, when supported by a computerised decision support system, nurses' reasoning was enabled by the continuous flow of digital clinical data, regular video-mediated contact and shared decision-making with the patient. These factors fostered an in-depth knowledge of the patients and acted as a foundation for the nurses' reasoning process. Nurses' reasoning frequently advanced beyond the computerised decision support system recommendations. Future studies are warranted to develop more accurate algorithms, increase system maturity, and improve the integration of the digital clinical information with clinical experiences, to support telemedicine nurses' reasoning process.

Understanding clinical and non-clinical decisions under uncertainty: a scenario-based survey.

PubMed

Simianu, Vlad V; Grounds, Margaret A; Joslyn, Susan L; LeClerc, Jared E; Ehlers, Anne P; Agrawal, Nidhi; Alfonso-Cristancho, Rafael; Flaxman, Abraham D; Flum, David R

2016-12-01

Prospect theory suggests that when faced with an uncertain outcome, people display loss aversion by preferring to risk a greater loss rather than incurring certain, lesser cost. Providing probability information improves decision making towards the economically optimal choice in these situations. Clinicians frequently make decisions when the outcome is uncertain, and loss aversion may influence choices. This study explores the extent to which prospect theory, loss aversion, and probability information in a non-clinical domain explains clinical decision making under uncertainty. Four hundred sixty two participants (n = 117 non-medical undergraduates, n = 113 medical students, n = 117 resident trainees, and n = 115 medical/surgical faculty) completed a three-part online task. First, participants completed an iced-road salting task using temperature forecasts with or without explicit probability information. Second, participants chose between less or more risk-averse ("defensive medicine") decisions in standardized scenarios. Last, participants chose between recommending therapy with certain outcomes or risking additional years gained or lost. In the road salting task, the mean expected value for decisions made by clinicians was better than for non-clinicians(-$1,022 vs -$1,061; <0.001). Probability information improved decision making for all participants, but non-clinicians improved more (mean improvement of $64 versus $33; p = 0.027). Mean defensive decisions decreased across training level (medical students 2.1 ± 0.9, residents 1.6 ± 0.8, faculty1.6 ± 1.1; p-trend < 0.001) and prospect-theory-concordant decisions increased (25.4%, 33.9%, and 40.7%;p-trend = 0.016). There was no relationship identified between road salting choices with defensive medicine and prospect-theory-concordant decisions. All participants made more economically-rational decisions when provided explicit probability information in a non-clinical domain. However, choices in the non-clinical domain were not related to prospect-theory concordant decision making and risk aversion tendencies in the clinical domain. Recognizing this discordance may be important when applying prospect theory to interventions aimed at improving clinical care.

Comparativism and the Grounds for Person-Centered Care and Shared Decision Making.

PubMed

Herlitz, Anders

2017-01-01

This article provides a new argument and a new value-theoretical ground for person-centered care and shared decision making that ascribes to it the role of enabling rational choice in situations involving clinical choice. Rather than referring to good health outcomes and/or ethical grounds such as patient autonomy, it argues that a plausible justification and ground for person-centered care and shared decision making is preservation of rationality in the face of comparative non-determinacy in clinical settings. Often, no alternative treatment will be better than or equal to every other alternative. In the face of such comparative non-determinacy, Ruth Chang has argued that we can make rational decisions by invoking reasons that are created through acts of willing. This article transfers this view to clinical decision making and argues that shared decision making provides a solution to non-determinacy problems in clinical settings. This view of the role of shared decision making provides a new understanding of its nature, and it also allows us to better understand when caregivers should engage in shared decision making and when they should not. Copyright 2017 The Journal of Clinical Ethics. All rights reserved.

Effects of reflection on clinical decision-making of intensive care unit nurses.

PubMed

Razieh, Shahrokhi; Somayeh, Ghafari; Fariba, Haghani

2018-07-01

Nurses are one of the most influential factors in overcoming the main challenges faced by health systems throughout the world. Every health system should, hence, empower nurses in clinical judgment and decision-making skills. This study evaluated the effects of implementing Tanner's reflection method on clinical decision-making of nurses working in an intensive care unit (ICU). This study used an experimental, pretest, posttest design. The setting was the intensive care unit of Amin Hospital Isfahan, Iran. The convenience sample included 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). This clinical trial was performed on 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). The nurses were selected by census sampling and randomly allocated to either the case or the control group. Data were collected using a questionnaire containing demographic characteristics and the clinical decision-making scale developed by Laurie and Salantera (NDMI-14). The questionnaire was completed before and one week after the intervention. The data were analyzed using SPSS 21.0. The two groups were not significantly different in terms of the level and mean scores of clinical decision-making before the intervention (P = 0.786). Based on the results of independent t-test, the mean score of clinical decision-making one week after the intervention was significantly higher in the case group than in the control group (P = 0.009; t = -2.69). The results of Mann Whitney test showed that one week after the intervention, the nurses' level of clinical decision-making in the case group rose to the next level (P = 0.001). Reflection could improve the clinical decision-making of ICU nurses. It is, thus, recommended to incorporate this method into the nursing curriculum and care practices. Copyright © 2018. Published by Elsevier Ltd.

Decision technologies and the independent professional: the future's challenge to learning and leadership

PubMed Central

Dowie, J.

2001-01-01

Most references to "leadership" and "learning" as sources of quality improvement in medical care reflect an implicit commitment to the decision technology of "clinical judgement". All attempts to sustain this waning decision technology by clinical guidelines, care pathways, "evidence based practice", problem based curricula, and other stratagems only increase the gap between what is expected of doctors in today's clinical situation and what is humanly possible, hence the morale, stress, and health problems they are increasingly experiencing. Clinical guidance programmes based on decision analysis represent the coming decision technology, and proactive adaptation will produce independent doctors who can deliver excellent evidence based and preference driven care while concentrating on the human aspects of the therapeutic relation, having been relieved of the unbearable burdens of knowledge and information processing currently laid on them. History is full of examples of the incumbents of dominant technologies preferring to die than to adapt, and medicine needs both learning and leadership if it is to avoid repeating this mistake. Key Words: decision technology; clinical guidance programmes; decision analysis PMID:11700381

The normalization heuristic: an untested hypothesis that may misguide medical decisions.

PubMed

Aberegg, Scott K; O'Brien, James M

2009-06-01

Medical practice is increasingly informed by the evidence from randomized controlled trials. When such evidence is not available, clinical hypotheses based on pathophysiological reasoning and common sense guide clinical decision making. One commonly utilized general clinical hypothesis is the assumption that normalizing abnormal laboratory values and physiological parameters will lead to improved patient outcomes. We refer to the general use of this clinical hypothesis to guide medical therapeutics as the "normalization heuristic". In this paper, we operationally define this heuristic and discuss its limitations as a rule of thumb for clinical decision making. We review historical and contemporaneous examples of normalization practices as empirical evidence for the normalization heuristic and to highlight its frailty as a guide for clinical decision making.

How can clinical practice guidelines be adapted to facilitate shared decision making? A qualitative key-informant study.

PubMed

van der Weijden, Trudy; Pieterse, Arwen H; Koelewijn-van Loon, Marije S; Knaapen, Loes; Légaré, France; Boivin, Antoine; Burgers, Jako S; Stiggelbout, Anne M; Faber, Marjan; Elwyn, Glyn

2013-10-01

To explore how clinical practice guidelines can be adapted to facilitate shared decision making. This was a qualitative key-informant study with group discussions and semi-structured interviews. First, 75 experts in guideline development or shared decision making participated in group discussions at two international conferences. Next, health professionals known as experts in depression or breast cancer, experts on clinical practice guidelines and/or shared decision making, and patient representatives were interviewed (N=20). Using illustrative treatment decisions on depression or breast cancer, we asked the interviewees to indicate as specifically as they could how guidelines could be used to facilitate shared decision making. Interviewees suggested some generic strategies, namely to include a separate chapter on the importance of shared decision making, to use language that encourages patient involvement, and to develop patient versions of guidelines. Recommendation-specific strategies, related to specific decision points in the guideline, were also suggested: These include structuring the presentation of healthcare options to increase professionals' option awareness; structuring the deliberation process between professionals and patients; and providing relevant patient support tools embedded at important decision points in the guideline. This study resulted in an overview of strategies to adapt clinical practice guidelines to facilitate shared decision making. Some strategies seemed more contentious than others. Future research should assess the feasibility and impact of these strategies to make clinical practice guidelines more conducive to facilitate shared decision making.

Cerebellar damage impairs the self-rating of regret feeling in a gambling task

PubMed Central

Clausi, Silvia; Coricelli, Giorgio; Pisotta, Iolanda; Pavone, Enea Francesco; Lauriola, Marco; Molinari, Marco; Leggio, Maria

2015-01-01

Anatomical, clinical, and neuroimaging evidence implicates the cerebellum in processing emotions and feelings. Moreover recent studies showed a cerebellar involvement in pathologies such as autism, schizophrenia and alexithymia, in which emotional processing have been found altered. However, cerebellar function in the modulation of emotional responses remains debated. In this study, emotions that are involved directly in decision-making were examined in 15 patients (six males; age range 17–60 years) affected by cerebellar damage and 15 well matched healthy controls. We used a gambling task, in which subjects’ choices and evaluation of outcomes with regard to their anticipated and actual emotional impact were analyzed. Emotions, such as regret and relief, were elicited, based on the outcome of the unselected gamble. Interestingly, despite their ability to avoid regret in subsequent choices, patients affected by cerebellar lesions were significantly impaired in evaluating the feeling of regret subjectively. These results demonstrate that the cerebellum is involved in conscious recognizing of negative feelings caused by the sense of self-responsibility for an incorrect decision. PMID:25999829

Four Factors of Clinical Decision Making: A Teaching Model.

ERIC Educational Resources Information Center

Leist, James C.; Konen, Joseph C.

1996-01-01

Four factors of clinical decision making identified by medical students include quality of care, cost, ethics, and legal concerns. This paper argues that physicians have two responsibilities in the clinical decision-making model: to be the primary advocate for quality health care and to ensure balance among the four factors, working in partnership…

[Effects of marijuana on cognition: a review form the neurobiological perspective].

PubMed

Torres, Gladys; Fiestas, Fabián

2012-03-01

Marijuana is one of the most commonly used psychoactive substances in society, mainly among youths. Its use has been consistently associated with several health problems, many of which have in common an impairment in the cognitive processes of behavior, including the memory, attention, emotion and decision making. There is evidence suggesting that cannabinoids, marijuana's primary psychoactive substance, have a negative effect in short-term memory, working memory, and decision making. It has also been found that cannabinoids affect attention and the interaction between cognitive events and emotion. This information can be used as an argument of biological plausibility to assess clinical and epidemiological research findings that show that marijuana`s use is associated to problems such as traffic accidents, psychosis, depression and poor academic records, among others.

Classifying clinical decision making: a unifying approach.

PubMed

Buckingham, C D; Adams, A

2000-10-01

This is the first of two linked papers exploring decision making in nursing which integrate research evidence from different clinical and academic disciplines. Currently there are many decision-making theories, each with their own distinctive concepts and terminology, and there is a tendency for separate disciplines to view their own decision-making processes as unique. Identifying good nursing decisions and where improvements can be made is therefore problematic, and this can undermine clinical and organizational effectiveness, as well as nurses' professional status. Within the unifying framework of psychological classification, the overall aim of the two papers is to clarify and compare terms, concepts and processes identified in a diversity of decision-making theories, and to demonstrate their underlying similarities. It is argued that the range of explanations used across disciplines can usefully be re-conceptualized as classification behaviour. This paper explores problems arising from multiple theories of decision making being applied to separate clinical disciplines. Attention is given to detrimental effects on nursing practice within the context of multidisciplinary health-care organizations and the changing role of nurses. The different theories are outlined and difficulties in applying them to nursing decisions highlighted. An alternative approach based on a general model of classification is then presented in detail to introduce its terminology and the unifying framework for interpreting all types of decisions. The classification model is used to provide the context for relating alternative philosophical approaches and to define decision-making activities common to all clinical domains. This may benefit nurses by improving multidisciplinary collaboration and weakening clinical elitism.

Affective decision-making and externalizing behaviors: the role of autonomic activity.

PubMed

Bubier, Jennifer L; Drabick, Deborah A G

2008-08-01

We tested a conceptual model involving the inter-relations among affective decision-making (indexed by a gambling task), autonomic nervous system (ANS) activity, and attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) symptoms in a largely impoverished, inner city sample of first through third grade children (N=63, 54% male). The present study hypothesized that impaired affective decision-making and decreased sympathetic and parasympathetic activation would be associated with higher levels of ADHD and ODD symptoms, and that low sympathetic and parasympathetic activation during an emotion-inducing task would mediate the relation between affective decision-making and child externalizing symptoms. In support of our model, disadvantageous decision-making on a gambling task was associated with ADHD hyperactivity/impulsivity symptoms among boys, and attenuated sympathetic activation during an emotion-inducing task mediated this relation. Support for the model was not found among girls.

Grand Challenges in Clinical Decision Support v10

PubMed Central

Sittig, Dean F.; Wright, Adam; Osheroff, Jerome A.; Middleton, Blackford; Teich, Jonathan M.; Ash, Joan S.; Campbell, Emily; Bates, David W.

2008-01-01

There is a pressing need for high-quality, effective means of designing, developing, presenting, implementing, evaluating, and maintaining all types of clinical decision support capabilities for clinicians, patients and consumers. Using an iterative, consensus-building process we identified a rank-ordered list of the top 10 grand challenges in clinical decision support. This list was created to educate and inspire researchers, developers, funders, and policy-makers. The list of challenges in order of importance that they be solved if patients and organizations are to begin realizing the fullest benefits possible of these systems consists of: Improve the human-computer interface; Disseminate best practices in CDS design, development, and implementation; Summarize patient-level information; Prioritize and filter recommendations to the user; Create an architecture for sharing executable CDS modules and services; Combine recommendations for patients with co-morbidities; Prioritize CDS content development and implementation; Create internet-accessible clinical decision support repositories; Use freetext information to drive clinical decision support; Mine large clinical databases to create new CDS. Identification of solutions to these challenges is critical if clinical decision support is to achieve its potential and improve the quality, safety and efficiency of healthcare. PMID:18029232

Emotion-affected decision making in human simulation.

PubMed

Zhao, Y; Kang, J; Wright, D K

2006-01-01

Human modelling is an interdisciplinary research field. The topic, emotion-affected decision making, was originally a cognitive psychology issue, but is now recognized as an important research direction for both computer science and biomedical modelling. The main aim of this paper is to attempt to bridge the gap between psychology and bioengineering in emotion-affected decision making. The work is based on Ortony's theory of emotions and bounded rationality theory, and attempts to connect the emotion process with decision making. A computational emotion model is proposed, and the initial framework of this model in virtual human simulation within the platform of Virtools is presented.

Hemispheric Activation Differences in Novice and Expert Clinicians during Clinical Decision Making

ERIC Educational Resources Information Center

Hruska, Pam; Hecker, Kent G.; Coderre, Sylvain; McLaughlin, Kevin; Cortese, Filomeno; Doig, Christopher; Beran, Tanya; Wright, Bruce; Krigolson, Olav

2016-01-01

Clinical decision making requires knowledge, experience and analytical/non-analytical types of decision processes. As clinicians progress from novice to expert, research indicates decision-making becomes less reliant on foundational biomedical knowledge and more on previous experience. In this study, we investigated how knowledge and experience…

Deliberation before determination: the definition and evaluation of good decision making.

PubMed

Elwyn, Glyn; Miron-Shatz, Talya

2010-06-01

In this article, we examine definitions of suggested approaches to measure the concept of good decisions, highlight the ways in which they converge, and explain why we have concerns about their emphasis on post-hoc estimations and post-decisional outcomes, their prescriptive concept of knowledge, and their lack of distinction between the process of deliberation, and the act of decision determination. There has been a steady trend to involve patients in decision making tasks in clinical practice, part of a shift away from paternalism towards the concept of informed choice. An increased understanding of the uncertainties that exist in medicine, arising from a weak evidence base and, in addition, the stochastic nature of outcomes at the individual level, have contributed to shifting the responsibility for decision making from physicians to patients. This led to increasing use of decision support and communication methods, with the ultimate aim of improving decision making by patients. Interest has therefore developed in attempting to define good decision making and in the development of measurement approaches. We pose and reflect whether decisions can be judged good or not, and, if so, how this goodness might be evaluated. We hypothesize that decisions cannot be measured by reference to their outcomes and offer an alternative means of assessment, which emphasizes the deliberation process rather than the decision's end results. We propose decision making comprises a pre-decisional process and an act of decision determination and consider how this model of decision making serves to develop a new approach to evaluating what constitutes a good decision making process. We proceed to offer an alternative, which parses decisions into the pre-decisional deliberation process, the act of determination and post-decisional outcomes. Evaluating the deliberation process, we propose, should comprise of a subjective sufficiency of knowledge, as well as emotional processing and affective forecasting of the alternatives. This should form the basis for a good act of determination.

The role of affect and cognition in health decision making.

PubMed

Keer, Mario; van den Putte, Bas; Neijens, Peter

2010-03-01

Both affective and cognitive evaluations of behaviours have been allocated various positions in theoretical models of decision making. Most often, they have been studied as direct determinants of either intention or overall evaluation, but these two possible positions have never been compared. The aim of this study was to determine whether affective and cognitive evaluations influence intention directly, or whether their influence is mediated by overall evaluation. A sample of 300 university students filled in questionnaires on their affective, cognitive, and overall evaluations in respect of 20 health behaviours. The data were interpreted using mediation analyses with the application of path modelling. Both affective and cognitive evaluations were found to have significantly predicted intention. The influence of affective evaluation was largely direct for each of the behaviours studied, whereas that of cognitive evaluation was partially direct and partially mediated by overall evaluation. These results indicate that decisions regarding the content of persuasive communication (affective vs. cognitive) are highly dependent on the theoretical model chosen. It is suggested that affective evaluation should be included as a direct determinant of intention in theories of decision making when predicting health behaviours.

Concept mapping in a critical care orientation program: a pilot study to develop critical thinking and decision-making skills in novice nurses.

PubMed

Wahl, Stacy E; Thompson, Anita M

2013-10-01

Newly graduated registered nurses who were hired into a critical care intensive care unit showed a lack of critical thinking skills to inform their clinical decision-making abilities. This study evaluated the effectiveness of concept mapping as a teaching tool to improve critical thinking and clinical decision-making skills in novice nurses. A self-evaluation tool was administered before and after the learning intervention. The 25-item tool measured five key indicators of the development of critical thinking skills: problem recognition, clinical decision-making, prioritization, clinical implementation, and reflection. Statistically significant improvements were seen in 10 items encompassing all five indicators. Concept maps are an effective tool for educators to use in assisting novice nurses to develop their critical thinking and clinical decision-making skills. Copyright 2013, SLACK Incorporated.

Deep and continuous palliative sedation (terminal sedation): clinical-ethical and philosophical aspects.

PubMed

Materstvedt, Lars Johan; Bosshard, Georg

2009-06-01

Terminal sedation continues to fuel debate. When confronted with a patient for whom terminal sedation is considered a possible treatment option, decision making can be difficult. In this paper we focus on the clinical-ethical issues, with an aim to provide clinicians with ways of framing the issue from an ethical point of view. In addition to the clinical-ethical issues, terminal sedation touches upon interesting and complex questions of an essentially philosophical nature. What it means to be a "person" is one such question, and is a topic that is relevant to clinical, daily practice. Accordingly, in the latter part of this paper we draw briefly on selected philosophical positions to elucidate this question. A doctor's belief of what it means to be a "person" might well affect their actions. For example, if a doctor believes terminal sedation involves the destruction of the person, they might not be willing to proceed with it.

Predictive testing for Huntington disease: social characteristics and knowledge of applicants, attitudes to the test procedure and decisions made after testing.

PubMed

Holloway, S; Mennie, M; Crosbie, A; Smith, B; Raeburn, S; Dinwoodie, D; Wright, A; May, H; Calder, K; Barron, L

1994-08-01

An investigation has been made of the social characteristics and knowledge and experience of Huntington disease (HD) for the first 80 individuals considering presymptomatic testing (applicants) at the medical genetics centres in Edinburgh and Glasgow and of attitudes to the test procedure and decisions made after testing for those who received a result. Sixty-one percent of applicants were female and 31% were over 40 years old. Almost all had a symptomatic parent but 38% did not know HD was in their family until they were over 25 years old and 48% had never received genetic counselling. Thirty-eight percent of applicants first heard of the test at the genetic clinic, 20% from a relative and 20% from the media, but none had received information from their GP. Thirty-one applicants did not have the test because they voluntarily withdrew (17 individuals), their family structure was unsuitable or no informative result was possible (11 individuals), or they were diagnosed clinically as being affected (3 individuals). Those who voluntarily withdrew did not differ significantly from the 49 who received a result in social characteristics or knowledge and experience of HD. Twenty-two individuals were found to be at increased risk (IR) (> 50% of becoming affected) and 27 to be at decreased risk (DR) (< 50% of becoming affected). There was a median period of 9 months between entering the test procedure and receiving a result and the main criticism of the procedure was that it took too long to complete and several individuals experienced considerable anxiety while awaiting their result.(ABSTRACT TRUNCATED AT 250 WORDS)

Adoption of Clinical Information Systems in Health Services Organizations

PubMed Central

Austin, Charles J.; Holland, Gloria J.

1988-01-01

This paper presents a conceptual model of factors which influence organizational decisions to invest in the installation of clinical information systems. Using results of previous research as a framework, the relative influence of clinical, fiscal, and strategic-institutional decision structures are examined. These adoption decisions are important in health services organizations because clinical information is essential for managing demand and allocating resources, managing quality of care, and controlling costs.

Optimal management of adults with pharyngitis – a multi-criteria decision analysis

PubMed Central

Singh, Sonal; Dolan, James G; Centor, Robert M

2006-01-01

Background Current practice guidelines offer different management recommendations for adults presenting with a sore throat. The key issue is the extent to which the clinical likelihood of a Group A streptococcal infection should affect patient management decisions. To help resolve this issue, we conducted a multi-criteria decision analysis using the Analytic Hierarchy Process. Methods We defined optimal patient management using four criteria: 1) reduce symptom duration; 2) prevent infectious complications, local and systemic; 3) minimize antibiotic side effects, minor and anaphylaxis; and 4) achieve prudent use of antibiotics, avoiding both over-use and under-use. In our baseline analysis we assumed that all criteria and sub-criteria were equally important except minimizing anaphylactic side effects, which was judged very strongly more important than minimizing minor side effects. Management strategies included: a) No test, No treatment; b) Perform a rapid strep test and treat if positive; c) Perform a throat culture and treat if positive; d) Perform a rapid strep test and treat if positive; if negative obtain a throat culture and treat if positive; and e) treat without further tests. We defined four scenarios based on the likelihood of group A streptococcal infection using the Centor score, a well-validated clinical index. Published data were used to estimate the likelihoods of clinical outcomes and the test operating characteristics of the rapid strep test and throat culture for identifying group A streptococcal infections. Results Using the baseline assumptions, no testing and no treatment is preferred for patients with Centor scores of 1; two strategies – culture and treat if positive and rapid strep with culture of negative results – are equally preferable for patients with Centor scores of 2; and rapid strep with culture of negative results is the best management strategy for patients with Centor scores 3 or 4. These results are sensitive to the priorities assigned to the decision criteria, especially avoiding over-use versus under-use of antibiotics, and the population prevalence of Group A streptococcal pharyngitis. Conclusion The optimal clinical management of adults with sore throat depends on both the clinical probability of a group A streptococcal infection and clinical judgments that incorporate individual patient and practice circumstances. PMID:16533386

Decision Aids for Multiple-Decision Disease Management as Affected by Weather Input Errors

USDA-ARS?s Scientific Manuscript database

Many disease management decision support systems (DSS) rely, exclusively or in part, on weather inputs to calculate an indicator for disease hazard. Error in the weather inputs, typically due to forecasting, interpolation or estimation from off-site sources, may affect model calculations and manage...

Efficiency of Fiscal Allocations in Site-Based Empowered Schools

ERIC Educational Resources Information Center

Meyer, Jerome Jay

2011-01-01

This study implemented a two phase concurrent mixed-methods design to generate a greater understanding of how elementary schools with increased autonomy in fiscal decision making allocated their money, how their site-based decisions affected allocative efficiency, and how increased autonomy affected site-based decision making when compared with a…

Key factors affecting dying children and their families.

PubMed

Hinds, Pamela S; Schum, Lisa; Baker, Justin N; Wolfe, Joanne

2005-01-01

The death of a child alters the life and health of others immediately and for the rest of their lives. How a child dies influences parents' abilities to continue their role functions as well as siblings' abilities to make and maintain friendships, and may be the basis for health care providers' decisions to exit direct care roles. Thus, facilitating a "good death"-an obvious care priority for all involved with the dying child-ought also to be a priority for the health of bereaved families and affected health care providers. Making this a care priority is complicated by a serious lack of data, as details of the last hours or weeks of a dying child or adolescent's life are largely unknown. The purpose of this paper is to identify key factors that affect the course of dying children and adolescents and that of their bereaved survivors, and to link those key factors to needed research that could produce clinically relevant findings to improve the care of these patients. Key factors described here include suffering (physical, psychological, and spiritual), communication, decision making, prognostic ambiguities, ability of the seriously ill child to give assent to research participation, and educational preparation of health care providers to give competent end-of-life care.

The Arithmetic of Emotion: Integration of Incidental and Integral Affect in Judgments and Decisions

PubMed Central

Västfjäll, Daniel; Slovic, Paul; Burns, William J.; Erlandsson, Arvid; Koppel, Lina; Asutay, Erkin; Tinghög, Gustav

2016-01-01

Research has demonstrated that two types of affect have an influence on judgment and decision making: incidental affect (affect unrelated to a judgment or decision such as a mood) and integral affect (affect that is part of the perceiver’s internal representation of the option or target under consideration). So far, these two lines of research have seldom crossed so that knowledge concerning their combined effects is largely missing. To fill this gap, the present review highlights differences and similarities between integral and incidental affect. Further, common and unique mechanisms that enable these two types of affect to influence judgment and choices are identified. Finally, some basic principles for affect integration when the two sources co-occur are outlined. These mechanisms are discussed in relation to existing work that has focused on incidental or integral affect but not both. PMID:27014136

Evidence-based practice of transfusion medicine: is it possible and what do the words mean?

PubMed

Vamvakas, Eleftherios C

2004-10-01

Evidence-based medicine (EBM) optimizes clinical decision making by dictating that clinical decisions be based on the best available research evidence and by integrating best research evidence with clinical expertise and patient values. Several rankings of the strength of the evidence generated from different types of clinical research designs have been presented, and, in addressing a particular problem, clinicians can base their decision making on the types of clinical reports that have been published, along with an assessment of the strengths and weaknesses of each study. At a policy level, the concept of EBM would dictate that policy decisions also be made based on the best available research evidence. In transfusion medicine, however, decisions are based on a broader range of inputs, and the criteria for evaluating the efficacy and/or cost-effectiveness of proposed interventions differ from those used in other areas. Reasons why policy decisions are often based on considerations other than the best research evidence include public expectations about transfusion safety and proposals for applying the precautionary principle to transfusion medicine. Using the debate over the appropriateness of introducing universal white-cell reduction as an example, this review describes 2 perspectives for assessing evidence and/or making clinical or policy decisions: the evidence-based approach and the precautionary-principle approach; and also considers whether decisions in transfusion medicine can be truly evidence based.

[Treatment regulations and treatment limits: factors influencing clinical decision-making].

PubMed

Baberg, H T; Kielstein, R; de Zeeuw, J; Sass, H-M

2002-08-02

Providing or withholding of treatment is based on a variety of factors. We sought for criteria in clinical decision making and reviewed attitudes towards clinical intuition and the patient's will. 503 physicians (25.6 % females; mean age 36.3) in 49 departments at nine hospitals of the universities Bochum and Magdeburg filled in a validated questionnaire. The most important factors in the decision to carry out a therapy were "international standards" and "own experience". The decision to omit a therapy was mainly influenced by the "patient's wish". Physicians with a higher status judged their own experience higher than young physicians, who considered the experience of colleagues more important. "Severe accompanying illnesses" and "multimorbidity" were the most frequently named reasons to withdraw a therapy. Intuitive decision-making was rare, especially in young physicians, although these decisions were seldom risky and often successful. A patient's will plays a prominent role in clinical decision making, especially in decisions to withdraw or to withhold treatment. Cost containment and research interest have been called less important, a remarkable response from research-based university hospitals. Also remarkable is the recognition and importance of clinical intuition in situations of complex or missing information. This important aspect is rarely discussed in the literature or in medical education. The widely voiced concern that priorities in clinical care are guided by scientific interest, financial or technical possibilities could not be confirmed.

SANDS: A Service-Oriented Architecture for Clinical Decision Support in a National Health Information Network

PubMed Central

Wright, Adam; Sittig, Dean F.

2008-01-01

In this paper we describe and evaluate a new distributed architecture for clinical decision support called SANDS (Service-oriented Architecture for NHIN Decision Support), which leverages current health information exchange efforts and is based on the principles of a service-oriented architecture. The architecture allows disparate clinical information systems and clinical decision support systems to be seamlessly integrated over a network according to a set of interfaces and protocols described in this paper. The architecture described is fully defined and developed, and six use cases have been developed and tested using a prototype electronic health record which links to one of the existing prototype National Health Information Networks (NHIN): drug interaction checking, syndromic surveillance, diagnostic decision support, inappropriate prescribing in older adults, information at the point of care and a simple personal health record. Some of these use cases utilize existing decision support systems, which are either commercially or freely available at present, and developed outside of the SANDS project, while other use cases are based on decision support systems developed specifically for the project. Open source code for many of these components is available, and an open source reference parser is also available for comparison and testing of other clinical information systems and clinical decision support systems that wish to implement the SANDS architecture. PMID:18434256

The use of bevacizumab among women with metastatic breast cancer: a survey on clinical practice and the ongoing controversy.

PubMed

Dawood, Shaheenah; Shaikh, Asim Jamal; Buchholz, Thomas A; Cortes, Javier; Cristofanilli, Massimo; Gupta, Sudeep; Gonzalez-Angulo, Ana M

2012-06-01

The US Food and Drug Administration's (FDA's) recent decision to remove the indication of bevacizumab for metastatic breast cancer (MBC) has fueled a debate in the breast cancer community. We conducted a survey to assess the perception of health care workers involved in the management of women with MBC on the FDA's decision to ascertain how it will affect practice and to determine how bevacizumab is commonly used in the community for MBC. E-mails were sent out between September and November 2010 using a database of 3000 addresses maintained by the United Arab Emirates Cancer Congress. Individuals working for Roche or Genentech were excluded. The survey consisted of 22 questions that were divided into 3 parts addressing each participant's demographic profile, their opinion of the FDA's decision, and the typical use of bevacizumab in the community in the setting of MBC. A total of 564 participants were included in the final analysis, contributing to an 18.8% response rate. Of these participants, 14.6% were from the United States, 7.8% were from Canada, 31.1% were from Europe, 2.0% were from the United Arab Emirates, 11.1% were from Asia, and 33.3% were from other countries. The majority of participants believed progression-free survival to be a surrogate for overall survival, that cost played a role in the FDA's decision, and that the decision would adversely affect the future of newer drugs currently being investigated for MBC. The majority of participants indicated that they would use bevacizumab for triple receptor-negative MBC (46.5%), would use it in a first-line setting (44.7%), and would use it in combination with paclitaxel (51.9%). Our survey results highlight the discord between the opinion of community oncologists and the FDA's recent decision to withdraw the indication of bevacizumab for MBC. Copyright © 2011 American Cancer Society.

A conceptual model for generating and validating in-session clinical judgments

PubMed Central

Jacinto, Sofia B.; Lewis, Cara C.; Braga, João N.; Scott, Kelli

2016-01-01

Objective Little attention has been paid to the nuanced and complex decisions made in the clinical session context and how these decisions influence therapy effectiveness. Despite decades of research on the dual-processing systems, it remains unclear when and how intuitive and analytical reasoning influence the direction of the clinical session. Method This paper puts forth a testable conceptual model, guided by an interdisciplinary integration of the literature, that posits that the clinical session context moderates the use of intuitive versus analytical reasoning. Results A synthesis of studies examining professional best practices in clinical decision-making, empirical evidence from clinical judgment research, and the application of decision science theories indicate that intuitive and analytical reasoning may have profoundly different impacts on clinical practice and outcomes. Conclusions The proposed model is discussed with respect to its implications for clinical practice and future research. PMID:27088962

Barriers for integrating personalized medicine into clinical practice: a qualitative analysis.

PubMed

Najafzadeh, Mehdi; Davis, Jennifer C; Joshi, Pamela; Marra, Carlo

2013-04-01

Personalized medicine-tailoring interventions based on individual's genetic information-will likely change routine clinical practice in the future. Yet, how practitioners plan to apply genetic information to inform medical decision making remains unclear. We aimed to investigate physician's perception about the future role of personalized medicine, and to identify the factors that influence their decision in using genetic testing in their practice. We conducted three semi-structured focus groups in three health regions (Fraser, Vancouver coastal, and Interior) in British Columbia, Canada. In the focus groups, participants discussed four topics on personalized medicine: (i) physicians' general understanding, (ii) advantages and disadvantages, (iii) potential impact and role in future clinical practice, and (iv) perceived barriers to integrating personalized medicine into clinical practice. Approximately 36% (n = 9) of physicians self-reported that they were not familiar with the concept of personalized medicine. After introducing the concept, the majority of physicians (68%, n = 19 of 28) were interested in incorporating personalized medicine in their practice, provided they have access to the necessary knowledge and tools. Participants mostly believed that genetic developments will directly affect their practice in the future. The key concerns highlighted were physician's access to clinical guidelines and training opportunities for the use of genetic testing and data interpretation. Despite the challenges that personalized medicine can create, in general, physicians in the focus groups expressed strong interest in using genetic information in their practice if they have access to the necessary knowledge and tools. Copyright © 2013 Wiley Periodicals, Inc.

The process of development of a prioritization tool for a clinical decision support build within a computerized provider order entry system: Experiences from St Luke's Health System.

PubMed

Wolf, Matthew; Miller, Suzanne; DeJong, Doug; House, John A; Dirks, Carl; Beasley, Brent

2016-09-01

To establish a process for the development of a prioritization tool for a clinical decision support build within a computerized provider order entry system and concurrently to prioritize alerts for Saint Luke's Health System. The process of prioritizing clinical decision support alerts included (a) consensus sessions to establish a prioritization process and identify clinical decision support alerts through a modified Delphi process and (b) a clinical decision support survey to validate the results. All members of our health system's physician quality organization, Saint Luke's Care as well as clinicians, administrators, and pharmacy staff throughout Saint Luke's Health System, were invited to participate in this confidential survey. The consensus sessions yielded a prioritization process through alert contextualization and associated Likert-type scales. Utilizing this process, the clinical decision support survey polled the opinions of 850 clinicians with a 64.7 percent response rate. Three of the top rated alerts were approved for the pre-implementation build at Saint Luke's Health System: Acute Myocardial Infarction Core Measure Sets, Deep Vein Thrombosis Prophylaxis within 4 h, and Criteria for Sepsis. This study establishes a process for developing a prioritization tool for a clinical decision support build within a computerized provider order entry system that may be applicable to similar institutions. © The Author(s) 2015.

Impact of delay in clinical presentation on the diagnostic management and prognosis of patients with suspected pulmonary embolism.

PubMed

den Exter, Paul L; van Es, Josien; Erkens, Petra M G; van Roosmalen, Mark J G; van den Hoven, Pim; Hovens, Marcel M C; Kamphuisen, Pieter W; Klok, Frederikus A; Huisman, Menno V

2013-06-15

The nonspecific clinical presentation of pulmonary embolism (PE) frequently leads to delay in its diagnosis. This study aimed to assess the impact of delay in presentation on the diagnostic management and clinical outcome of patients with suspected PE. In 4,044 consecutive patients with suspected PE, patients presenting more than 7 days from the onset of symptoms were contrasted with those presenting within 7 days as regards the safety of excluding PE on the basis of a clinical decision rule combined with D-dimer testing. Patients were followed for 3 months to assess the rates of recurrent venous thromboembolism and mortality. A delayed presentation (presentation >7 d) was present in 754 (18.6%) of the patients. The failure rate of an unlikely clinical probability and normal D-dimer test was 0.5% (95% confidence interval [CI], 0.01-2.7) for patients with and 0.5% (95% CI, 0.2-1.2) for those without diagnostic delay. D-dimer testing yielded a sensitivity of 99% (95% CI, 96-99%) and 98% (95% CI, 97-99%) in these groups, respectively. Patients with PE with diagnostic delay more frequently had centrally located PE (41% vs. 26%; P < 0.001). The cumulative rates of recurrent venous thromboembolism (4.6% vs. 2.7%; P = 0.14) and mortality (7.6% vs. 6.6%; P = 0.31) were not different for patients with and without delayed presentation. PE can be safely excluded based on a clinical decision rule and D-dimer testing in patients with a delayed clinical presentation. A delayed presentation for patients who survived acute PE was associated with a more central PE location, although this did not affect the clinical outcome at 3 months.

Severity in irritable bowel syndrome: a Rome Foundation Working Team report.

PubMed

Drossman, Douglas A; Chang, L; Bellamy, N; Gallo-Torres, H E; Lembo, A; Mearin, F; Norton, N J; Whorwell, P

2011-10-01

The concept of severity in irritable bowel syndrome (IBS) is clinically recognized and operative in diagnostic decision making and treatment planning. Yet, there is no consensus on its definition, and there are limited data on the prevalence of severity subgroups, its medical and psychosocial determinants, and its association with other health status measures. The aims of the Rome Foundation Working Team Committee were to summarize current research, to develop a consensus of understanding on this concept, and to make recommendations for its use in research and clinical care. In 2006, a multinational committee of clinical investigators with expertise in IBS and/or psychometric research methods undertook a systematic review of the literature relating to severity in IBS. Owing to limited data, the Foundation commissioned three clinical studies to better characterize the concept of severity in IBS, and summary information and recommendations for future research and clinical care were developed. The main findings were: (i) severity in IBS is defined as a biopsychosocial composite of patient-reported gastrointestinal and extraintestinal symptoms, degree of disability, and illness-related perceptions and behaviors; (ii) both visceral and central nervous system physiological factors affect severity; as severity increases, the central nervous system provides a greater contribution; (iii) severity is related to and influences health-related quality of life and health behaviors and also guides diagnostic and therapeutic clinical decision making; (iv) severity can be subcategorized into clinically meaningful subgroups as mild (∼40%), moderate (∼35%), and severe (∼25%), and this provides a working model for use in future research and clinical care. Future work is required to understand more precisely the factors contributing to severity and to develop a valid patient-reported instrument to measure severity in IBS.

Sex-Differences, Handedness, and Lateralization in the Iowa Gambling Task

PubMed Central

Singh, Varsha

2016-01-01

In a widely used decision-making task, the Iowa Gambling Task (IGT), male performance is observed to be superior to that of females, and is attributed to right lateralization (i.e., right hemispheric dominance). It is as yet unknown whether sex-differences in affect and motor lateralization have implications for sex-specific lateralization in the IGT, and specifically, whether sex-difference in performance in the IGT changes with right-handedness or with affect lateralization (decision valence, and valence-directed motivation). The present study (N = 320; 160 males) examined the effects of right-handedness (right-handedness vs. non-right-handedness) as a measure of motor lateralization, decision valence (reward vs. punishment IGT), and valence-directedness of task motivation (valence-directed vs. non-directed instructions), as measures of affective lateralization on IGT decision making. Analyses of variance revealed that both male and female participants showed valence-induced inconsistencies in advantageous decision-making; however, right-handed females made more disadvantageous decisions in a reward IGT. These results suggest that IGT decision-making may be largely right-lateralized in right-handed males, and show that sex and lateralized differences (motor and affect) have implications for sex-differences in IGT decision-making. Implications of the results are discussed with reference to lateralization and sex-differences in cognition. PMID:27303316

Animal to human translational paradigms relevant for approach avoidance conflict decision making.

PubMed

Kirlic, Namik; Young, Jared; Aupperle, Robin L

2017-09-01

Avoidance behavior in clinical anxiety disorders is often a decision made in response to approach-avoidance conflict, resulting in a sacrifice of potential rewards to avoid potential negative affective consequences. Animal research has a long history of relying on paradigms related to approach-avoidance conflict to model anxiety-relevant behavior. This approach includes punishment-based conflict, exploratory, and social interaction tasks. There has been a recent surge of interest in the translation of paradigms from animal to human, in efforts to increase generalization of findings and support the development of more effective mental health treatments. This article briefly reviews animal tests related to approach-avoidance conflict and results from lesion and pharmacologic studies utilizing these tests. We then provide a description of translational human paradigms that have been developed to tap into related constructs, summarizing behavioral and neuroimaging findings. Similarities and differences in findings from analogous animal and human paradigms are discussed. Lastly, we highlight opportunities for future research and paradigm development that will support the clinical utility of this translational work. Copyright © 2017 Elsevier Ltd. All rights reserved.

Measuring up: musings of a family doctor on the employee time clock.

PubMed

Kannai, Ruth

2013-01-01

Recently, at the health maintenance organization (HMO) where I work, they introduced an employee time clock. As in many other workplaces, doctors across the country are now obligated to punch the clock at the beginning and end of their workday. This is the final act in an ongoing attempt to enhance management of doctors' schedules: limit nonurgent appointments to 10 minutes, define planned or urgent home visits, and control a physician's time, as well as managerial and clinical decisions. In this story I describe a day in the life of a family doctor, a salaried employee at a large HMO where there is now a time clock. I provide details on how the introduction of the clock influences small everyday clinical decisions that potentially affect the quality and depth of treatment while sharing the internal dialogue that accompanies me as I reaffirm my professional integrity again and again with each hastened visit. I also bring the internal dialogue of 2 of my patients, to illustrate the emotional world on the other side of these 10-minute interventions.

Applicability of randomized trials in radiation oncology to standard clinical practice.

PubMed

Apisarnthanarax, Smith; Swisher-McClure, Samuel; Chiu, Wing K; Kimple, Randall J; Harris, Stephen L; Morris, David E; Tepper, Joel E

2013-08-15

Randomized controlled trials (RCTs) are commonly used to inform clinical practice; however, it is unclear how generalizable RCT data are to patients in routine clinical practice. The authors of this report assessed the availability and applicability of randomized evidence guiding medical decisions in a cohort of patients who were evaluated for consideration of definitive management in a radiation oncology clinic. The medical records of consecutive, new patient consultations between January and March 2007 were reviewed. Patient medical decisions were classified as those with (Group 1) or without (Group 2) available, relevant level I evidence (phase 3 RCT) supporting recommended treatments. Group 1 medical decisions were further divided into 3 groups based on the extent of fulfilling eligibility criteria for each RCT: Group 1A included decisions that fulfilled all eligibility criteria; Group 1B, decisions that did not fulfill at least 1 minor eligibility criteria; or Group 1C, decisions that did not fulfill at least 1 major eligibility criteria. Patient and clinical characteristics were tested for correlations with the availability of evidence. Of the 393 evaluable patients, malignancies of the breast (30%), head and neck (18%), and genitourinary system (14%) were the most common presenting primary disease sites. Forty-seven percent of all medical decisions (n = 451) were made without available (36%) or applicable (11%) randomized evidence to inform clinical decision making. Primary tumor diagnosis was significantly associated with the availability of evidence (P < .0001). A significant proportion of medical decisions in an academic radiation oncology clinic were made without available or applicable level I evidence, underscoring the limitations of relying solely on RCTs for the development of evidence-based health care. Copyright © 2013 American Cancer Society.

Diffusion Modelling Reveals the Decision Making Processes Underlying Negative Judgement Bias in Rats.

PubMed

Hales, Claire A; Robinson, Emma S J; Houghton, Conor J

2016-01-01

Human decision making is modified by emotional state. Rodents exhibit similar biases during interpretation of ambiguous cues that can be altered by affective state manipulations. In this study, the impact of negative affective state on judgement bias in rats was measured using an ambiguous-cue interpretation task. Acute treatment with an anxiogenic drug (FG7142), and chronic restraint stress and social isolation both induced a bias towards more negative interpretation of the ambiguous cue. The diffusion model was fit to behavioural data to allow further analysis of the underlying decision making processes. To uncover the way in which parameters vary together in relation to affective state manipulations, independent component analysis was conducted on rate of information accumulation and distances to decision threshold parameters for control data. Results from this analysis were applied to parameters from negative affective state manipulations. These projected components were compared to control components to reveal the changes in decision making processes that are due to affective state manipulations. Negative affective bias in rodents induced by either FG7142 or chronic stress is due to a combination of more negative interpretation of the ambiguous cue, reduced anticipation of the high reward and increased anticipation of the low reward.

Clinical decision-making described by Swedish prehospital emergency care nurse students - An exploratory study.

PubMed

Nilsson, Tomas; Lindström, Veronica

2016-07-01

The purpose of this study was to explore the PECN students' clinical decision-making during a seven-week clinical rotation in the ambulance services. Developing expertise in prehospital emergency care practices requires both theoretical and empirical learning. A prehospital emergency care nurse (PECN) is a Registered Nurse (RN) with one year of additional training in emergency care. There has been little investigation of how PECN students describe their decision-making during a clinical rotation. A qualitative study design was used, and 12 logbooks written by the Swedish PECN students were analysed using content analysis. The students wrote about 997 patient encounters - ambulance assignments during their clinical rotation. Four themes emerged as crucial for the students' decision-making: knowing the patient, the context-situation awareness in the ambulance service, collaboration, and evaluation. Based on the themes, students made decisions on how to respond to patients' illnesses. The PECN students used several variables in their decision-making. The decision- making was an on-going process during the whole ambulance assignment. The university has the responsibility to guide the students during their transition from an RN to a PECN. The findings of the study can support the educators and clinical supervisors in developing the programme of study for becoming a PECN. Copyright © 2015 Elsevier Ltd. All rights reserved.

[Cancer screening in clinical practice: the value of shared decision-making].

PubMed

Cornuz, Jacques; Junod, Noëlle; Pasche, Olivier; Guessous, Idris

2010-07-14

Shared decision-making approach to uncertain clinical situations such as cancer screening seems more appropriate than ever. Shared decision making can be defined as an interactive process where physician and patient share all the stages of the decision making process. For patients who wish to be implicated in the management of their health conditions, physicians might express difficulty to do so. Use of patient decision aids appears to improve such process of shared decision making.

Transplantation at the nexus of behavioral economics and health care delivery.

PubMed

Schnier, K E; Cox, J C; McIntyre, C; Ruhil, R; Sadiraj, V; Turgeon, N

2013-01-01

The transplant surgeon's decision to accept and utilize an organ typically is made within a constrained time window, explicitly cognizant of numerous health-related risks and under the potential influence of considerable regulatory and institutional pressures. This decision affects the health of two distinct populations, those patients receiving organ transplants and those waiting to receive a transplant; it also influences the physician's life and their institute's productivity. The numerous, at times nonaligned, incentives established by the complex clinical and regulatory environment, have been derived specifically to influence physicians' behaviors, and though well intended, may lead to responses that are nonoptimal when considering the myriad stakeholders being influenced. This may compromise the quality of care provided to the population at risk, and has potential to influence the physician-patient relationship. A synergistic collaboration between transplant physicians and economists that is focused on this decision environment may help to alleviate these strains. This viewpoint discusses behavioral economic principles and how they might be applied to transplantation. Specifically, the previous medical decision-making literature on transplantation will be reviewed and a discussion on how a behavioral model of physician decision making can be utilized will be explored. To date this approach has not been integrated into transplantation decision making. No claim to original US government works Journal compilation © 2012 The American Society of Transplantation and the American Society of Transplant Surgeons.

How shrinks think: decision making in psychiatry.

PubMed

Bhugra, Dinesh; Malliaris, Yanni; Gupta, Susham

2010-10-01

Psychiatrists use biopsychosocial models in identifying aetiological factors in assessing their patients and similar approaches in planning management. Models in decision making will be influenced by previous experience, training, age and gender, among other factors. Critical thinking and evidence base are both important components in the process of reaching clinical decisions. Expected outcome of treatment may be another factor. The way we think influences our decision making, clinical or otherwise. With patients expecting and taking larger roles in their own management, there needs to be a shift towards patient-centred care in decision making. Further exploration in how clinical decisions are made by psychiatrists is necessary. An understanding of the manner in which therapeutic alliances are formed between the clinician and the patient is necessary to understand decision making.

Predictive models in cancer management: A guide for clinicians.

PubMed

Kazem, Mohammed Ali

2017-04-01

Predictive tools in cancer management are used to predict different outcomes including survival probability or risk of recurrence. The uptake of these tools by clinicians involved in cancer management has not been as common as other clinical tools, which may be due to the complexity of some of these tools or a lack of understanding of how they can aid decision-making in particular clinical situations. The aim of this article is to improve clinicians' knowledge and understanding of predictive tools used in cancer management, including how they are built, how they can be applied to medical practice, and what their limitations may be. Literature review was conducted to investigate the role of predictive tools in cancer management. All predictive models share similar characteristics, but depending on the type of the tool its ability to predict an outcome will differ. Each type has its own pros and cons, and its generalisability will depend on the cohort used to build the tool. These factors will affect the clinician's decision whether to apply the model to their cohort or not. Before a model is used in clinical practice, it is important to appreciate how the model is constructed, what its use may add over and above traditional decision-making tools, and what problems or limitations may be associated with it. Understanding all the above is an important step for any clinician who wants to decide whether or not use predictive tools in their practice. Copyright © 2016 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

General physicians: born or made? The use of a tracking database to answer medical workforce questions.

PubMed

Poole, P; McHardy, K; Janssen, A

2009-07-01

The aim of the study was to use a tracking database to investigate the perceived influence of various factors on career choices of New Zealand medical graduates and to examine specifically whether experiences at medical school may have an effect on a decision to become a general physician. Questionnaires were distributed to medical students in the current University of Auckland programme at entry and exit points. The surveys have been completed by two entry cohorts and an exit one since 2006. The response rates were 70 and 88% in the entry and exit groups, respectively. More than 75% of exiting students reported an interest in pursuing a career in general internal medicine. In 42%, this is a 'strong interest' in general medicine compared with 23% in the entry cohort (P < 0.0001). There is correlation between a positive experience in a clinical rotation and the reported level of interest in that specialty with those indicating a good experience likely to specify career intentions in that area. Having a positive experience in a clinical rotation, positive role models and flexibility in training are the most influential factors affecting career decisions in Auckland medical students. Only 11% of study respondents reported that student loan burden has a significant influence on career decisions. Quality experiences on attachments seem essential for undergraduates to promote interest in general medicine. There is potential for curriculum design and clinical experiences to be formulated to promote the 'making' of these doctors. Tracking databases will assist in answering some of these questions.

Points to consider for prioritizing clinical genetic testing services: a European consensus process oriented at accountability for reasonableness

PubMed Central

Severin, Franziska; Borry, Pascal; Cornel, Martina C; Daniels, Norman; Fellmann, Florence; Victoria Hodgson, Shirley; Howard, Heidi C; John, Jürgen; Kääriäinen, Helena; Kayserili, Hülya; Kent, Alastair; Koerber, Florian; Kristoffersson, Ulf; Kroese, Mark; Lewis, Celine; Marckmann, Georg; Meyer, Peter; Pfeufer, Arne; Schmidtke, Jörg; Skirton, Heather; Tranebjærg, Lisbeth; Rogowski, Wolf H

2015-01-01

Given the cost constraints of the European health-care systems, criteria are needed to decide which genetic services to fund from the public budgets, if not all can be covered. To ensure that high-priority services are available equitably within and across the European countries, a shared set of prioritization criteria would be desirable. A decision process following the accountability for reasonableness framework was undertaken, including a multidisciplinary EuroGentest/PPPC-ESHG workshop to develop shared prioritization criteria. Resources are currently too limited to fund all the beneficial genetic testing services available in the next decade. Ethically and economically reflected prioritization criteria are needed. Prioritization should be based on considerations of medical benefit, health need and costs. Medical benefit includes evidence of benefit in terms of clinical benefit, benefit of information for important life decisions, benefit for other people apart from the person tested and the patient-specific likelihood of being affected by the condition tested for. It may be subject to a finite time window. Health need includes the severity of the condition tested for and its progression at the time of testing. Further discussion and better evidence is needed before clearly defined recommendations can be made or a prioritization algorithm proposed. To our knowledge, this is the first time a clinical society has initiated a decision process about health-care prioritization on a European level, following the principles of accountability for reasonableness. We provide points to consider to stimulate this debate across the EU and to serve as a reference for improving patient management. PMID:25248395

Points to consider for prioritizing clinical genetic testing services: a European consensus process oriented at accountability for reasonableness.

PubMed

Severin, Franziska; Borry, Pascal; Cornel, Martina C; Daniels, Norman; Fellmann, Florence; Victoria Hodgson, Shirley; Howard, Heidi C; John, Jürgen; Kääriäinen, Helena; Kayserili, Hülya; Kent, Alastair; Koerber, Florian; Kristoffersson, Ulf; Kroese, Mark; Lewis, Celine; Marckmann, Georg; Meyer, Peter; Pfeufer, Arne; Schmidtke, Jörg; Skirton, Heather; Tranebjærg, Lisbeth; Rogowski, Wolf H

2015-06-01

Given the cost constraints of the European health-care systems, criteria are needed to decide which genetic services to fund from the public budgets, if not all can be covered. To ensure that high-priority services are available equitably within and across the European countries, a shared set of prioritization criteria would be desirable. A decision process following the accountability for reasonableness framework was undertaken, including a multidisciplinary EuroGentest/PPPC-ESHG workshop to develop shared prioritization criteria. Resources are currently too limited to fund all the beneficial genetic testing services available in the next decade. Ethically and economically reflected prioritization criteria are needed. Prioritization should be based on considerations of medical benefit, health need and costs. Medical benefit includes evidence of benefit in terms of clinical benefit, benefit of information for important life decisions, benefit for other people apart from the person tested and the patient-specific likelihood of being affected by the condition tested for. It may be subject to a finite time window. Health need includes the severity of the condition tested for and its progression at the time of testing. Further discussion and better evidence is needed before clearly defined recommendations can be made or a prioritization algorithm proposed. To our knowledge, this is the first time a clinical society has initiated a decision process about health-care prioritization on a European level, following the principles of accountability for reasonableness. We provide points to consider to stimulate this debate across the EU and to serve as a reference for improving patient management.

The effectiveness of simulation activities on the cognitive abilities of undergraduate third-year nursing students: a randomised control trial.

PubMed

Secomb, Jacinta; McKenna, Lisa; Smith, Colleen

2012-12-01

To provide evidence on the effectiveness of simulation activities on the clinical decision-making abilities of undergraduate nursing students. Based on previous research, it was hypothesised that the higher the cognitive score, the greater the ability a nursing student would have to make informed valid decisions in their clinical practice. Globally, simulation is being espoused as an education method that increases the competence of health professionals. At present, there is very little evidence to support current investment in time and resources. Following ethical approval, fifty-eight third-year undergraduate nursing students were randomised in a pretest-post-test group-parallel controlled trial. The learning environment preferences (LEP) inventory was used to test cognitive abilities in order to refute the null hypothesis that activities in computer-based simulated learning environments have a negative effect on cognitive abilities when compared with activities in skills laboratory simulated learning environments. There was no significant difference in cognitive development following two cycles of simulation activities. Therefore, it is reasonable to assume that two simulation tasks, either computer-based or laboratory-based, have no effect on an undergraduate student's ability to make clinical decisions in practice. However, there was a significant finding for non-English first-language students, which requires further investigation. More longitudinal studies that quantify the education effects of simulation on the cognitive, affective and psychomotor attributes of health science students and professionals from both English-speaking and non-English-speaking backgrounds are urgently required. It is also recommended that to achieve increased participant numbers and prevent non-participation owing to absenteeism, further studies need to be imbedded directly into curricula. This investigation confirms the effect of simulation activities on real-life clinical practice, and the comparative learning benefits with traditional clinical practice and university education remain unknown. © 2012 Blackwell Publishing Ltd.

Transforming clinical practice guidelines and clinical pathways into fast-and-frugal decision trees to improve clinical care strategies.

PubMed

Djulbegovic, Benjamin; Hozo, Iztok; Dale, William

2018-02-27

Contemporary delivery of health care is inappropriate in many ways, largely due to suboptimal Q5 decision-making. A typical approach to improve practitioners' decision-making is to develop evidence-based clinical practice guidelines (CPG) by guidelines panels, who are instructed to use their judgments to derive practice recommendations. However, mechanisms for the formulation of guideline judgments remains a "black-box" operation-a process with defined inputs and outputs but without sufficient knowledge of its internal workings. Increased explicitness and transparency in the process can be achieved by implementing CPG as clinical pathways (CPs) (also known as clinical algorithms or flow-charts). However, clinical recommendations thus derived are typically ad hoc and developed by experts in a theory-free environment. As any recommendation can be right (true positive or negative), or wrong (false positive or negative), the lack of theoretical structure precludes the quantitative assessment of the management strategies recommended by CPGs/CPs. To realize the full potential of CPGs/CPs, they need to be placed on more solid theoretical grounds. We believe this potential can be best realized by converting CPGs/CPs within the heuristic theory of decision-making, often implemented as fast-and-frugal (FFT) decision trees. This is possible because FFT heuristic strategy of decision-making can be linked to signal detection theory, evidence accumulation theory, and a threshold model of decision-making, which, in turn, allows quantitative analysis of the accuracy of clinical management strategies. Fast-and-frugal provides a simple and transparent, yet solid and robust, methodological framework connecting decision science to clinical care, a sorely needed missing link between CPGs/CPs and patient outcomes. We therefore advocate that all guidelines panels express their recommendations as CPs, which in turn should be converted into FFTs to guide clinical care. © 2018 John Wiley & Sons, Ltd.

[Clinical decision making and critical thinking in the nursing diagnostic process].

PubMed

Müller-Staub, Maria

2006-10-01

The daily routine requires complex thinking processes of nurses, but clinical decision making and critical thinking are underestimated in nursing. A great demand for educational measures in clinical judgement related with the diagnostic process was found in nurses. The German literature hardly describes nursing diagnoses as clinical judgements about human reactions on health problems / life processes. Critical thinking is described as an intellectual, disciplined process of active conceptualisation, application and synthesis of information. It is gained through observation, experience, reflection and communication and leads thinking and action. Critical thinking influences the aspects of clinical decision making a) diagnostic judgement, b) therapeutic reasoning and c) ethical decision making. Human reactions are complex processes and in their course, human behavior is interpreted in the focus of health. Therefore, more attention should be given to the nursing diagnostic process. This article presents the theoretical framework of the paper "Clinical decision making: Fostering critical thinking in the nursing diagnostic process through case studies".

Creating Shareable Clinical Decision Support Rules for a Pharmacogenomics Clinical Guideline Using Structured Knowledge Representation.

PubMed

Linan, Margaret K; Sottara, Davide; Freimuth, Robert R

2015-01-01

Pharmacogenomics (PGx) guidelines contain drug-gene relationships, therapeutic and clinical recommendations from which clinical decision support (CDS) rules can be extracted, rendered and then delivered through clinical decision support systems (CDSS) to provide clinicians with just-in-time information at the point of care. Several tools exist that can be used to generate CDS rules that are based on computer interpretable guidelines (CIG), but none have been previously applied to the PGx domain. We utilized the Unified Modeling Language (UML), the Health Level 7 virtual medical record (HL7 vMR) model, and standard terminologies to represent the semantics and decision logic derived from a PGx guideline, which were then mapped to the Health eDecisions (HeD) schema. The modeling and extraction processes developed here demonstrate how structured knowledge representations can be used to support the creation of shareable CDS rules from PGx guidelines.

The effect of high-fidelity patient simulation on the critical thinking and clinical decision-making skills of new graduate nurses.

PubMed

Maneval, Rhonda; Fowler, Kimberly A; Kays, John A; Boyd, Tiffany M; Shuey, Jennifer; Harne-Britner, Sarah; Mastrine, Cynthia

2012-03-01

This study was conducted to determine whether the addition of high-fidelity patient simulation to new nurse orientation enhanced critical thinking and clinical decision-making skills. A pretest-posttest design was used to assess critical thinking and clinical decision-making skills in two groups of graduate nurses. Compared with the control group, the high-fidelity patient simulation group did not show significant improvement in mean critical thinking or clinical decision-making scores. When mean scores were analyzed, both groups showed an increase in critical thinking scores from pretest to posttest, with the high-fidelity patient simulation group showing greater gains in overall scores. However, neither group showed a statistically significant increase in mean test scores. The effect of high-fidelity patient simulation on critical thinking and clinical decision-making skills remains unclear. Copyright 2012, SLACK Incorporated.

[Shared decision-making in acute psychiatric medicine : Contraindication or a challenge?

PubMed

Heres, S; Hamann, J

2017-09-01

The concept of shared decision-making (SDM) has existed since the 1990s in multiple fields of somatic medicine but has only been poorly applied in psychiatric clinical routine despite broad acceptance and promising outcomes in clinical studies on its positive effects. The concept itself and its practicability in mental health are carefully assessed and strategies for its future implementation in psychiatric medicine are presented in this article. Ongoing clinical studies probing some of those strategies are further outlined. On top of the ubiquitous shortage of time in clinical routine, psychiatrists report their concern about patients' limited abilities in sharing decisions and their own fear of potentially harmful decisions resulting from a shared process. Misinterpretation of shared decision-making restricting the health care professional to rather an informed choice scenario and their own adhesion to the traditional paternalistic decision-making approach further add to SDM's underutilization. Those hurdles could be overcome by communication skill workshops for all mental health care professionals, including nursing personnels, psychologists, social workers and physicians, as well as the use of decision aids and training courses for patients to motivate and empower them in sharing decisions with the medical staff. By this, the patient-centered treatment approach demanded by guidelines, carers and users could be further facilitated in psychiatric clinical routine.

In-House or in Court? Legal Challenges to University Decisions

ERIC Educational Resources Information Center

Kamvounias, Patty; Varnham, Sally

2006-01-01

Every day, decisions are made in universities that affect students. When a decision adversely affects a particular student, what means of redress does that student have? The circumstances in which a student has a legal claim against their university are generally unclear. Courts have traditionally tended to draw a distinction between "purely…

The Effects of Decision-Making Style and Cognitive Thought Patterns on Negative Career Thoughts

ERIC Educational Resources Information Center

Paivandy, Sheba; Bullock, Emily E.; Reardon, Robert C.; Kelly, F. Donald

2008-01-01

People's thoughts and beliefs about themselves and their career options affect their ability to make decisions. Career counselors would benefit from knowing the factors that contribute to negative career thoughts. This study examined two unexplored factors that may affect the development and maintenance of negative career thoughts, decision-making…

How Does a Shared Decision-Making (SDM) Intervention for Oncologists Affect Participation Style and Preference Matching in Patients with Breast and Colon Cancer?

PubMed

Bieber, Christiane; Nicolai, Jennifer; Gschwendtner, Kathrin; Müller, Nicole; Reuter, Katrin; Buchholz, Angela; Kallinowski, Birgit; Härter, Martin; Eich, Wolfgang

2018-06-01

The aims of this study are to assess patients' preferred and perceived decision-making roles and preference matching in a sample of German breast and colon cancer patients and to investigate how a shared decision-making (SDM) intervention for oncologists influences patients' preferred and perceived decision-making roles and the attainment of preference matches. This study is a post hoc analysis of a randomised controlled trial (RCT) on the effects of an SDM intervention. The SDM intervention was a 12-h SDM training program for physicians in combination with decision board use. For this study, we analysed a subgroup of 107 breast and colon cancer patients faced with serious treatment decisions who provided data on specific questionnaires with regard to their preferred and perceived decision-making roles (passive, SDM or active). Patients filled in questionnaires immediately following a decision-relevant consultation (t1) with their oncologist. Eleven of these patients' 27 treating oncologists had received the SDM intervention within the RCT. A majority of cancer patients (60%) preferred SDM. A match between preferred and perceived decision-making roles was reached for 72% of patients. The patients treated by SDM-trained physicians perceived greater autonomy in their decision making (p < 0.05) with more patients perceiving SDM or an active role, but their preference matching was not influenced. A SDM intervention for oncologists boosted patient autonomy but did not improve preference matching. This highlights the already well-known reluctance of physicians to engage in explicit role clarification. German Clinical Trials Register DRKS00000539; Funding Source: German Cancer Aid.

A theory-based decision aid for patients with cancer: results of feasibility and acceptability testing of DecisionKEYS for cancer.

PubMed

Hollen, Patricia J; Gralla, Richard J; Jones, Randy A; Thomas, Christopher Y; Brenin, David R; Weiss, Geoffrey R; Schroen, Anneke T; Petroni, Gina R

2013-03-01

Appropriate utilization of treatment is a goal for all patients undergoing cancer treatment. Proper treatment maximizes benefit and limits exposure to unnecessary measures. This report describes findings of the feasibility and acceptability of implementing a short, clinic-based decision aid and presents an in-depth clinical profile of the participants. This descriptive study used a prospective, quantitative approach to obtain the feasibility and acceptability of a decision aid (DecisionKEYS for Balancing Choices) for use in clinical settings. It combined results of trials of patients with three different common malignancies. All groups used the same decision aid series. Participants included 80 patients with solid tumors (22 with newly diagnosed breast cancer, 19 with advanced prostate cancer, and 39 with advanced lung cancer) and their 80 supporters as well as their physicians and nurses, for a total of 160 participants and 10 health professionals. The decision aid was highly acceptable to patient and supporter participants in all diagnostic groups. It was feasible for use in clinic settings; the overall value was rated highly. Of six physicians, all found the interactive format with the help of the nurse as feasible and acceptable. Nurses also rated the decision aid favorably. This intervention provides the opportunity to enhance decision making about cancer treatment and warrants further study including larger and more diverse groups. Strengths of the study included a theoretical grounding, feasibility testing of a practical clinic-based intervention, and summative evaluation of acceptability of the intervention by patient and supporter pairs. Further research also is needed to test the effectiveness of the decision aid in diverse clinical settings and to determine if this intervention can decrease overall costs.

Does the Spine Surgeon’s Experience Affect Fracture Classification, Assessment of Stability, and Treatment Plan in Thoracolumbar Injuries?

PubMed Central

Kanna, Rishi Mugesh; Schroeder, Gregory D.; Oner, Frank Cumhur; Vialle, Luiz; Chapman, Jens; Dvorak, Marcel; Fehlings, Michael; Shetty, Ajoy Prasad; Schnake, Klaus; Kandziora, Frank; Vaccaro, Alexander R.

2017-01-01

Study Design: Prospective survey-based study. Objectives: The AO Spine thoracolumbar injury classification has been shown to have good reproducibility among clinicians. However, the influence of spine surgeons’ clinical experience on fracture classification, stability assessment, and decision on management based on this classification has not been studied. Furthermore, the usefulness of varying imaging modalities including radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) in the decision process was also studied. Methods: Forty-one spine surgeons from different regions, acquainted with the AOSpine classification system, were provided with 30 thoracolumbar fractures in a 3-step assessment: first radiographs, followed by CT and MRI. Surgeons classified the fracture, evaluated stability, chose management, and identified reasons for any changes. The surgeons were divided into 2 groups based on years of clinical experience as <10 years (n = 12) and >10 years (n = 29). Results: There were no significant differences between the 2 groups in correctly classifying A1, B2, and C type fractures. Surgeons with less experience had more correct diagnosis in classifying A3 (47.2% vs 38.5% in step 1, 73.6% vs 60.3% in step 2 and 77.8% vs 65.5% in step 3), A4 (16.7% vs 24.1% in step 1, 72.9% vs 57.8% in step 2 and 70.8% vs 56.0% in step3) and B1 injuries (31.9% vs 20.7% in step 1, 41.7% vs 36.8% in step 2 and 38.9% vs 33.9% in step 3). In the assessment of fracture stability and decision on treatment, the less and more experienced surgeons performed equally. The selection of a particular treatment plan varied in all subtypes except in A1 and C type injuries. Conclusion: Surgeons’ experience did not significantly affect overall fracture classification, evaluating stability and planning the treatment. Surgeons with less experience had a higher percentage of correct classification in A3 and A4 injuries. Despite variations between them in classification, the assessment of overall stability and management decisions were similar between the 2 groups. PMID:28815158

Does the Spine Surgeon's Experience Affect Fracture Classification, Assessment of Stability, and Treatment Plan in Thoracolumbar Injuries?

PubMed

Rajasekaran, Shanmuganathan; Kanna, Rishi Mugesh; Schroeder, Gregory D; Oner, Frank Cumhur; Vialle, Luiz; Chapman, Jens; Dvorak, Marcel; Fehlings, Michael; Shetty, Ajoy Prasad; Schnake, Klaus; Kandziora, Frank; Vaccaro, Alexander R

2017-06-01

Prospective survey-based study. The AO Spine thoracolumbar injury classification has been shown to have good reproducibility among clinicians. However, the influence of spine surgeons' clinical experience on fracture classification, stability assessment, and decision on management based on this classification has not been studied. Furthermore, the usefulness of varying imaging modalities including radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) in the decision process was also studied. Forty-one spine surgeons from different regions, acquainted with the AOSpine classification system, were provided with 30 thoracolumbar fractures in a 3-step assessment: first radiographs, followed by CT and MRI. Surgeons classified the fracture, evaluated stability, chose management, and identified reasons for any changes. The surgeons were divided into 2 groups based on years of clinical experience as <10 years (n = 12) and >10 years (n = 29). There were no significant differences between the 2 groups in correctly classifying A1, B2, and C type fractures. Surgeons with less experience had more correct diagnosis in classifying A3 (47.2% vs 38.5% in step 1, 73.6% vs 60.3% in step 2 and 77.8% vs 65.5% in step 3), A4 (16.7% vs 24.1% in step 1, 72.9% vs 57.8% in step 2 and 70.8% vs 56.0% in step3) and B1 injuries (31.9% vs 20.7% in step 1, 41.7% vs 36.8% in step 2 and 38.9% vs 33.9% in step 3). In the assessment of fracture stability and decision on treatment, the less and more experienced surgeons performed equally. The selection of a particular treatment plan varied in all subtypes except in A1 and C type injuries. Surgeons' experience did not significantly affect overall fracture classification, evaluating stability and planning the treatment. Surgeons with less experience had a higher percentage of correct classification in A3 and A4 injuries. Despite variations between them in classification, the assessment of overall stability and management decisions were similar between the 2 groups.

[Peripheral nervous system and speech disorders].

PubMed

Ferri, Lluís

2014-02-24

Disorders affecting the lower motor neurons in childhood, with a congenital or acquired aetiology, give rise to difficulties in neuromotor response and, therefore, motor disorders affecting speech in a period that is especially critical for the development of language. The low incidence of this pathology, its comorbidity with other brain conditions and its uncertain prognosis make it a particularly interesting area of study. The purpose of this work is to review the motor disorders affecting speech in flaccid dysarthria, together with its functional evaluation and speech therapy interventions. The study aims to carry out the clinical characterisation of the disorders affecting verbal production of a peripheral origin, and more specifically flaccid dysarthria and its respiratory, phonatory, resonance, articulatory and prosodic manifestations. The analysis then goes on to outline the functional evaluation and lines of intervention for its treatment are proposed. The clinical manifestations of flaccid dysarthria are very heterogeneous and range from very slight difficulties in articulation to severe disorders that seriously limit the capacity for verbal expression. In most cases, a functional examination yields valuable findings for its identification and classification, for determining the need for complementary evaluations and for establishing the most suitable programme of speech therapy. The guided participation of the family and the interdisciplinary approach are factors that play a decisive role in improving these processes.

Skill sharing and delegation practice in two Queensland regional allied health cancer care services: a comparison of tasks.

PubMed

Passfield, Juanine; Nielsen, Ilsa; Brebner, Neil; Johnstone, Cara

2017-07-24

Objective Delegation and skill sharing are emerging service strategies for allied health (AH) professionals working in Queensland regional cancer care services. The aim of the present study was to describe the consistency between two services for the types and frequency of tasks provided and the agreement between teams in the decision to delegate or skill share clinical tasks, thereby determining the potential applicability to other services. Methods Datasets provided by two similar services were collated. Descriptive statistical analyses were used to assess the extent of agreement. Results In all, 214 tasks were identified as being undertaken by the services (92% agreement). Across the services, 70 tasks were identified as high frequency (equal to or more frequently than weekly) and 29 as not high frequency (46% agreement). Of the 68 tasks that were risk assessed, agreement was 66% for delegation and 60% for skill sharing, with high-frequency and intervention tasks more likely to be delegated. Conclusions Strong consistency was apparent for the clinical tasks undertaken by the two cancer care AH teams, with moderate agreement for the frequency of tasks performed. The proportion of tasks considered appropriate for skill sharing and/or delegation was similar, although variation at the task level was apparent. Further research is warranted to examine the range of factors that affect the decision to skill share or delegate. What is known about the topic? There is limited research evidence regarding the use of skill sharing and delegation service models for AH in cancer care services. In particular, the extent to which decisions about task safety and appropriateness for delegation or skill sharing can be generalised across services has not been investigated. What does this paper add? This study investigated the level of clinical task consistency between two similar AH cancer care teams in regional centres. It also examined the level of agreement with regard to delegation and skill sharing to provide an indication of the level of local service influence on workforce and service model decisions. What are the implications for practitioners? Local factors have a modest influence on delegation and skill sharing decisions of AH teams. Practitioners need to be actively engaged in decision making at the local level to ensure the clinical service model meets local needs. However, teams should also capitalise on commonalities between settings to limit duplication of training and resource development through collaborative networks.

Treatment factors affecting longitudinal quality of life in new onset pediatric epilepsy.

PubMed

Modi, Avani C; Ingerski, Lisa M; Rausch, Joseph R; Glauser, Tracy A

2011-05-01

Recognizing the importance of patient-reported outcomes, this longitudinal, prospective study examined: Changes in health-related quality of life (HRQOL) over seven months following antiepileptic drug (AED) initiation and the relationship of seizures, AED side-effects, and AED type to HRQOL. Parents of 124 children with newly diagnosed epilepsy completed measures of HRQOL and side-effects at each clinic visit. Treatment information was also collected. HRQOL remained stable over time; however, seizures and AED side-effects significantly affected multiple HRQOL domains. Higher seizure activity was associated with decreased Physical HRQOL. Side-effects were negatively associated with all HRQOL domains. Children taking carbamazepine who experienced higher side-effects early in therapy demonstrated declining emotional functioning compared to children experiencing no/some side-effects. AED side-effects, AED type, and seizure frequency were associated with longitudinal HRQOL in children with newly-diagnosed epilepsy. Routine assessment of AED side-effects and HRQOL may be useful for clinical decision making.

Strategies to facilitate shared decision-making about pediatric oncology clinical trial enrollment: A systematic review.

PubMed

Robertson, Eden G; Wakefield, Claire E; Signorelli, Christina; Cohn, Richard J; Patenaude, Andrea; Foster, Claire; Pettit, Tristan; Fardell, Joanna E

2018-07-01

We conducted a systematic review to identify the strategies that have been recommended in the literature to facilitate shared decision-making regarding enrolment in pediatric oncology clinical trials. We searched seven databases for peer-reviewed literature, published 1990-2017. Of 924 articles identified, 17 studies were eligible for the review. We assessed study quality using the 'Mixed-Methods Appraisal Tool'. We coded the results and discussions of papers line-by-line using nVivo software. We categorized strategies thematically. Five main themes emerged: 1) decision-making as a process, 2) individuality of the process; 3) information provision, 4) the role of communication, or 5) decision and psychosocial support. Families should have adequate time to make a decision. HCPs should elicit parents' and patients' preferences for level of information and decision involvement. Information should be clear and provided in multiple modalities. Articles also recommended providing training for healthcare professionals and access to psychosocial support for families. High quality, individually-tailored information, open communication and psychosocial support appear vital in supporting decision-making regarding enrollment in clinical trials. These data will usefully inform future decision-making interventions/tools to support families making clinical trial decisions. A solid evidence-base for effective strategies which facilitate shared decision-making is needed. Copyright © 2018 Elsevier B.V. All rights reserved.

How do small groups make decisions? : A theoretical framework to inform the implementation and study of clinical competency committees.

PubMed

Chahine, Saad; Cristancho, Sayra; Padgett, Jessica; Lingard, Lorelei

2017-06-01

In the competency-based medical education (CBME) approach, clinical competency committees are responsible for making decisions about trainees' competence. However, we currently lack a theoretical model for group decision-making to inform this emerging assessment phenomenon. This paper proposes an organizing framework to study and guide the decision-making processes of clinical competency committees.This is an explanatory, non-exhaustive review, tailored to identify relevant theoretical and evidence-based papers related to small group decision-making. The search was conducted using Google Scholar, Web of Science, MEDLINE, ERIC, and PsycINFO for relevant literature. Using a thematic analysis, two researchers (SC & JP) met four times between April-June 2016 to consolidate the literature included in this review.Three theoretical orientations towards group decision-making emerged from the review: schema, constructivist, and social influence. Schema orientations focus on how groups use algorithms for decision-making. Constructivist orientations focus on how groups construct their shared understanding. Social influence orientations focus on how individual members influence the group's perspective on a decision. Moderators of decision-making relevant to all orientations include: guidelines, stressors, authority, and leadership.Clinical competency committees are the mechanisms by which groups of clinicians will be in charge of interpreting multiple assessment data points and coming to a shared decision about trainee competence. The way in which these committees make decisions can have huge implications for trainee progression and, ultimately, patient care. Therefore, there is a pressing need to build the science of how such group decision-making works in practice. This synthesis suggests a preliminary organizing framework that can be used in the implementation and study of clinical competency committees.

At Least I Tried: The Relationship between Regulatory Focus and Regret Following Action vs. Inaction

PubMed Central

Itzkin, Adi; Van Dijk, Dina; Azar, Ofer H.

2016-01-01

Regret is an unpleasant feeling that may arise following decisions that ended poorly, and may affect the decision-maker's well-being and future decision making. Some studies show that a decision to act leads to greater regret than a decision not to act when both resulted in failure, because the latter is usually the norm. In some cases, when the norm is to act, this pattern is reversed. We suggest that the decision maker's regulatory focus, affects regret after action or inaction. Specifically, promotion-focused individuals, who tend to be more proactive, view action as more normal than prevention-focused individuals, and therefore experience regulatory fit when an action decision is made. Hence, we hypothesized that promotion-focused individuals will feel less regret than prevention-focused individuals when a decision to act ended poorly. In addition, we hypothesized that a trigger for change implied in the situation, decreases the level of regret following action. We tested our hypotheses on a sample of 330 participants enrolled in an online survey. The participants received six decision scenarios, in which they were asked to evaluate the level of regret following action and inaction. Individual regulatory focus was measured by two different scales. Promotion-focused individuals attributed less regret than prevention-focused individuals to action decisions. Regret following inaction was not affected by regulatory focus. In addition, a trigger for change decreases regret following action. Orthodox people tend to attribute more regret than non-orthodox to a person who made an action decision. The results contribute to the literature by showing that not only the situation but also the decision maker's orientation affects the regret after action vs. inaction. PMID:27833581

Impact of data transparency: Scientific publications

PubMed Central

Joshi, Mohit; Bhardwaj, Payal

2018-01-01

Data transparency has been an important aspect of medical research as it helps in enabling evidence-based decisions in medicine which leads to foster trust among the patients and research community alike. Currently, it is one of the key talking points owing to a number of initiatives taken by the pharmaceutical organizations, regulatory bodies, and the other decision enablers of the industry. Thanks to this, there are a number of ways by which a single piece of datum is available through multiple access points, namely, clinical trial disclosures (CTDs), clinical study reports (CSRs), plain language summaries, and scientific publications including abstracts, posters, and manuscripts, to name a few. This may pose a burden of documentation on the pharmaceutical organizations, demanding downsizing of medical writing documents. Since CTDs, CSRs, and other regulatory document are more or less template driven; there may not be much scope to interfere with their structure and submission timings. Scientific publications, on the other hand, provide the flexibility of presenting the clinical data that is typically not dependent on a particular format and timelines. The present paper discusses how the upcoming data transparency initiatives could affect the publication practices across the pharmaceutical industry and what could pharmaceutical companies do to get the maximum benefit out of the data transparency initiatives. PMID:29430415

Impact of data transparency: Scientific publications.

PubMed

Joshi, Mohit; Bhardwaj, Payal

2018-01-01

Data transparency has been an important aspect of medical research as it helps in enabling evidence-based decisions in medicine which leads to foster trust among the patients and research community alike. Currently, it is one of the key talking points owing to a number of initiatives taken by the pharmaceutical organizations, regulatory bodies, and the other decision enablers of the industry. Thanks to this, there are a number of ways by which a single piece of datum is available through multiple access points, namely, clinical trial disclosures (CTDs), clinical study reports (CSRs), plain language summaries, and scientific publications including abstracts, posters, and manuscripts, to name a few. This may pose a burden of documentation on the pharmaceutical organizations, demanding downsizing of medical writing documents. Since CTDs, CSRs, and other regulatory document are more or less template driven; there may not be much scope to interfere with their structure and submission timings. Scientific publications, on the other hand, provide the flexibility of presenting the clinical data that is typically not dependent on a particular format and timelines. The present paper discusses how the upcoming data transparency initiatives could affect the publication practices across the pharmaceutical industry and what could pharmaceutical companies do to get the maximum benefit out of the data transparency initiatives.

Assessing Option Grid® practicability and feasibility for facilitating shared decision making: An exploratory study.

PubMed

Tsulukidze, Maka; Grande, Stuart W; Gionfriddo, Michael R

2015-07-01

To assess the feasibility of Option Grids(®)for facilitating shared decision making (SDM) in simulated clinical consultations and explore clinicians' views on their practicability. We used mixed methods approach to analyze clinical consultations using the Observer OPTION instrument and thematic analysis for follow-up interviews with clinicians. Clinicians achieved high scores on information sharing and low scores on preference elicitation and integration. Four themes were identified: (1) Barriers affect practicability of Option Grids(®); (2) Option Grids(®) facilitate the SDM process; (3) Clinicians are aware of the gaps in their practice of SDM; (4) Training and ongoing feedback on the optimal use of Option Grids(®) are necessary. Use of Option Grids(®) by clinicians with background knowledge in SDM did not facilitate optimal levels of competency on the SDM core concepts of preference elicitation and integration. Future research must evaluate the impact of training on the use of Option Grids(®), and explore how best to help clinicians bridge the gap between knowledge and action. Clinicians proficiently imparting information in simulations struggled to elicit and integrate patient preferences - understanding this gap and developing strategies to close it are the next steps for implementing SDM into clinical practice. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

A qualitative exploration of the informed consent process in hematopoietic cell transplantation clinical research and opportunities for improvement.

PubMed

Raj, M; Choi, S W; Platt, J

2017-02-01

Informed consent (IC) struggles to meet the ethical principles it strives to embody in the context of hematopoietic cell transplantation (HCT). Patients often participate in multiple clinical trials making it difficult to effectively inform the participants and fulfill complex regulations. The recent Notice of Proposed Rule Making would make major changes to federal requirements, providing a timely opportunity to evaluate existing practice. Twenty health care professionals within a Midwest Academic Medical Center involved in obtaining IC in the HCT clinic or involved in patient care during or after the IC process were interviewed to understand: (1) how they approached the IC process; (2) how they described a 'successful' IC process; and (3) opportunities for innovation. Narrative and discourse analyses of interviews indicate that providers understand IC to be a collaborative process requiring engagement and participation of providers, patients and caregivers. 'Markers of success' were identified including cognitive, affective and procedural markers focusing on patient understanding and comfort with the decision to participate. Opportunities for innovating the process included use of decision aids and tablet-based technology, and better use of patient portals. Our findings suggest specific interventions for the IC process that could support the process of consent for providers, patients and caregivers.

Influence of schizophrenia diagnosis on providers' practice decisions.

PubMed

Sullivan, Greer; Mittal, Dinesh; Reaves, Christina M; Haynes, Tiffany F; Han, Xiaotong; Mukherjee, Snigdha; Morris, Scott; Marsh, Laura; Corrigan, Patrick W

2015-08-01

Persons with schizophrenia often receive suboptimal physical health care, but the reasons are poorly understood. Vignettes have been used to examine how a patient's race, gender, or physical health influences a provider's practice; in this study, we used vignettes to examine the effect of a mental health diagnosis (schizophrenia) on providers' clinical expectations and decision making regarding physical health care. A cross-sectional survey was administered from August 2011 to April 2012 to 275 primary care and mental health providers in 5 US Department of Veterans Affairs medical centers. Vignettes described identical scenarios for patients with and without schizophrenia. The survey assessed providers' clinical expectations of patients (adherence, competence, ability to read and understand health education materials) and practice behaviors (referrals to weight reduction, pain management, and sleep study). Clinicians expected persons with schizophrenia would be less adherent to treatment (P = .04), less able to read and understand educational materials (P = .03), and less capable of managing their health and personal affairs (P < .01). Providers were less likely to refer a patient with schizophrenia to a weight-reduction program (P = .03). Other types of referral decisions (for pain management and sleep study) were not influenced by a schizophrenia diagnosis. For both mental health and primary care providers, a history of schizophrenia was found to negatively affect provider expectations of patients' adherence to treatment, ability to understand educational materials, and capacity to manage their treatment and financial affairs as well as some treatment decisions, such as referral to a weight-reduction program. © Copyright 2015 Physicians Postgraduate Press, Inc.

How does trust affect patient preferences for participation in decision-making?

PubMed

Kraetschmer, Nancy; Sharpe, Natasha; Urowitz, Sara; Deber, Raisa B

2004-12-01

Does trust in physicians aid or hinder patient autonomy? We examine the relationship between trust in the recipient's doctor, and desire for a participative role in decisions about medical treatment. We conducted a cross-sectional survey in an urban Canadian teaching hospital. A total of 606 respondents in three clinics (breast cancer, prostate cancer, fracture) completed questionnaires. The instrument included the Problem Solving Decision Making (PSDM) Scale, which used two vignettes (current health condition, chest pain) to categorize respondents by preferred role, and the Trust-in-Physician Scale. Few respondents preferred an autonomous role (2.9% for the current health condition vignette and 1.2% for the chest pain vignette); most preferred shared decision-making (DM) (67.3% current health condition; 48.7% chest pain) or a passive role (29.6% current health condition; 50.1% chest pain). Trust-in-physician yielded 6.3% with blind trust, 36.1% with high trust, 48.6% moderate trust and 9.0% low trust. As hypothesized, autonomous patients had relatively low levels of trust, passive respondents were more likely to have blind trust, while shared respondents had high but not excessive trust. Trust had a significant influence on preferred role even after controlling for the demographic factors such as sex, age and education. Very few respondents wish an autonomous role; those who do tend to have lower trust in their providers. Familiarity with a clinical condition increases desire for a shared (as opposed to passive) role. Shared DM often accompanies, and may require, a trusting patient-physician relationship.

Method of predicting a change in an economy

DOEpatents

Pryor, Richard J [Albuquerque, NM; Basu, Nipa [Albany, NY

2006-01-10

An economy whose activity is to be predicted comprises a plurality of decision makers. Decision makers include, for example, households, government, industry, and banks. The decision makers are represented by agents, where an agent can represent one or more decision makers. Each agent has decision rules that determine the agent's actions. Each agent can affect the economy by affecting variable conditions characteristic of the economy or the internal state of other agents. Agents can communicate actions through messages. On a multiprocessor computer, the agents can be assigned to processing elements.

Using a Clinical Knowledge Base to Assess Comorbidity Interrelatedness Among Patients with Multiple Chronic Conditions.

PubMed

Zulman, Donna M; Martins, Susana B; Liu, Yan; Tu, Samson W; Hoffman, Brian B; Asch, Steven M; Goldstein, Mary K

2015-01-01

Decision support tools increasingly integrate clinical knowledge such as medication indications and contraindications with electronic health record (EHR) data to support clinical care and patient safety. The availability of this encoded information and patient data provides an opportunity to develop measures of clinical decision complexity that may be of value for quality improvement and research efforts. We investigated the feasibility of using encoded clinical knowledge and EHR data to develop a measure of comorbidity interrelatedness (the degree to which patients' co-occurring conditions interact to generate clinical complexity). Using a common clinical scenario-decisions about blood pressure medications in patients with hypertension-we quantified comorbidity interrelatedness by calculating the number of indications and contraindications to blood pressure medications that are generated by patients' comorbidities (e.g., diabetes, gout, depression). We examined properties of comorbidity interrelatedness using data from a decision support system for hypertension in the Veterans Affairs Health Care System.

An integrated review of the correlation between critical thinking ability and clinical decision-making in nursing.

PubMed

Lee, Daphne Sk; Abdullah, Khatijah Lim; Subramanian, Pathmawathi; Bachmann, Robert Thomas; Ong, Swee Leong

2017-12-01

To explore whether there is a correlation between critical thinking ability and clinical decision-making among nurses. Critical thinking is currently considered as an essential component of nurses' professional judgement and clinical decision-making. If confirmed, nursing curricula may be revised emphasising on critical thinking with the expectation to improve clinical decision-making and thus better health care. Integrated literature review. The integrative review was carried out after a comprehensive literature search using electronic databases Ovid, EBESCO MEDLINE, EBESCO CINAHL, PROQuest and Internet search engine Google Scholar. Two hundred and 22 articles from January 1980 to end of 2015 were retrieved. All studies evaluating the relationship between critical thinking and clinical decision-making, published in English language with nurses or nursing students as the study population, were included. No qualitative studies were found investigating the relationship between critical thinking and clinical decision-making, while 10 quantitative studies met the inclusion criteria and were further evaluated using the Quality Assessment and Validity Tool. As a result, one study was excluded due to a low-quality score, with the remaining nine accepted for this review. Four of nine studies established a positive relationship between critical thinking and clinical decision-making. Another five studies did not demonstrate a significant correlation. The lack of refinement in studies' design and instrumentation were arguably the main reasons for the inconsistent results. Research studies yielded contradictory results as regard to the relationship between critical thinking and clinical decision-making; therefore, the evidence is not convincing. Future quantitative studies should have representative sample size, use critical thinking measurement tools related to the healthcare sector and evaluate the predisposition of test takers towards their willingness and ability to think. There is also a need for qualitative studies to provide a fresh approach in exploring the relationship between these variables uncovering currently unknown contributing factors. This review confirmed that evidence to support the existence of relationships between critical thinking and clinical decision-making is still unsubstantiated. Therefore, it serves as a call for nurse leaders and nursing academics to produce quality studies in order to firmly support or reject the hypothesis that there is a statistically significant correlation between critical thinking and clinical decision-making. © 2017 John Wiley & Sons Ltd.

Gallbladder polyps: factors affecting surgical decision.

PubMed

Sarkut, Pinar; Kilicturgay, Sadik; Ozer, Ali; Ozturk, Ersin; Yilmazlar, Tuncay

2013-07-28

To determine the factors affecting the decision to perform surgery, and the efficiency of ultrasonography (USG) in detecting gallbladder polyps (GP). Data for 138 patients who underwent cholecystectomy between 1996 and 2012 in our clinic with a diagnosis of GP were retrospectively analyzed. Demographic data, clinical presentation, principal symptoms, ultrasonographic and histopathological findings were evaluated. Patients were evaluated in individual groups according to the age of the patients (older or younger than 50 years old) and polyp size (bigger or smaller than 10 mm) and characteristics of the polyps (pseudopolyp or real polyps). χ(2) tests were used for the statistical evaluation of the data. The median age was 50 (26-85) years and 91 of patients were female. Of 138 patients who underwent cholecystectomy with GP diagnosis, only 99 had a histopathologically defined polyp; 77 of them had pseudopolyps and 22 had true polyps. Twenty-one patients had adenocarcinoma. Of these 21 patients, 11 were male, their median age was 61 (40-85) years and all malignant polyps had diameters > 10 mm (P < 0.0001). Of 138 patients in whom surgery were performed, 112 had ultrasonographic polyps with diameters < 10 mm. Of the other 26 patients who also had polyps with diameters > 10 mm, 22 had true polyps. The sensitivity of USG was 84.6% for polyps with diameters > 10 mm (P < 0.0001); however it was only 66% in polyps with diameters < 10 mm. The risk of malignancy was high in the patients over 50 years old who had single polyps with diameters > 10 mm.

Personalizing Drug Selection Using Advanced Clinical Decision Support

PubMed Central

Pestian, John; Spencer, Malik; Matykiewicz, Pawel; Zhang, Kejian; Vinks, Alexander A.; Glauser, Tracy

2009-01-01

This article describes the process of developing an advanced pharmacogenetics clinical decision support at one of the United States’ leading pediatric academic medical centers. This system, called CHRISTINE, combines clinical and genetic data to identify the optimal drug therapy when treating patients with epilepsy or Attention Deficit Hyperactivity Disorder. In the discussion a description of clinical decision support systems is provided, along with an overview of neurocognitive computing and how it is applied in this setting. PMID:19898682

Stress and anxiety effects on positive skin test responses in young adults with allergic rhinitis.

PubMed

Heffner, Kathi L; Kiecolt-Glaser, Janice K; Glaser, Ronald; Malarkey, William B; Marshall, Gailen D

2014-07-01

Anxiety and psychological stress affect allergy-related immune function. How these relations influence the evaluations of patients with allergic rhinitis is unknown. To examine whether anxiety and stress exposure affect skin prick test (SPT) responses to common allergens for which patients with atopy showed no prior positive SPT response. Patients with allergic rhinitis, evidenced by clinical history and SPT results, were admitted twice to a hospital research unit for 4 hours. In a crossover design, SPT wheals were assessed before and after the Trier Social Stress Test and then the following morning; for comparison, SPT wheals were assessed before and after a laboratory session without a stressor. Analyses focused on wheal responses for common allergens that tested negative (wheal size <3 mm larger than saline) from SPTs performed at multiple baseline assessments. After the Trier Social Stress Test, more anxious patients with atopy had a higher incidence of positive SPT reactions to antigens that previously tested negative. Anxiety was unrelated to positive SPT incidence under nonstressful conditions. Based on clinical symptom reports, newly positive SPT reactions after the stressor were apparently corrections of previously false-negative SPT reactions. The SPT wheal responses for allergens previously testing negative were enhanced after a stressor. Histamine (positive control) or saline (negative control) SPT responses were not affected. A laboratory stressor affected allergen SPT responses in more anxious patients with allergic rhinitis. In addition to clinical history, assessment of anxiety and current stress at the time of the SPT may provide valuable information about a patient's allergic status and aid in clinical decision making. Copyright © 2014 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Assessing clinical reasoning (ASCLIRE): Instrument development and validation.

PubMed

Kunina-Habenicht, Olga; Hautz, Wolf E; Knigge, Michel; Spies, Claudia; Ahlers, Olaf

2015-12-01

Clinical reasoning is an essential competency in medical education. This study aimed at developing and validating a test to assess diagnostic accuracy, collected information, and diagnostic decision time in clinical reasoning. A norm-referenced computer-based test for the assessment of clinical reasoning (ASCLIRE) was developed, integrating the entire clinical decision process. In a cross-sectional study participants were asked to choose as many diagnostic measures as they deemed necessary to diagnose the underlying disease of six different cases with acute or sub-acute dyspnea and provide a diagnosis. 283 students and 20 content experts participated. In addition to diagnostic accuracy, respective decision time and number of used relevant diagnostic measures were documented as distinct performance indicators. The empirical structure of the test was investigated using a structural equation modeling approach. Experts showed higher accuracy rates and lower decision times than students. In a cross-sectional comparison, the diagnostic accuracy of students improved with the year of study. Wrong diagnoses provided by our sample were comparable to wrong diagnoses in practice. We found an excellent fit for a model with three latent factors-diagnostic accuracy, decision time, and choice of relevant diagnostic information-with diagnostic accuracy showing no significant correlation with decision time. ASCLIRE considers decision time as an important performance indicator beneath diagnostic accuracy and provides evidence that clinical reasoning is a complex ability comprising diagnostic accuracy, decision time, and choice of relevant diagnostic information as three partly correlated but still distinct aspects.

Chimpanzees and Bonobos Exhibit Emotional Responses to Decision Outcomes

PubMed Central

Rosati, Alexandra G.; Hare, Brian

2013-01-01

The interface between cognition, emotion, and motivation is thought to be of central importance in understanding complex cognitive functions such as decision-making and executive control in humans. Although nonhuman apes have complex repertoires of emotional expression, little is known about the role of affective processes in ape decision-making. To illuminate the evolutionary origins of human-like patterns of choice, we investigated decision-making in humans' closest phylogenetic relatives, chimpanzees (Pan troglodytes) and bonobos (Pan paniscus). In two studies, we examined these species' temporal and risk preferences, and assessed whether apes show emotional and motivational responses in decision-making contexts. We find that (1) chimpanzees are more patient and more risk-prone than are bonobos, (2) both species exhibit affective and motivational responses following the outcomes of their decisions, and (3) some emotional and motivational responses map onto species-level and individual-differences in decision-making. These results indicate that apes do exhibit emotional responses to decision-making, like humans. We explore the hypothesis that affective and motivational biases may underlie the psychological mechanisms supporting value-based preferences in these species. PMID:23734175

[Advance care planning and severe chronic diseases].

PubMed

Diestre Ortín, Germán; González Sequero, Vanessa; Collell Domènech, Núria; Pérez López, Francisca; Hernando Robles, Pablo

2013-01-01

Advanced care planning (ACP) helps in make decisions on the health problems of people who have lost the capacity for informed consent. It has proven particularly useful in addressing the end of life. The aim of this study was to determine the prevalence of ACP in patients with severe chronic diseases. Review of medical records of patients with dementia, amyotrophic lateral sclerosis, Parkinson's disease, chronic obstructive pulmonary disease or interstitial lung disease, heart failure, chronic kidney disease on dialysis and cancer, all in advanced stages. We collected data on living wills or registered prior decisions by the physician according to clinical planned. A total of 135 patients were studied. There was a record of ACP in 22 patients (16.3%). In most of them it was planned not to start any vital treatment in the event of high risk of imminent death and lacking the ability to make decisions. Only two patients were had a legal living will. The registration of ACP is relatively low, and this can affect decision-making in accordance with the personal values of patients when they do not have the capacity to exercise informed consent. Copyright © 2012 SEGG. Published by Elsevier Espana. All rights reserved.

Decision-Making in Critical Limb Ischemia: A Markov Simulation.

PubMed

Deutsch, Aaron J; Jain, C Charles; Blumenthal, Kimberly G; Dickinson, Mark W; Neilan, Anne M

2017-11-01

Critical limb ischemia (CLI) is a feared complication of peripheral vascular disease that often requires surgical management and may require amputation of the affected limb. We developed a decision model to inform clinical management for a 63-year-old woman with CLI and multiple medical comorbidities, including advanced heart failure and diabetes. We developed a Markov decision model to evaluate 4 strategies: amputation, surgical bypass, endovascular therapy (e.g. stent or revascularization), and medical management. We measured the impact of parameter uncertainty using 1-way, 2-way, and multiway sensitivity analyses. In the base case, endovascular therapy yielded similar discounted quality-adjusted life months (26.50 QALMs) compared with surgical bypass (26.34 QALMs). Both endovascular and surgical therapies were superior to amputation (18.83 QALMs) and medical management (11.08 QALMs). This finding was robust to a wide range of periprocedural mortality weights and was most sensitive to long-term mortality associated with endovascular and surgical therapies. Utility weights were not stratified by patient comorbidities; nonetheless, our conclusion was robust to a range of utility weight values. For a patient with CLI, endovascular therapy and surgical bypass provided comparable clinical outcomes. However, this finding was sensitive to long-term mortality rates associated with each procedure. Both endovascular and surgical therapies were superior to amputation or medical management in a range of scenarios. Copyright © 2017 Elsevier Inc. All rights reserved.

A synthesis of drug reimbursement decision-making processes in organisation for economic co-operation and development countries.

PubMed

Barnieh, Lianne; Manns, Braden; Harris, Anthony; Blom, Marja; Donaldson, Cam; Klarenbach, Scott; Husereau, Don; Lorenzetti, Diane; Clement, Fiona

2014-01-01

The use of a restrictive formulary, with placement determined through a drug-reimbursement decision-making process, is one approach to managing drug expenditures. To describe the processes in drug reimbursement decision-making systems currently used in national publicly funded outpatient prescription drug insurance plans. By using the Organisation for Economic Co-operation and Development (OECD) nations as the sampling frame, a search was done in the published literature, followed by the gray literature. Collected data were verified by a system expert within the prescription drug insurance plan in each country to ensure the accuracy of key data elements across countries. All but one country provided at least one publicly funded prescription drug formulary. Many systems have adopted similar processes of drug reimbursement decision making. All but three systems required additional consideration of clinical evidence within the decision-making process. Transparency of recommendations varied between systems, from having no information publicly available (three systems) to all information available and accessible to the public (16 systems). Only four countries did not consider cost within the drug reimbursement decision-making process. There were similarities in the decision-making process for drug reimbursement across the systems; however, only five countries met the highest standard of transparency, requirement of evidence, and ability to appeal. Future work should focus on examining how these processes may affect formulary listing decisions for drugs between countries. © 2013 International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Published by International Society for Pharmacoeconomics and Outcomes Research (ISPOR) All rights reserved.

Cyborg practices: call-handlers and computerised decision support systems in urgent and emergency care.

PubMed

Pope, Catherine; Halford, Susan; Turnbull, Joanne; Prichard, Jane

2014-06-01

This article draws on data collected during a 2-year project examining the deployment of a computerised decision support system. This computerised decision support system was designed to be used by non-clinical staff for dealing with calls to emergency (999) and urgent care (out-of-hours) services. One of the promises of computerised decisions support technologies is that they can 'hold' vast amounts of sophisticated clinical knowledge and combine it with decision algorithms to enable standardised decision-making by non-clinical (clerical) staff. This article draws on our ethnographic study of this computerised decision support system in use, and we use our analysis to question the 'automated' vision of decision-making in healthcare call-handling. We show that embodied and experiential (human) expertise remains central and highly salient in this work, and we propose that the deployment of the computerised decision support system creates something new, that this conjunction of computer and human creates a cyborg practice.

42 CFR 430.104 - Decisions that affect FFP.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) MEDICAL ASSISTANCE PROGRAMS GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS Hearings on Conformity of State Medicaid Plans and Practice to Federal Requirements § 430.104 Decisions that affect FFP...

Diagnostic performances of clinical laboratory tests using Triton X-100 to reduce the biohazard associated with routine testing of Ebola virus-infected patients.

PubMed

Tempestilli, Massimo; Pucci, Luigia; Notari, Stefania; Di Caro, Antonino; Castilletti, Concetta; Rivelli, Maria Rosaria; Agrati, Chiara; Pucillo, Leopoldo Paolo

2015-11-01

Ebola virus, an enveloped virus, is the cause of the largest and most complex Ebola virus disease (EVD) outbreak in West Africa. Blood or body fluids of an infected person may represent a biohazard to laboratory workers. Laboratory tests of virus containing specimens should be conducted in referral centres at biosafety level 4, but based on the severity of clinical symptoms, basic laboratories might be required to execute urgent tests for patients suspected of EVD. The aim of this work was to compare the analytical performances of laboratory tests when Triton X-100, a chemical agent able to inactivate other enveloped viruses, was added to specimens. Results of clinical chemistry, coagulation and haematology parameters on samples before and after the addition of 0.1% (final concentration) of Triton X-100 and 1 h of incubation at room temperature were compared. Overall, results showed very good agreement by all statistical analyses. Triton X-100 at 0.1% did not significantly affect the results for the majority of the analytes tested. Triton X-100 at 0.1% can be used to reduce the biohazard in performing laboratory tests on samples from patients with EVD without affecting clinical decisions.

Reward-Related Decision-Making in Pediatric Major Depressive Disorder: An fMRI Study

ERIC Educational Resources Information Center

Forbes, Erika E.; Christopher May, J.; Siegle, Greg J.; Ladouceur, Cecile D.; Ryan, Neal D.; Carter, Cameron S.; Birmaher, Boris; Axelson, David A.; Dahl, Ronald E.

2006-01-01

Background: Although reward processing is considered an important part of affective functioning, few studies have investigated reward-related decisions or responses in young people with affective disorders. Depression is postulated to involve decreased activity in reward-related affective systems. Methods: Using functional magnetic resonance…

Endodontic decisions based on clinical appearance.

PubMed

Lobprise, H B; Bloom, B C

2001-08-01

Too often, endodontically compromised teeth are ignored because they are not accurately identified, nor their significance realized. By systematically evaluating each potentially affected tooth, a practitioner can correctly diagnose endodontic cases and plan therapy accordingly. Endodontic pathology, with non-vital pulps and subsequent abscessation, can affect not only the tooth but also the rest of the patient. Physical examination, both external and oral, can be combined with tactile and transillumination assessment. Radiographic appraisal is essential in determining periapical health, both to determine the vitality of the tooth and to ascertain if endodontic therapy is appropriate, of if extraction is the best choice. This report aims to provide the reader with a clearer understanding of diagnosing endodontic cases to facilitate selection of the appropriate treatment.

On Elementary Affective Decisions: To Like Or Not to Like, That Is the Question

PubMed Central

Jacobs, Arthur; Hofmann, Markus J.; Kinder, Annette

2016-01-01

Perhaps the most ubiquitous and basic affective decision of daily life is deciding whether we like or dislike something/somebody, or, in terms of psychological emotion theories, whether the object/subject has positive or negative valence. Indeed, people constantly make such liking decisions within a glimpse and, importantly, often without expecting any obvious benefit or knowing the exact reasons for their judgment. In this paper, we review research on such elementary affective decisions (EADs) that entail no direct overt reward with a special focus on Neurocognitive Poetics and discuss methods and models for investigating the neuronal and cognitive-affective bases of EADs to verbal materials with differing degrees of complexity. In line with evolutionary and appraisal theories of (aesthetic) emotions and data from recent neurocognitive studies, the results of a decision tree modeling approach simulating EADs to single words suggest that a main driving force behind EADs is the extent to which such high-dimensional stimuli are associated with the “basic” emotions joy/happiness and disgust. PMID:27933013

TMS affects moral judgment, showing the role of DLPFC and TPJ in cognitive and emotional processing.

PubMed

Jeurissen, Danique; Sack, Alexander T; Roebroeck, Alard; Russ, Brian E; Pascual-Leone, Alvaro

2014-01-01

Decision-making involves a complex interplay of emotional responses and reasoning processes. In this study, we use TMS to explore the neurobiological substrates of moral decisions in humans. To examining the effects of TMS on the outcome of a moral-decision, we compare the decision outcome of moral-personal and moral-impersonal dilemmas to each other and examine the differential effects of applying TMS over the right DLPFC or right TPJ. In this comparison, we find that the TMS-induced disruption of the DLPFC during the decision process, affects the outcome of the moral-personal judgment, while TMS-induced disruption of TPJ affects only moral-impersonal conditions. In other words, we find a double-dissociation between DLPFC and TPJ in the outcome of a moral decision. Furthermore, we find that TMS-induced disruption of the DLPFC during non-moral, moral-impersonal, and moral-personal decisions lead to lower ratings of regret about the decision. Our results are in line with the dual-process theory and suggest a role for both the emotional response and cognitive reasoning process in moral judgment. Both the emotional and cognitive processes were shown to be involved in the decision outcome.

Dairy cow culling strategies: making economical culling decisions.

PubMed

Lehenbauer, T W; Oltjen, J W

1998-01-01

The purpose of this report was to examine important economic elements of culling decisions, to review progress in development of culling decision support systems, and to discern some of the potentially rewarding areas for future research on culling models. Culling decisions have an important influence on the economic performance of the dairy but are often made in a nonprogrammed fashion and based partly on the intuition of the decision maker. The computer technology that is available for dairy herd management has made feasible the use of economic models to support culling decisions. Financial components--including profit, cash flow, and risk--are major economic factors affecting culling decisions. Culling strategies are further influenced by short-term fluctuations in cow numbers as well as by planned herd expansion. Changes in herd size affect the opportunity cost for postponed replacement and may alter the relevance of optimization strategies that assume a fixed herd size. Improvements in model components related to biological factors affecting future cow performance, including milk production, reproductive status, and mastitis, appear to offer the greatest economic potential for enhancing culling decision support systems. The ultimate value of any culling decision support system for developing economic culling strategies will be determined by its results under field conditions.

Information management to enable personalized medicine: stakeholder roles in building clinical decision support.

PubMed

Downing, Gregory J; Boyle, Scott N; Brinner, Kristin M; Osheroff, Jerome A

2009-10-08

Advances in technology and the scientific understanding of disease processes are presenting new opportunities to improve health through individualized approaches to patient management referred to as personalized medicine. Future health care strategies that deploy genomic technologies and molecular therapies will bring opportunities to prevent, predict, and pre-empt disease processes but will be dependent on knowledge management capabilities for health care providers that are not currently available. A key cornerstone to the potential application of this knowledge will be effective use of electronic health records. In particular, appropriate clinical use of genomic test results and molecularly-targeted therapies present important challenges in patient management that can be effectively addressed using electronic clinical decision support technologies. Approaches to shaping future health information needs for personalized medicine were undertaken by a work group of the American Health Information Community. A needs assessment for clinical decision support in electronic health record systems to support personalized medical practices was conducted to guide health future development activities. Further, a suggested action plan was developed for government, researchers and research institutions, developers of electronic information tools (including clinical guidelines, and quality measures), and standards development organizations to meet the needs for personalized approaches to medical practice. In this article, we focus these activities on stakeholder organizations as an operational framework to help identify and coordinate needs and opportunities for clinical decision support tools to enable personalized medicine. This perspective addresses conceptual approaches that can be undertaken to develop and apply clinical decision support in electronic health record systems to achieve personalized medical care. In addition, to represent meaningful benefits to personalized decision-making, a comparison of current and future applications of clinical decision support to enable individualized medical treatment plans is presented. If clinical decision support tools are to impact outcomes in a clear and positive manner, their development and deployment must therefore consider the needs of the providers, including specific practice needs, information workflow, and practice environment.

Information management to enable personalized medicine: stakeholder roles in building clinical decision support

PubMed Central

2009-01-01

Background Advances in technology and the scientific understanding of disease processes are presenting new opportunities to improve health through individualized approaches to patient management referred to as personalized medicine. Future health care strategies that deploy genomic technologies and molecular therapies will bring opportunities to prevent, predict, and pre-empt disease processes but will be dependent on knowledge management capabilities for health care providers that are not currently available. A key cornerstone to the potential application of this knowledge will be effective use of electronic health records. In particular, appropriate clinical use of genomic test results and molecularly-targeted therapies present important challenges in patient management that can be effectively addressed using electronic clinical decision support technologies. Discussion Approaches to shaping future health information needs for personalized medicine were undertaken by a work group of the American Health Information Community. A needs assessment for clinical decision support in electronic health record systems to support personalized medical practices was conducted to guide health future development activities. Further, a suggested action plan was developed for government, researchers and research institutions, developers of electronic information tools (including clinical guidelines, and quality measures), and standards development organizations to meet the needs for personalized approaches to medical practice. In this article, we focus these activities on stakeholder organizations as an operational framework to help identify and coordinate needs and opportunities for clinical decision support tools to enable personalized medicine. Summary This perspective addresses conceptual approaches that can be undertaken to develop and apply clinical decision support in electronic health record systems to achieve personalized medical care. In addition, to represent meaningful benefits to personalized decision-making, a comparison of current and future applications of clinical decision support to enable individualized medical treatment plans is presented. If clinical decision support tools are to impact outcomes in a clear and positive manner, their development and deployment must therefore consider the needs of the providers, including specific practice needs, information workflow, and practice environment. PMID:19814826

Information and decision-making needs among people with affective disorders - results of an online survey.

PubMed

Liebherz, Sarah; Tlach, Lisa; Härter, Martin; Dirmaier, Jörg

2015-01-01

Patient decision aids are one possibility for enabling and encouraging patients to participate in medical decisions. This paper aims to describe patients' information and decision-making needs as a prerequisite for the development of high-quality, web-based patient decision aids for affective disorders. We conducted an online cross-sectional survey by using a self-administered questionnaire including items on Internet use, online health information needs, role in decision making, and important treatment decisions, performing descriptive and comparative statistical analyses. A total of 210 people with bipolar disorder/mania as well as 112 people with unipolar depression participated in the survey. Both groups specified general information search as their most relevant information need and decisions on treatment setting (inpatient or outpatient) as well as decisions on pharmacological treatment as the most difficult treatment decisions. For participants with unipolar depression, decisions concerning psychotherapeutic treatment were also especially difficult. Most participants of both groups preferred shared decisions but experienced less shared decisions than desired. Our results show the importance of information for patients with affective disorders, with a focus on pharmacological treatment and on the different treatment settings, and highlight patients' requirements to be involved in the decision-making process. Since our sample reported a chronic course of disease, we do not know if our results are applicable for newly diagnosed patients. Further studies should consider how the reported needs could be addressed in health care practice.

Factors Affecting Career Decision-Making: Further Validation of the O'Neil Career-Sex Role Model and the Career Factor Checklist.

ERIC Educational Resources Information Center

Meinecke, Christine; O'Neil, James M.

Many correlates of vocational choice have been suggested by career development theorists. A career decision-making model developed by O'Neil, Meeker, and Borgers suggests six factors (individual, societal, familial, socioeconomic, situational, psychosocial-emotional) that affect both sex role socialization and career decision-making. The validity…

An Integrative Process Approach on Judgment and Decision Making: The Impact of Arousal, Affect, Motivation, and Cognitive Ability

ERIC Educational Resources Information Center

Roets, Arne; Van Hiel, Alain

2011-01-01

This article aims to integrate the findings from various research traditions on human judgment and decision making, focusing on four process variables: arousal, affect, motivation, and cognitive capacity/ability. We advocate a broad perspective referred to as the integrative process approach (IPA) of decision making, in which these process…