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Sample records for affect clinical decision

  1. A study to explore if dentists' anxiety affects their clinical decision-making.

    PubMed

    Chipchase, S Y; Chapman, H R; Bretherton, R

    2017-02-24

    Aims To develop a measure of dentists' anxiety in clinical situations; to establish if dentists' anxiety in clinical situations affected their self-reported clinical decision-making; to establish if occupational stress, as demonstrated by burnout, is associated with anxiety in clinical situations and clinical decision-making; and to explore the relationship between decision-making style and the clinical decisions which are influenced by anxiety.Design Cross-sectional study.Setting Primary Dental Care.Subjects and methods A questionnaire battery [Maslach Burnout Inventory, measuring burnout; Melbourne Decision Making Questionnaire, measuring decision-making style; Dealing with Uncertainty Questionnaire (DUQ), measuring coping with diagnostic uncertainty; and a newly designed Dentists' Anxieties in Clinical Situations Scale, measuring dentists' anxiety (DACSS-R) and change of treatment (DACSS-C)] was distributed to dentists practicing in Nottinghamshire and Lincolnshire. Demographic data were collected and dentists gave examples of anxiety-provoking situations and their responses to them.Main outcome measure Respondents' self-reported anxiety in various clinical situations on a 11-point Likert Scale (DACSS-R) and self-reported changes in clinical procedures (Yes/No; DACSS-C). The DACSS was validated using multiple t-tests and a principal component analysis. Differences in DACSS-R ratings and burnout, decision-making and dealing with uncertainty were explored using Pearson correlations and multiple regression analysis. Qualitative data was subject to a thematic analysis.Results The DACSS-R revealed a four-factor structure and had high internal reliability (Cronbach's α = 0.94). Those with higher DACSS-R scores of anxiety were more likely to report changes in clinical procedures (DACSS-C scores). DACSS-R scores were associated with decision-making self-esteem and style as measured by the MDMQ and all burnout subscales, though not with scores on the DUQ scale

  2. The future in clinical genetics: affective forecasting biases in patient and clinician decision making.

    PubMed

    Peters, S A; Laham, S M; Pachter, N; Winship, I M

    2014-04-01

    When clinicians facilitate and patients make decisions about predictive genetic testing, they often base their choices on the predicted emotional consequences of positive and negative test results. Research from psychology and decision making suggests that such predictions may often be biased. Work on affective forecasting-predicting one's future emotional states-shows that people tend to overestimate the impact of (especially negative) emotional events on their well-being; a phenomenon termed the impact bias. In this article, we review the causes and consequences of the impact bias in medical decision making, with a focus on applying such findings to predictive testing in clinical genetics. We also recommend strategies for reducing the impact bias and consider the ethical and practical implications of doing so.

  3. The influence of the law on clinical decisions affecting life and death.

    PubMed

    Havard, J D

    1983-07-01

    force fed irrespective of their prospects of survival and suffering which this will cause them and their parents. Clinical decisions have been most seriously affected by recent developments in the law of negligence. 1 of the main reasons for this has been the unsatisfactory way in which the adversary system of law ldeals with expert evidence. Attempts have been made to provide courts of law in the UK an agreed statement on expert medical matters, there is a long way to go before reaching the position achieved in many civil law countries on the continent of Europe where the experts recognized by the court hammer out an agreed upon opinion through scientific discourse and without the restrictions of evidentiary rules which are aimed more at the establishment of facts than the validity of scientific opinion. Those who attack the medical profession as being paternalistic and authoritative in making clinical decisions involving life and death fail to realize that the easy way out for the medical profession is to treat every case, however hopeless, with the full technology available, disregarding the patient's and family's interests, the costs in resources, and ignoring the stark reality of the problem.

  4. Clinical decision support foundations.

    PubMed

    Pradhan, Malcolm; Liaw, Siaw Teng

    2010-01-01

    This chapter gives an educational overview of: * The elements of a clinical decision; * The elements of decision making: prior probability, evidence (likelihood), posterior probability, actions, utility (value); * A framework for decision making, and support, encompassing validity, utility, importance and certainty; and * The required elements of a clinical decision support system. * The role of knowledge management in the construction and maintenance of clinical decision support.

  5. The clinical decision analysis using decision tree.

    PubMed

    Bae, Jong-Myon

    2014-01-01

    The clinical decision analysis (CDA) has used to overcome complexity and uncertainty in medical problems. The CDA is a tool allowing decision-makers to apply evidence-based medicine to make objective clinical decisions when faced with complex situations. The usefulness and limitation including six steps in conducting CDA were reviewed. The application of CDA results should be done under shared decision with patients' value.

  6. The clinical decision analysis using decision tree

    PubMed Central

    Bae, Jong-Myon

    2014-01-01

    The clinical decision analysis (CDA) has used to overcome complexity and uncertainty in medical problems. The CDA is a tool allowing decision-makers to apply evidence-based medicine to make objective clinical decisions when faced with complex situations. The usefulness and limitation including six steps in conducting CDA were reviewed. The application of CDA results should be done under shared decision with patients’ value. PMID:25358466

  7. How clinical decisions are made.

    PubMed

    Bate, Louise; Hutchinson, Andrew; Underhill, Jonathan; Maskrey, Neal

    2012-10-01

    There is much variation in the implementation of the best available evidence into clinical practice. These gaps between evidence and practice are often a result of multiple individual decisions. When making a decision, there is so much potentially relevant information available, it is impossible to know or process it all (so called 'bounded rationality'). Usually, a limited amount of information is selected to reach a sufficiently satisfactory decision, a process known as satisficing. There are two key processes used in decision making: System 1 and System 2. System 1 involves fast, intuitive decisions; System 2 is a deliberate analytical approach, used to locate information which is not instantly recalled. Human beings unconsciously use System 1 processing whenever possible because it is quicker and requires less effort than System 2. In clinical practice, gaps between evidence and practice can occur when a clinician develops a pattern of knowledge, which is then relied on for decisions using System 1 processing, without the activation of a System 2 check against the best available evidence from high quality research. The processing of information and decision making may be influenced by a number of cognitive biases, of which the decision maker may be unaware. Interventions to encourage appropriate use of System 1 and System 2 processing have been shown to improve clinical decision making. Increased understanding of decision making processes and common sources of error should help clinical decision makers to minimize avoidable mistakes and increase the proportion of decisions that are better.

  8. Models of Affective Decision Making

    PubMed Central

    Charpentier, Caroline J.; De Neve, Jan-Emmanuel; Li, Xinyi; Roiser, Jonathan P.; Sharot, Tali

    2016-01-01

    Intuitively, how you feel about potential outcomes will determine your decisions. Indeed, an implicit assumption in one of the most influential theories in psychology, prospect theory, is that feelings govern choice. Surprisingly, however, very little is known about the rules by which feelings are transformed into decisions. Here, we specified a computational model that used feelings to predict choices. We found that this model predicted choice better than existing value-based models, showing a unique contribution of feelings to decisions, over and above value. Similar to the value function in prospect theory, our feeling function showed diminished sensitivity to outcomes as value increased. However, loss aversion in choice was explained by an asymmetry in how feelings about losses and gains were weighted when making a decision, not by an asymmetry in the feelings themselves. The results provide new insights into how feelings are utilized to reach a decision. PMID:27071751

  9. 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

  10. The Road Not So Travelled: Should Measurement of Vitamin D Epimers during Pregnancy Affect Our Clinical Decisions?

    PubMed

    Karras, Spyridon N; Kotsa, Kalliopi; Angeloudi, Elena; Zebekakis, Pantelis; Naughton, Declan P

    2017-01-28

    Observational studies suggest an adverse effect of maternal hypovitaminosis D during pregnancy. However, intervention studies failed to show convincing benefit from vitamin D supplementation during pregnancy. With analytical advances, vitamin D can now be measured in ten forms-including as epimers-which were thought to be biologically inactive, but can critically impair immunoassays. The aim of this commentary is to highlight the potential clinical and analytical significance of vitamin D epimers in the interpretation of vitamin D roles in pregnancy. Epimers may contribute a considerable proportion of total vitamin D-especially in the neonate-which renders the majority of common assays questionable. Furthermore, epimers have been suggested to have activity in laboratory studies, and evidence suggests that the fetus contributes significantly to epimer production. Maternal epimer levels contribute significantly to predict neonate circulating 25-hydroxyvitamin D concentrations. In conclusion, the existence of various vitamin D forms (such as epimers) has been established, and their clinical significance remains obscure. These results underscore the need for accurate measurements to appraise vitamin D status, in order to understand the current gap between observational and supplementation studies on the field.

  11. The Road Not So Travelled: Should Measurement of Vitamin D Epimers during Pregnancy Affect Our Clinical Decisions?

    PubMed Central

    Karras, Spyridon N.; Kotsa, Kalliopi; Angeloudi, Elena; Zebekakis, Pantelis; Naughton, Declan P.

    2017-01-01

    Observational studies suggest an adverse effect of maternal hypovitaminosis D during pregnancy. However, intervention studies failed to show convincing benefit from vitamin D supplementation during pregnancy. With analytical advances, vitamin D can now be measured in ten forms—including as epimers—which were thought to be biologically inactive, but can critically impair immunoassays. The aim of this commentary is to highlight the potential clinical and analytical significance of vitamin D epimers in the interpretation of vitamin D roles in pregnancy. Epimers may contribute a considerable proportion of total vitamin D—especially in the neonate—which renders the majority of common assays questionable. Furthermore, epimers have been suggested to have activity in laboratory studies, and evidence suggests that the fetus contributes significantly to epimer production. Maternal epimer levels contribute significantly to predict neonate circulating 25-hydroxyvitamin D concentrations. In conclusion, the existence of various vitamin D forms (such as epimers) has been established, and their clinical significance remains obscure. These results underscore the need for accurate measurements to appraise vitamin D status, in order to understand the current gap between observational and supplementation studies on the field. PMID:28134839

  12. Economic Choices. Political Decisions that Affect You.

    ERIC Educational Resources Information Center

    Fritsche, Joellen M.; And Others

    The purpose of this book is to help students understand why the U.S. Government is involved in the economy, the underlying social values that government tries to promote, and how U.S. economic decisions affect the global economy. It was designed to give them the background they need to form their own opinions about the role of government in the…

  13. Stereotype threat affects financial decision making.

    PubMed

    Carr, Priyanka B; Steele, Claude M

    2010-10-01

    The research presented in this article provides the first evidence that one's decision making can be influenced by concerns about stereotypes and the devaluation of one's identity. Many studies document gender differences in decision making, and often attribute these differences to innate and stable factors, such as biological and hormonal differences. In three studies, we found that stereotype threat affected decision making and led to gender differences in loss-aversion and risk-aversion behaviors. In Study 1, women subjected to stereotype threat in academic and business settings were more loss averse than both men and women who were not facing the threat of being viewed in light of negative stereotypes. We found no gender differences in loss-aversion behavior in the absence of stereotype threat. In Studies 2a and 2b, we found the same pattern of effects for risk-aversion behavior that we had observed for loss-aversion behavior. In addition, in Study 2b, ego depletion mediated the effects of stereotype threat on women's decision making. These results suggest that individuals' decision making can be influenced by stereotype concerns.

  14. Can access limits on sales representatives to physicians affect clinical prescription decisions? A study of recent events with diabetes and lipid drugs.

    PubMed

    Chressanthis, George A; Khedkar, Pratap; Jain, Nitin; Poddar, Prashant; Seiders, Michael G

    2012-07-01

    The authors explored to what extent important medical decisions by practitioners can be influenced by pharmaceutical representatives and, in particular, whether restricting such access could delay appropriate changes in clinical practice. Medical practices were divided into four categories based on the degree of sales representative access to clinicians: very low, low, medium, and high from a database compiled by ZS Associates called AccessMonitor (Evanston, IL) used extensively by many pharmaceutical companies. Clinical decisions of 58,647 to 72,114 physicians were statistically analyzed using prescription data from IMS Health (Danbury, CT) in three critical areas: an innovative drug for type 2 diabetes (sitagliptin), an older diabetes drug with a new Food and Drug Administration-required black box warning for cardiovascular safety (rosiglitazone), and a combination lipid therapy that had reported negative outcomes in a clinical trial (simvastatin+ezetimbe). For the uptake of the new diabetes agent, the authors found that physicians with very low access to representatives had the lowest adoption of this new therapy and took 1.4 and 4.6 times longer to adopt than physicians in the low- and medium-access restriction categories, respectively. In responding to the black box warning for rosiglitazone, the authors found that physicians with very low access were 4.0 times slower to reduce their use of this treatment than those with low access. Likewise, there was significantly less response in terms of changing prescribing to the negative news with the lipid therapy for physicians in more access-restricted offices. Overall, cardiologists were the most responsive to information changes relative to primary care physicians. These findings emphasize that limiting access to pharmaceutical representatives can have the unintended effect of reducing appropriate responses to negative information about drugs just as much as responses to positive information about innovative

  15. Affective Forecasting: An Unrecognized Challenge in Making Serious Health Decisions

    PubMed Central

    Arnold, Robert M.

    2008-01-01

    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. PMID:18665428

  16. How the magnitude of clinical severity and recurrence risk affects reproductive decisions in adult males with different forms of progressive muscular dystrophy.

    PubMed Central

    Eggers, S; Zatz, M

    1998-01-01

    The reproductive history of 177 male patients affected with Becker (BMD) (n=69), limb-girdle (LGMD) (n=54), and facioscapulohumeral (FSHMD) (n=54) muscular dystrophy (MD) was analysed according to severity of the disease (BMD>LGMD>FSHMD) and magnitude of recurrence risk (RR) (high for FSHMD, intermediate for BMD, and low for LGMD). Additionally, 62 male patients were interviewed on psychosocial issues, in order to disentangle the factors influencing reproductive decisions among patients affected with MD. Among male adults, significantly more FSHMD than LGMD or BMD patients were married and had children. Age specific reproductive outcome was 0.31-0.32 for BMD, 0.51-0.62 for LGMD, and 0.58-1.02 for FSHMD, reflecting the influence of the disease's severity. High RRs did not significantly diminish reproduction after genetic counselling or correlate with less prospective desire for children. Instead, early onset, severity of the disease, and past reproductive history were found to diminish reproductive outcome after genetic counselling, and prospective family planning was also found to be influenced by past reproductive history as well as by emotional/sexual dysfunction with the opposite sex. PMID:9541101

  17. How the magnitude of clinical severity and recurrence risk affects reproductive decisions in adult males with different forms of progressive muscular dystrophy.

    PubMed

    Eggers, S; Zatz, M

    1998-03-01

    The reproductive history of 177 male patients affected with Becker (BMD) (n=69), limb-girdle (LGMD) (n=54), and facioscapulohumeral (FSHMD) (n=54) muscular dystrophy (MD) was analysed according to severity of the disease (BMD>LGMD>FSHMD) and magnitude of recurrence risk (RR) (high for FSHMD, intermediate for BMD, and low for LGMD). Additionally, 62 male patients were interviewed on psychosocial issues, in order to disentangle the factors influencing reproductive decisions among patients affected with MD. Among male adults, significantly more FSHMD than LGMD or BMD patients were married and had children. Age specific reproductive outcome was 0.31-0.32 for BMD, 0.51-0.62 for LGMD, and 0.58-1.02 for FSHMD, reflecting the influence of the disease's severity. High RRs did not significantly diminish reproduction after genetic counselling or correlate with less prospective desire for children. Instead, early onset, severity of the disease, and past reproductive history were found to diminish reproductive outcome after genetic counselling, and prospective family planning was also found to be influenced by past reproductive history as well as by emotional/sexual dysfunction with the opposite sex.

  18. Clinical Decision Support and Palivizumab

    PubMed Central

    Hogan, A.; Michel, J.; Localio, A.R.; Karavite, D.; Song, L.; Ramos, M.J.; Fiks, A.G.; Lorch, S.; Grundmeier, R.W.

    2015-01-01

    Background and Objectives Palivizumab can reduce hospitalizations due to respiratory syncytial virus (RSV), but many eligible infants fail to receive the full 5-dose series. The efficacy of clinical decision support (CDS) in fostering palivizumab receipt has not been studied. We sought a comprehensive solution for identifying eligible patients and addressing barriers to palivizumab administration. Methods We developed workflow and CDS tools targeting patient identification and palivizumab administration. We randomized 10 practices to receive palivizumab-focused CDS and 10 to receive comprehensive CDS for premature infants in a 3-year longitudinal cluster-randomized trial with 2 baseline and 1 intervention RSV seasons. Results There were 356 children eligible to receive palivizumab, with 194 in the palivizumab-focused group and 162 in the comprehensive CDS group. The proportion of doses administered to children in the palivizumab-focused intervention group increased from 68.4% and 65.5% in the two baseline seasons to 84.7% in the intervention season. In the comprehensive intervention group, proportions of doses administered declined during the baseline seasons (from 71.9% to 62.4%) with partial recovery to 67.9% during the intervention season. The palivizumab-focused group improved by 19.2 percentage points in the intervention season compared to the prior baseline season (p < 0.001), while the comprehensive intervention group only improved 5.5 percentage points (p = 0.288). The difference in change between study groups was significant (p = 0.05). Conclusions Workflow and CDS tools integrated in an EHR may increase the administration of palivizumab. The support focused on palivizumab, rather than comprehensive intervention, was more effective at improving palivizumab administration. PMID:26767069

  19. ClinicalAccess: a clinical decision support tool.

    PubMed

    Crowell, Karen; Vardell, Emily

    2015-01-01

    ClinicalAccess is a new clinical decision support tool that uses a question-and-answer format to mirror clinical decision-making strategies. The unique format of ClinicalAccess delivers concise, authoritative answers to more than 120,000 clinical questions. This column presents a review of the product, a sample search, and a comparison with other point-of-care search engines.

  20. Family patterns of decision-making in pediatric clinical trials.

    PubMed

    Snethen, Julia A; Broome, Marion E; Knafl, Kathleen; Deatrick, Janet A; Angst, Denise B

    2006-06-01

    The decision-making process related to a child's participation in clinical trials often involves multiple family members. The aim of this study was to compare family patterns of decision-making within and across family units in pediatric clinical trials. Participants for this secondary analysis included 14 families from a larger study of informed consent. Four distinct patterns of decision-making were identified: Exclusionary, informative, collaborative, and delegated. These patterns varied with regard to three dimensions of parents' decision-making goals, child level of involvement, and the parental role. These patterns of decision-making affect how parents and children communicate with health professionals and influence the effectiveness of health care providers interactions with the family related to the decision-making process.

  1. 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.

  2. 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.

  3. Clinical Decision Making of Rural Novice Nurses

    ERIC Educational Resources Information Center

    Seright, Teresa J.

    2010-01-01

    The purpose of this study was to develop substantive theory regarding decision making by the novice nurse in a rural hospital setting. Interviews were guided by the following research questions: What cues were used by novice rural registered nurses in order to make clinical decisions? What were the sources of feedback which influenced subsequent…

  4. A shotgun wedding: business decision support meets clinical decision support.

    PubMed

    Oliveira, Jason

    2002-01-01

    By effectively closing the loop between the data, analytics, processes, and methods supporting business and clinical decision making, a healthcare organization closes the loop between its knowledge generation activities and its actions at the bedside: knowledge guiding actions, actions generating knowledge.

  5. LIMSI @ 2014 Clinical Decision Support Track

    DTIC Science & Technology

    2014-11-01

    Clinical Decision Support 1 Introduction The goal of the Clinical Decision Support Track is to retrieve relevant biomedical articles given a patient record...queries: • Diagnosis: "diagnosis"[MeSH Terms] OR "diagnosis, oral"[MeSH Terms] OR "diagnostic equipment "[MeSH Terms] OR "diagnostic services"[MeSH Terms...particular biomedical domain or search strategy) that were created as part of the CISMeF project[2]3. The Test query was manually created for 3These and

  6. 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.

  7. Entrustment Decision Making in Clinical Training.

    PubMed

    Ten Cate, Olle; Hart, Danielle; Ankel, Felix; Busari, Jamiu; Englander, Robert; Glasgow, Nicholas; Holmboe, Eric; Iobst, William; Lovell, Elise; Snell, Linda S; Touchie, Claire; Van Melle, Elaine; Wycliffe-Jones, Keith

    2016-02-01

    The decision to trust a medical trainee with the critical responsibility to care for a patient is fundamental to clinical training. When carefully and deliberately made, such decisions can serve as significant stimuli for learning and also shape the assessment of trainees. Holding back entrustment decisions too much may hamper the trainee's development toward unsupervised practice. When carelessly made, however, they jeopardize patient safety. Entrustment decision-making processes, therefore, deserve careful analysis.Members (including the authors) of the International Competency-Based Medical Education Collaborative conducted a content analysis of the entrustment decision-making process in health care training during a two-day summit in September 2013 and subsequently reviewed the pertinent literature to arrive at a description of the critical features of this process, which informs this article.The authors discuss theoretical backgrounds and terminology of trust and entrustment in the clinical workplace. The competency-based movement and the introduction of entrustable professional activities force educators to rethink the grounds for assessment in the workplace. Anticipating a decision to grant autonomy at a designated level of supervision appears to align better with health care practice than do most current assessment practices. The authors distinguish different modes of trust and entrustment decisions and elaborate five categories, each with related factors, that determine when decisions to trust trainees are made: the trainee, supervisor, situation, task, and the relationship between trainee and supervisor. The authors' aim in this article is to lay a theoretical foundation for a new approach to workplace training and assessment.

  8. Strategies for Teaching Clinical Decision-Making.

    ERIC Educational Resources Information Center

    Boney, Jo; Baker, Jacqueline D.

    1997-01-01

    Research and a literature review suggest that nurses lack skills for effective clinical decision making. An educational program that facilitated development of critical thinking focused on four qualities: determining accuracy of information, determining bias, identifying inconsistencies in reasoning, and evaluating the strength of an argument. (SK)

  9. Query Reformulation for Clinical Decision Support Search

    DTIC Science & Technology

    2014-11-01

    Query Reformulation for Clinical Decision Support Search Luca Soldaini, Arman Cohan, Andrew Yates, Nazli Goharian, Ophir Frieder Information...work, we present a query reformulation approach that addresses the unique formulation of case reports, making them suitable to be used on a general... reformulation approach does not directly take into account the generic question type (diagnosis, test, treatment) provided with each approach. To ameliorate

  10. 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

  11. Acute stress does not affect risky monetary decision-making.

    PubMed

    Sokol-Hessner, Peter; Raio, Candace M; Gottesman, Sarah P; Lackovic, Sandra F; Phelps, Elizabeth A

    2016-12-01

    The ubiquitous and intense nature of stress responses necessitate that we understand how they affect decision-making. Despite a number of studies examining risky decision-making under stress, it is as yet unclear whether and in what way stress alters the underlying processes that shape our choices. This is in part because previous studies have not separated and quantified dissociable valuation and decision-making processes that can affect choices of risky options, including risk attitudes, loss aversion, and choice consistency, among others. Here, in a large, fully-crossed two-day within-subjects design, we examined how acute stress alters risky decision-making. On each day, 120 participants completed either the cold pressor test or a control manipulation with equal probability, followed by a risky decision-making task. Stress responses were assessed with salivary cortisol. We fit an econometric model to choices that dissociated risk attitudes, loss aversion, and choice consistency using hierarchical Bayesian techniques to both pool data and allow heterogeneity in decision-making. Acute stress was found to have no effect on risk attitudes, loss aversion, or choice consistency, though participants did become more loss averse and more consistent on the second day relative to the first. In the context of an inconsistent previous literature on risk and acute stress, our findings provide strong and specific evidence that acute stress does not affect risk attitudes, loss aversion, or consistency in risky monetary decision-making.

  12. Cognitive Elements in Clinical Decision-Making

    ERIC Educational Resources Information Center

    Dunphy, Bruce C.; Cantwell, Robert; Bourke, Sid; Fleming, Mark; Smith, Bruce; Joseph, K. S.; Dunphy, Stacey L

    2010-01-01

    Physician cognition, metacognition and affect may have an impact upon the quality of clinical reasoning. The purpose of this study was to examine the relationship between measures of physician metacognition and affect and patient outcomes in obstetric practice. Reflective coping (RC), proactive coping, need for cognition (NFC), tolerance for…

  13. Computerized Clinical Decision Support: Contributions from 2014

    PubMed Central

    Koutkias, V.

    2015-01-01

    Summary Objective To summarize recent research and propose a selection of best papers published in 2014 in the field of computerized clinical decision support for the Decision Support section of the IMIA yearbook. Method A literature review was performed by searching two bibliographic databases for papers related to clinical decision support systems (CDSSs) and computerized provider order entry systems in order to select a list of candidate best papers to be then peer-reviewed by external reviewers. A consensus meeting between the two section editors and the editorial team was finally organized to conclude on the selection of best papers. Results Among the 1,254 returned papers published in 2014, the full review process selected four best papers. The first one is an experimental contribution to a better understanding of unintended uses of CDSSs. The second paper describes the effective use of previously collected data to tailor and adapt a CDSS. The third paper presents an innovative application that uses pharmacogenomic information to support personalized medicine. The fourth paper reports on the long-term effect of the routine use of a CDSS for antibiotic therapy. Conclusions As health information technologies spread more and more meaningfully, CDSSs are improving to answer users’ needs more accurately. The exploitation of previously collected data and the use of genomic data for decision support has started to materialize. However, more work is still needed to address issues related to the correct usage of such technologies, and to assess their effective impact in the long term. PMID:26293858

  14. Probability, clinical decision making and hypothesis testing

    PubMed Central

    Banerjee, A.; Jadhav, S. L.; Bhawalkar, J. S.

    2009-01-01

    Few clinicians grasp the true concept of probability expressed in the ‘P value.’ For most, a statistically significant P value is the end of the search for truth. In fact, the opposite is the case. The present paper attempts to put the P value in proper perspective by explaining different types of probabilities, their role in clinical decision making, medical research and hypothesis testing. PMID:21234167

  15. Dialogic Consensus In Clinical Decision-Making.

    PubMed

    Walker, Paul; Lovat, Terry

    2016-12-01

    This paper is predicated on the understanding that clinical encounters between clinicians and patients should be seen primarily as inter-relations among persons and, as such, are necessarily moral encounters. It aims to relocate the discussion to be had in challenging medical decision-making situations, including, for example, as the end of life comes into view, onto a more robust moral philosophical footing than is currently commonplace. In our contemporary era, those making moral decisions must be cognizant of the existence of perspectives other than their own, and be attuned to the demands of inter-subjectivity. Applicable to clinical practice, we propose and justify a Habermasian approach as one useful means of achieving what can be described as dialogic consensus. The Habermasian approach builds around, first, his discourse theory of morality as universalizable to all and, second, communicative action as a cooperative search for truth. It is a concrete way to ground the discourse which must be held in complex medical decision-making situations, in its actual reality. Considerations about the theoretical underpinnings of the application of dialogic consensus to clinical practice, and potential difficulties, are explored.

  16. 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.

  17. Creating clinical decision support systems for respiratory medicine.

    PubMed

    Tams, Carl G; Euliano, Neil R

    2015-01-01

    Clinical decision support systems are vital for advances in improving patient therapeutic care. We share lessons learned from creating two respiratory clinical decisions support systems for ventilating patients in a critical care setting.

  18. Audience affects decision-making in a marmoset communication network.

    PubMed

    Toarmino, Camille R; Wong, Lauren; Miller, Cory T

    2017-01-01

    An audience can have a profound effect on the dynamics of communicative interactions. As a result, non-human primates often adjust their social decision-making strategies depending on the audience composition at a given time. Here we sought to test how the unique vocal behaviour of multiple audience members affected decisions to communicate. To address this issue, we developed a novel experimental paradigm in which common marmosets directly interacted with multiple 'virtual monkeys' (VMs), each of whom represented an individual marmoset with distinct vocal behaviour. This active social signalling paradigm provided subjects an opportunity to interact with and learn about the behaviour of each VM in the network and apply this knowledge in subsequent communicative decisions. We found that subjects' propensity to interact with particular VMs was determined by the behaviour of each VM in the audience and suggests that marmoset social decision-making strategies are highly adaptive to nuances of the immediate communication network.

  19. Issues of trust and ethics in computerized clinical decision support systems.

    PubMed

    Alexander, Gregory L

    2006-01-01

    Clinical decision support systems are computer technologies that model and provide support for human decision-making processes. Decision support mechanisms facilitate and enhance a clinician's ability to make decisions at the point of care. Decisions are facilitated through technology by using automated mechanisms that provide alerts or messages to clinicians about a potential patient problem. A clinician's level of trust in these technologies to support decision making is affected by how knowledge is represented in these tools, their ability to make reasonable decisions, and how they are designed. Furthermore, ethical tensions occur if these systems do not promote standards, if clinicians do not understand how to use these systems, and when professional relationships are affected. Issues of trust and ethical concerns will be examined in this article, using a research study of midwestern nursing homes that implemented a clinical decision support system.

  20. Factors, Correlates, Emotional Barriers Affecting Career Decisions of College Students.

    ERIC Educational Resources Information Center

    O'Neil, James M.; And Others

    The correlates of career choice and the problem areas affecting career decisions are important to counseling psychologists. They are important to understanding the complexities of vocational behavior, facilitating differential treatment in counseling, and developing preventive career programs for men, women, and special groups. The effects of the…

  1. Subjective measures and clinical decision making.

    PubMed

    Delitto, A

    1989-07-01

    I have attempted to use Feinstein's model of clinimetric indexes and his criteria as a focus for further development of measures that in physical therapy are currently considered "soft" or "subjective". I feel this development will enhance the body of knowledge by objectifying a portion of clinical assessment (eg, the patient's complaints, "subjective" portion of the POMR's SOAP format) that is in tremendous need of quantification. By making these "soft" data "hard," I feel we will enhance the decision-making power of clinicians.

  2. Suicide Danger: Clinical Estimation and Decision.

    ERIC Educational Resources Information Center

    Maltsberger, John T.

    1988-01-01

    Maintains that traditional mental status examination and clinical intuition or empathetic judgment are insufficient to predict suicide. Describes five components involved in the formulation of suicide risk: analysis of the patient's past response to stress, assessment of vulnerability to life-threatening affects, assessment of exterior sustaining…

  3. Best Practices in Clinical Decision Support

    PubMed Central

    Wright, Adam; Phansalkar, Shobha; Bloomrosen, Meryl; Jenders, Robert A.; Bobb, Anne M.; Halamka, John D.; Kuperman, Gilad; Payne, Thomas H.; Teasdale, S.; Vaida, A. J.; Bates, D. W.

    2010-01-01

    Background Evidence demonstrates that clinical decision support (CDS) is a powerful tool for improving healthcare quality and ensuring patient safety. However, implementing and maintaining effective decision support interventions presents multiple technical and organizational challenges. Purpose To identify best practices for CDS, using the domain of preventive care reminders as an example. Methods We assembled a panel of experts in CDS and held a series of facilitated online and inperson discussions. We analyzed the results of these discussions using a grounded theory method to elicit themes and best practices. Results Eight best practice themes were identified as important: deliver CDS in the most appropriate ways, develop effective governance structures, consider use of incentives, be aware of workflow, keep content current, monitor and evaluate impact, maintain high quality data, and consider sharing content. Keys themes within each of these areas were also described. Conclusion Successful implementation of CDS requires consideration of both technical and socio-technical factors. The themes identified in this study provide guidance on crucial factors that need consideration when CDS is implemented across healthcare settings. These best practice themes may be useful for developers, implementers, and users of decision support. PMID:21991299

  4. Driving and dementia: a clinical decision pathway

    PubMed Central

    Carter, Kirsty; Monaghan, Sophie; O'Brien, John; Teodorczuk, Andrew; Mosimann, Urs; Taylor, John-Paul

    2015-01-01

    Objective This study aimed to develop a pathway to bring together current UK legislation, good clinical practice and appropriate management strategies that could be applied across a range of healthcare settings. Methods The pathway was constructed by a multidisciplinary clinical team based in a busy Memory Assessment Service. A process of successive iteration was used to develop the pathway, with input and refinement provided via survey and small group meetings with individuals from a wide range of regional clinical networks and diverse clinical backgrounds as well as discussion with mobility centres and Forum of Mobility Centres, UK. Results We present a succinct clinical pathway for patients with dementia, which provides a decision-making framework for how health professionals across a range of disciplines deal with patients with dementia who drive. Conclusions By integrating the latest guidance from diverse roles within older people's health services and key experts in the field, the resulting pathway reflects up-to-date policy and encompasses differing perspectives and good practice. It is potentially a generalisable pathway that can be easily adaptable for use internationally, by replacing UK legislation for local regulations. A limitation of this pathway is that it does not address the concern of mild cognitive impairment and how this condition relates to driving safety. © 2014 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons, Ltd. PMID:24865643

  5. Reducing Risk with Clinical Decision Support

    PubMed Central

    Maloney, F.L.; Feblowitz, J.; Samal, L.; Sato, L.; Wright, A.

    2014-01-01

    Summary Objective Identify clinical opportunities to intervene to prevent a malpractice event and determine the proportion of malpractice claims potentially preventable by clinical decision support (CDS). Materials and Methods Cross-sectional review of closed malpractice claims over seven years from one malpractice insurance company and seven hospitals in the Boston area. For each event, clinical opportunities to intervene to avert the malpractice event and the presence or absence of CDS that might have a role in preventing the event, were assigned by a panel of expert raters. Compensation paid out to resolve a claim (indemnity), was associated with each CDS type. Results Of the 477 closed malpractice cases, 359 (75.3%) were categorized as substantiated and 195 (54%) had at least one opportunity to intervene. Common opportunities to intervene related to performance of procedure, diagnosis, and fall prevention. We identified at least one CDS type for 63% of substantiated claims. The 41 CDS types identified included clinically significant test result alerting, diagnostic decision support and electronic tracking of instruments. Cases with at least one associated intervention accounted for $40.3 million (58.9%) of indemnity. Discussion CDS systems and other forms of health information technology (HIT) are expected to improve quality of care, but their potential to mitigate risk had not previously been quantified. Our results suggest that, in addition to their known benefits for quality and safety, CDS systems within HIT have a potential role in decreasing malpractice payments. Conclusion More than half of malpractice events and over $40 million of indemnity were potentially preventable with CDS. PMID:25298814

  6. Decision aids for multiple-decision disease management as affected by weather input errors.

    PubMed

    Pfender, W F; Gent, D H; Mahaffee, W F; Coop, L B; Fox, A D

    2011-06-01

    Many disease management decision support systems (DSSs) 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 management decision recommendations. The extent to which errors in weather inputs affect the quality of the final management outcome depends on a number of aspects of the disease management context, including whether management consists of a single dichotomous decision, or of a multi-decision process extending over the cropping season(s). Decision aids for multi-decision disease management typically are based on simple or complex algorithms of weather data which may be accumulated over several days or weeks. It is difficult to quantify accuracy of multi-decision DSSs due to temporally overlapping disease events, existence of more than one solution to optimizing the outcome, opportunities to take later recourse to modify earlier decisions, and the ongoing, complex decision process in which the DSS is only one component. One approach to assessing importance of weather input errors is to conduct an error analysis in which the DSS outcome from high-quality weather data is compared with that from weather data with various levels of bias and/or variance from the original data. We illustrate this analytical approach for two types of DSS, an infection risk index for hop powdery mildew and a simulation model for grass stem rust. Further exploration of analysis methods is needed to address problems associated with assessing uncertainty in multi-decision DSSs.

  7. Clinical Decision Support Systems for the Practice of Evidence-based Medicine

    PubMed Central

    Sim, Ida; Gorman, Paul; Greenes, Robert A.; Haynes, R. Brian; Kaplan, Bonnie; Lehmann, Harold; Tang, Paul C.

    2001-01-01

    Background: The use of clinical decision support systems to facilitate the practice of evidence-based medicine promises to substantially improve health care quality. Objective: To describe, on the basis of the proceedings of the Evidence and Decision Support track at the 2000 AMIA Spring Symposium, the research and policy challenges for capturing research and practice-based evidence in machine-interpretable repositories, and to present recommendations for accelerating the development and adoption of clinical decision support systems for evidence-based medicine. Results: The recommendations fall into five broad areas—capture literature-based and practice-based evidence in machine-interpretable knowledge bases; develop maintainable technical and methodological foundations for computer-based decision support; evaluate the clinical effects and costs of clinical decision support systems and the ways clinical decision support systems affect and are affected by professional and organizational practices; identify and disseminate best practices for work flow–sensitive implementations of clinical decision support systems; and establish public policies that provide incentives for implementing clinical decision support systems to improve health care quality. Conclusions: Although the promise of clinical decision support system–facilitated evidence-based medicine is strong, substantial work remains to be done to realize the potential benefits. PMID:11687560

  8. Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice

    PubMed Central

    Hajjaj, FM; Salek, MS; Basra, MKA; Finlay, AY

    2010-01-01

    Summary This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional community, and features of clinical practice such as private versus public practice as well as local management policies. This review brings together the different strands of knowledge concerning non-clinical influences on clinical decision-making. This aspect of decision-making may be the biggest obstacle to the reality of practising evidence-based medicine. It needs to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine. PMID:20436026

  9. Affective decision making in women with borderline personality disorder.

    PubMed

    LeGris, Jeannette; Toplak, Maggie; Links, Paul S

    2014-10-01

    The affective decision making of 41 recently treated outpatient women with borderline personality disorder (BPD) was compared to 41 healthy controls using the Iowa Gambling Task (IGT). Non-affective executive functions (EF) of working memory, interference control, and motor inhibition were also compared. Associations among affective and non-affective EF were examined. Despite normal range intelligence, Stroop interference, motor inhibition, and working memory, women with BPD made significantly more disadvantageous IGT decisions than controls (Cohen's d = .72) that were unrelated to substance abuse history, education, psychotropic use, or attentional deficits. Correlates of EF and IGT performance varied by group. Intellect, BPD, and intact behavioral control explained 35% of the adjusted variance in net IGT performance. Disadvantageous IGT decision making was the only EF to predict BPD. IGT deficits in BPD may be separable from IQ and other EF as supported by the somatic marker hypothesis and suggest a stable, trait-like vulnerability favoring immediate reward over long-term gain in women with the disorder.

  10. Getting out alive: how predators affect the decision to metamorphose.

    PubMed

    Relyea, Rick A

    2007-06-01

    Metamorphosis has intrigued biologists for a long time as an extreme form of complex life cycles that are ubiquitous in animals. While investigated from a variety of perspectives, the ecological focus has been on identifying and understanding the ecological factors that affect an individual's decision on when, and at what size, to metamorphose. Predation is a major factor that affects metamorphic decisions and a recent review by Benard (Annu Rev Ecol Evol Syst 35:651-673, 2004)) documented how predator cues induce metamorphic changes relative to model predictions. Importantly, however, real predators affect larval prey via several mechanisms beyond simple induction. In this paper, I contrast the leading models of metamorphosis, provide an overview of the multiple ways that predators can directly and indirectly affect larval growth and development (via induction, thinning, and selection), and identify how each process should affect the time to and size at metamorphosis. With this mechanistic foundation established, I then turn to the well-studied model system of larval amphibians to synthesize studies on: (1) caged predators (which cause only induction), and (2) lethal predators (which cause induction, thinning, and selection). Among the caged-predator studies, the chemical cues emitted by predators rarely induce a smaller size at metamorphosis or a shorter time to metamorphosis, which is in direct contrast to theoretical predictions but in agreement with Benard's (Annu Rev Ecol Evol Syst 35:651-673, 2004) review based on a considerably smaller dataset. Among the lethal-predator studies, there is a diversity of outcomes depending upon the relative importance of induction versus thinning with the relative importance of the two processes appearing to change with larval density. Finally, I review the persistent effects of larval predators after metamorphosis including both phenotypic and fitness effects. At the end, I outline a number of future directions to allow

  11. Decision Aids for Multiple-Decision Disease Management as Affected by Weather Input Errors

    Technology Transfer Automated Retrieval System (TEKTRAN)

    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...

  12. Affective and cognitive mechanisms of risky decision making.

    PubMed

    Shimp, Kristy G; Mitchell, Marci R; Beas, B Sofia; Bizon, Jennifer L; Setlow, Barry

    2015-01-01

    The ability to make advantageous decisions under circumstances in which there is a risk of adverse consequences is an important component of adaptive behavior; however, extremes in risk taking (either high or low) can be maladaptive and are characteristic of a number of neuropsychiatric disorders. To better understand the contributions of various affective and cognitive factors to risky decision making, cohorts of male Long-Evans rats were trained in a "Risky Decision making Task" (RDT), in which they made discrete trial choices between a small, "safe" food reward and a large, "risky" food reward accompanied by varying probabilities of footshock. Experiment 1 evaluated the relative contributions of the affective stimuli (i.e., punishment vs. reward) to RDT performance by parametrically varying the magnitudes of the footshock and large reward. Varying the shock magnitude had a significant impact on choice of the large, "risky" reward, such that greater magnitudes were associated with reduced choice of the large reward. In contrast, varying the large, "risky" reward magnitude had minimal influence on reward choice. Experiment 2 compared individual variability in RDT performance with performance in an attentional set shifting task (assessing cognitive flexibility), a delayed response task (assessing working memory), and a delay discounting task (assessing impulsive choice). Rats characterized as risk averse in the RDT made more perseverative errors on the set shifting task than did their risk taking counterparts, whereas RDT performance was not related to working memory abilities or impulsive choice. In addition, rats that showed greater delay discounting (greater impulsive choice) showed corresponding poorer performance in the working memory task. Together, these results suggest that reward-related decision making under risk of punishment is more strongly influenced by the punishment than by the reward, and that risky and impulsive decision making are associated with

  13. Clinical Decision Support Systems and Prevention

    PubMed Central

    Njie, Gibril J.; Proia, Krista K.; Thota, Anilkrishna B.; Finnie, Ramona K.C.; Hopkins, David P.; Banks, Starr M.; Callahan, David B.; Pronk, Nicolaas P.; Rask, Kimberly J.; Lackland, Daniel T.; Kottke, Thomas E.

    2016-01-01

    Context Clinical decision support systems (CDSSs) can help clinicians assess cardiovascular disease (CVD) risk and manage CVD risk factors by providing tailored assessments and treatment recommendations based on individual patient data. The goal of this systematic review was to examine the effectiveness of CDSSs in improving screening for CVD risk factors, practices for CVD-related preventive care services such as clinical tests and prescribed treatments, and management of CVD risk factors. Evidence acquisition An existing systematic review (search period, January 1975–January 2011) of CDSSs for any condition was initially identified. Studies of CDSSs that focused on CVD prevention in that review were combined with studies identified through an updated search (January 2011–October 2012). Data analysis was conducted in 2013. Evidence synthesis A total of 45 studies qualified for inclusion in the review. Improvements were seen for recommended screening and other preventive care services completed by clinicians, recommended clinical tests completed by clinicians, and recommended treatments prescribed by clinicians (median increases of 3.8, 4.0, and 2.0 percentage points, respectively). Results were inconsistent for changes in CVD risk factors such as systolic and diastolic blood pressure, total and low-density lipoprotein cholesterol, and hemoglobin A1C levels. Conclusions CDSSs are effective in improving clinician practices related to screening and other preventive care services, clinical tests, and treatments. However, more evidence is needed from implementation of CDSSs within the broad context of comprehensive service delivery aimed at reducing CVD risk and CVD-related morbidity and mortality. PMID:26477805

  14. WaterlooClarke: TREC 2015 Clinical Decision Support Track

    DTIC Science & Technology

    2015-11-20

    WaterlooClarke: TREC 2015 Clinical Decision Support Track Amira Ghenai1, Eldar Khalilov1, Pavel Valov1, and Charles L. A. Clarke1 1Department of...Abstract Clinical decision support systems help physicians with finding additional information about a partic- ular medical case. In this paper, we...develop a clinical decision support system that, based on a short medical case description, can recommend research articles to answer some common

  15. Serotonin and Dopamine: Unifying Affective, Activational, and Decision Functions

    PubMed Central

    Cools, Roshan; Nakamura, Kae; Daw, Nathaniel D

    2011-01-01

    Serotonin, like dopamine (DA), has long been implicated in adaptive behavior, including decision making and reinforcement learning. However, although the two neuromodulators are tightly related and have a similar degree of functional importance, compared with DA, we have a much less specific understanding about the mechanisms by which serotonin affects behavior. Here, we draw on recent work on computational models of dopaminergic function to suggest a framework by which many of the seemingly diverse functions associated with both DA and serotonin—comprising both affective and activational ones, as well as a number of other functions not overtly related to either—can be seen as consequences of a single root mechanism. PMID:20736991

  16. 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…

  17. The value of foresight: how prospection affects decision-making.

    PubMed

    Pezzulo, Giovanni; Rigoli, Francesco

    2011-01-01

    Traditional theories of decision-making assume that utilities are based on the intrinsic value of outcomes; in turn, these values depend on associations between expected outcomes and the current motivational state of the decision-maker. This view disregards the fact that humans (and possibly other animals) have prospection abilities, which permit anticipating future mental processes and motivational and emotional states. For instance, we can evaluate future outcomes in light of the motivational state we expect to have when the outcome is collected, not (only) when we make a decision. Consequently, we can plan for the future and choose to store food to be consumed when we expect to be hungry, not immediately. Furthermore, similarly to any expected outcome, we can assign a value to our anticipated mental processes and emotions. It has been reported that (in some circumstances) human subjects prefer to receive an unavoidable punishment immediately, probably because they are anticipating the dread associated with the time spent waiting for the punishment. This article offers a formal framework to guide neuroeconomic research on how prospection affects decision-making. The model has two characteristics. First, it uses model-based Bayesian inference to describe anticipation of cognitive and motivational processes. Second, the utility-maximization process considers these anticipations in two ways: to evaluate outcomes (e.g., the pleasure of eating a pie is evaluated differently at the beginning of a dinner, when one is hungry, and at the end of the dinner, when one is satiated), and as outcomes having a value themselves (e.g., the case of dread as a cost of waiting for punishment). By explicitly accounting for the relationship between prospection and value, our model provides a framework to reconcile the utility-maximization approach with psychological phenomena such as planning for the future and dread.

  18. The Value of Foresight: How Prospection Affects Decision-Making

    PubMed Central

    Pezzulo, Giovanni; Rigoli, Francesco

    2011-01-01

    Traditional theories of decision-making assume that utilities are based on the intrinsic value of outcomes; in turn, these values depend on associations between expected outcomes and the current motivational state of the decision-maker. This view disregards the fact that humans (and possibly other animals) have prospection abilities, which permit anticipating future mental processes and motivational and emotional states. For instance, we can evaluate future outcomes in light of the motivational state we expect to have when the outcome is collected, not (only) when we make a decision. Consequently, we can plan for the future and choose to store food to be consumed when we expect to be hungry, not immediately. Furthermore, similarly to any expected outcome, we can assign a value to our anticipated mental processes and emotions. It has been reported that (in some circumstances) human subjects prefer to receive an unavoidable punishment immediately, probably because they are anticipating the dread associated with the time spent waiting for the punishment. This article offers a formal framework to guide neuroeconomic research on how prospection affects decision-making. The model has two characteristics. First, it uses model-based Bayesian inference to describe anticipation of cognitive and motivational processes. Second, the utility-maximization process considers these anticipations in two ways: to evaluate outcomes (e.g., the pleasure of eating a pie is evaluated differently at the beginning of a dinner, when one is hungry, and at the end of the dinner, when one is satiated), and as outcomes having a value themselves (e.g., the case of dread as a cost of waiting for punishment). By explicitly accounting for the relationship between prospection and value, our model provides a framework to reconcile the utility-maximization approach with psychological phenomena such as planning for the future and dread. PMID:21747755

  19. Clinical decision-making in senior nursing students in Iran.

    PubMed

    Jahanpour, Faezeh; Sharif, Farkhondeh; Salsali, Mahvash; Kaveh, Mohammad H; Williams, Leonie M

    2010-12-01

    Clinical decision-making is the basis for professional nursing practice. This can be taught and learned through appropriate teaching and clinical experiences. Unfortunately, it has been observed that many graduates are unable to demonstrate suitable clinical decision-making skills. Research and study on the process of decision-making and factors influencing it assists educators to find the appropriate educational and clinical strategies to teach nursing students. To explore the experience of nursing students and their view points regarding the factors influencing their development of clinical decision-making skills. An exploratory qualitative approach utilizing grounded theory methods was used; focus group interviews were undertaken with 32 fourth year nursing students and data were analysed using constant comparative analysis. Four main themes emerged from the data: clinical instructor incompetency, low self-efficacy, unconducive clinical learning climate and experiencing stress. The data indicated that students could not make clinical decisions independently. The findings of this study support the need to reform aspects of the curriculum in Iran in order to increase theory-practice integration and prepare a conductive clinical learning climate that enhances learning clinical decision-making with less stress.

  20. 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

  1. Personalizing Drug Selection Using Advanced Clinical Decision Support.

    PubMed

    Pestian, John; Spencer, Malik; Matykiewicz, Pawel; Zhang, Kejian; Vinks, Alexander A; Glauser, Tracy

    2009-06-23

    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.

  2. Improving children's affective decision making in the Children's Gambling Task.

    PubMed

    Andrews, Glenda; Moussaumai, Jennifer

    2015-11-01

    Affective decision making was examined in 108 children (3-, 4-, and 5-year-olds) using the Children's Gambling Task (CGT). Children completed the CGT and then responded to awareness questions. Children in the binary_experience and binary_experience+awareness (not control) conditions first completed two simpler versions. Children in the binary_experience+awareness condition also responded to questions about relational components of the simpler versions. Experience with simpler versions facilitated decision making in 4- and 5-year-olds, but 3-year-olds' advantageous choices declined across trial blocks in the binary_experience and control conditions. Responding to questions about relational components further benefited the 4- and 5-year-olds. The 3-year-olds' advantageous choices on the final block were at chance level in the binary_experience+awareness condition but were below chance level in the other conditions. Awareness following the CGT was strongly correlated with advantageous choices and with age. Awareness was demonstrated by 5-year-olds (all conditions) and 4-year-olds (binary_experience and binary_experience+awareness) but not by 3-year-olds. The findings demonstrate the importance of complexity and conscious awareness in cognitive development.

  3. Patient decision-making for clinical genetics.

    PubMed

    Anderson, Gwen

    2007-03-01

    Medicine is incorporating genetic services into all avenues of health-care, ranging from the rarest to the most common diseases. Cognitive theories of decision-making still dominate professionals' understanding of patient decision-making about how to use genetic information and whether to have testing. I discovered a conceptual model of decision-making while carrying out a phenomenological-hermeneutic descriptive study of a convenience sample of 12 couples who were interviewed while deciding whether to undergo prenatal genetic testing. Thirty-two interviews were conducted with 12 men and 12 women separately. Interviews were transcribed verbatim and all data were analyzed using three levels of coding that were sorted into 30 categories and then abstracted into three emergent meta-themes that described men's and women's attempts to make sense and find meaning in how to best use prenatal genetic technology. Their descriptions of how they thought about, communicated, and coped with their decision were so detailed it was possible to discern nine different types of thinking they engaged in while deciding to accept or decline testing. They believed that decision-making is a process of working through your own personal style of thinking. This might include only one or any combination of the following types of thinking: analytical, ethical, moral, reflective, practical, hypothetical, judgmental, scary, and second sight, as described in detail by these 12 couples.

  4. Clinical Decision Making among Dental Students and General Practitioners.

    ERIC Educational Resources Information Center

    Grembowski, David; And Others

    1989-01-01

    Senior dental students and family dental practitioners were surveyed concerning their choice of pairs of alternative treatments and the technical and patient factors influencing their decisions. Greater agreement in clinical decision-making was found among dentists than among students for all four pairs of alternative services. (MSE)

  5. The factors facilitating and inhibiting effective clinical decision-making in nursing: a qualitative study

    PubMed Central

    Hagbaghery, Mohsen Adib; Salsali, Mahvash; Ahmadi, Fazlolah

    2004-01-01

    Background Nurses' practice takes place in a context of ongoing advances in research and technology. The dynamic and uncertain nature of health care environment requires nurses to be competent decision-makers in order to respond to clients' needs. Recently, the public and the government have criticized Iranian nurses because of poor quality of patient care. However nurses' views and experiences on factors that affect their clinical function and clinical decision-making have rarely been studied. Methods Grounded theory methodology was used to analyze the participants' lived experiences and their viewpoints regarding the factors affecting their clinical function and clinical decision-making. Semi-structured interviews and participant observation methods were used to gather the data. Thirty-eight participants were interviewed and twelve sessions of observation were carried out. Constant comparative analysis method was used to analyze the data. Results Five main themes emerged from the data. From the participants' points of view, "feeling competent", "being self-confident", "organizational structure", "nursing education", and "being supported" were considered as important factors in effective clinical decision-making. Conclusion As participants in this research implied, being competent and self-confident are the most important personal factors influencing nurses clinical decision-making. Also external factors such as organizational structure, access to supportive resources and nursing education have strengthening or inhibiting effects on the nurses' decisions. Individual nurses, professional associations, schools of nursing, nurse educators, organizations that employ nurses and government all have responsibility for developing and finding strategies that facilitate nurses' effective clinical decision-making. They are responsible for identifying barriers and enhancing factors within the organizational structure that facilitate nurses' clinical decision-making. PMID

  6. The factors facilitating and inhibiting effective clinical decision-making in nursing: a qualitative study.

    PubMed

    Hagbaghery, Mohsen Adib; Salsali, Mahvash; Ahmadi, Fazlolah

    2004-04-06

    BACKGROUND: Nurses' practice takes place in a context of ongoing advances in research and technology. The dynamic and uncertain nature of health care environment requires nurses to be competent decision-makers in order to respond to clients' needs. Recently, the public and the government have criticized Iranian nurses because of poor quality of patient care. However nurses' views and experiences on factors that affect their clinical function and clinical decision-making have rarely been studied. METHODS: Grounded theory methodology was used to analyze the participants' lived experiences and their viewpoints regarding the factors affecting their clinical function and clinical decision-making. Semi-structured interviews and participant observation methods were used to gather the data. Thirty-eight participants were interviewed and twelve sessions of observation were carried out. Constant comparative analysis method was used to analyze the data. RESULTS: Five main themes emerged from the data. From the participants' points of view, "feeling competent", "being self-confident", "organizational structure", "nursing education", and "being supported" were considered as important factors in effective clinical decision-making. CONCLUSION: As participants in this research implied, being competent and self-confident are the most important personal factors influencing nurses clinical decision-making. Also external factors such as organizational structure, access to supportive resources and nursing education have strengthening or inhibiting effects on the nurses' decisions. Individual nurses, professional associations, schools of nursing, nurse educators, organizations that employ nurses and government all have responsibility for developing and finding strategies that facilitate nurses' effective clinical decision-making. They are responsible for identifying barriers and enhancing factors within the organizational structure that facilitate nurses' clinical decision-making.

  7. The reliability of an epilepsy treatment clinical decision support system.

    PubMed

    Standridge, Shannon; Faist, Robert; Pestian, John; Glauser, Tracy; Ittenbach, Richard

    2014-10-01

    We developed a content validated computerized epilepsy treatment clinical decision support system to assist clinicians with selecting the best antiepilepsy treatments. Before disseminating our computerized epilepsy treatment clinical decision support system, further rigorous validation testing was necessary. As reliability is a precondition of validity, we verified proof of reliability first. We evaluated the consistency of the epilepsy treatment clinical decision support system in three areas including the preferred antiepilepsy drug choice, the top three recommended choices, and the rank order of the three choices. We demonstrated 100% reliability on 15,000 executions involving a three-step process on five different common pediatric epilepsy syndromes. Evidence for the reliability of the epilepsy treatment clinical decision support system was essential for the long-term viability of the system, and served as a crucial component for the next phase of system validation.

  8. A Framework and Model for Evaluating Clinical Decision Support Architectures

    PubMed Central

    Wright, Adam; Sittig, Dean F.

    2008-01-01

    In this paper, we develop a four-phase model for evaluating architectures for clinical decision support that focuses on: defining a set of desirable features for a decision support architecture; building a proof-of-concept prototype; demonstrating that the architecture is useful by showing that it can be integrated with existing decision support systems and comparing its coverage to that of other architectures. We apply this framework to several well-known decision support architectures, including Arden Syntax, GLIF, SEBASTIAN and SAGE PMID:18462999

  9. Developing and implementing computerized protocols for standardization of clinical decisions.

    PubMed

    Morris, A H

    2000-03-07

    Humans have only a limited ability to incorporate information in decision making. In certain situations, the mismatch between this limitation and the availability of extensive information contributes to the varying performance and high error rate of clinical decision makers. Variation in clinical practice is due in part to clinicians' poor compliance with guidelines and recommended therapies. The use of decision-support tools is a response to both the information revolution and poor compliance. Computerized protocols used to deliver decision support can be configured to contain much more detail than textual guidelines or paper-based flow diagrams. Such protocols can generate patient-specific instructions for therapy that can be carried out with little interclinician variability; however, clinicians must be willing to modify personal styles of clinical management. Protocols need not be perfect. Several defensible and reasonable approaches are available for clinical problems. However, one of these reasonable approaches must be chosen and incorporated into the protocol to promote consistent clinical decisions. This reasoning is the basis of an explicit method of decision support that allows the rigorous evaluation of interventions, including use of the protocols themselves. Computerized protocols for mechanical ventilation and management of intravenous fluid and hemodynamic factors in patients with the acute respiratory distress syndrome provide case studies for this discussion.

  10. The relationship of career decision self-efficacy, trait anxiety, and affectivity among undergraduate students.

    PubMed

    Işik, Erkan

    2012-12-01

    This study examined the relationship between career decision self-efficacy and personal-emotional life, including trait anxiety and positive and negative affect in a sample of 249 undergraduate students. Turkish versions of career decision self-efficacy scale-short form, positive and negative affect schedule, and trait anxiety inventory were administrated. Higher career decision self-efficacy was associated with higher positive affectivity and lower trait anxiety and negative affectivity. Trait anxiety and positive affect were the significant predictors of career decision self-efficacy. Implications for career counseling and ideas for future research were discussed.

  11. Reducing Diagnostic Error with Computer-Based Clinical Decision Support

    ERIC Educational Resources Information Center

    Greenes, Robert A.

    2009-01-01

    Information technology approaches to delivering diagnostic clinical decision support (CDS) are the subject of the papers to follow in the proceedings. These will address the history of CDS and present day approaches (Miller), evaluation of diagnostic CDS methods (Friedman), and the role of clinical documentation in supporting diagnostic decision…

  12. Virtual medical record implementation for enhancing clinical decision support.

    PubMed

    Gomoi, Valentin-Sergiu; Dragu, Daniel; Stoicu-Tivadar, Vasile

    2012-01-01

    Development of clinical decision support systems (CDS) is a process which highly depends on the local databases, this resulting in low interoperability. To increase the interoperability of CDS a standard representation of clinical information is needed. The paper suggests a CDS architecture which integrates several HL7 standards and the new vMR (virtual Medical Record). The clinical information for the CDS systems (the vMR) is represented with Topic Maps technology. Beside the implementation of the vMR, the architecture integrates: a Data Manager, an interface, a decision making system (based on Egadss), a retrieving data module. Conclusions are issued.

  13. Clinical decision support: the power behind the electronic health record.

    PubMed

    Glaser, John

    2008-07-01

    There are six strategic objectives for promoting adoption of clinical decision support: Use a standardized format for representing clinical data and CDS interventions. Ensure appropriate access to clinical data and CDS interventions. Provide support and incentives for providers to use CDS. Disseminate information about best practices for system design, CDS delivery, and CDS implementation. Continue national demonstrations and evaluation of CDS use. Leverage data interchange between EHRs.

  14. The thinking doctor: clinical decision making in contemporary medicine.

    PubMed

    Trimble, Michael; Hamilton, Paul

    2016-08-01

    Diagnostic errors are responsible for a significant number of adverse events. Logical reasoning and good decision-making skills are key factors in reducing such errors, but little emphasis has traditionally been placed on how these thought processes occur, and how errors could be minimised. In this article, we explore key cognitive ideas that underpin clinical decision making and suggest that by employing some simple strategies, physicians might be better able to understand how they make decisions and how the process might be optimised.

  15. Medical and nursing clinical decision making: a comparative epistemological analysis.

    PubMed

    Rashotte, Judy; Carnevale, F A

    2004-07-01

    The aim of this article is to explore the complex forms of knowledge involved in diagnostic and interventional decision making by comparing the processes in medicine and nursing, including nurse practitioners. Many authors assert that the practice of clinical decision making involves the application of theoretical knowledge (acquired in the classroom and textbooks) as well as research evidence, upon concrete particular cases. This approach draws on various universal principles and algorithms to facilitate the task. On the other hand, others argue that this involves an intuitive form of judgement that is difficult to teach, one that is acquired principally through experience. In an exploration of these issues, this article consists of three sections. A clarification of terms commonly used when discussing decision making is provided in the first section. In the second section, an epistemological analysis of decision making is presented by examining several perspectives and comparing them for their use in the nursing and medical literature. Bunge's epistemological framework for decision making (based on scientific realism) is explored for its fit with the aims of medicine and nursing. The final section presents a discussion of knowledge utilization and decision making as it relates to the implications for the education and ongoing development of nurse practitioners. It is concluded that Donald Schön's conception of reflective practice best characterizes the skillful conduct of clinical decision making.

  16. Automating Guidelines for Clinical Decision Support: Knowledge Engineering and Implementation

    PubMed Central

    Tso, Geoffrey J.; Tu, Samson W.; Oshiro, Connie; Martins, Susana; Ashcraft, Michael; Yuen, Kaeli W.; Wang, Dan; Robinson, Amy; Heidenreich, Paul A.; Goldstein, Mary K.

    2016-01-01

    As utilization of clinical decision support (CDS) increases, it is important to continue the development and refinement of methods to accurately translate the intention of clinical practice guidelines (CPG) into a computable form. In this study, we validate and extend the 13 steps that Shiffman et al.5 identified for translating CPG knowledge for use in CDS. During an implementation project of ATHENA-CDS, we encoded complex CPG recommendations for five common chronic conditions for integration into an existing clinical dashboard. Major decisions made during the implementation process were recorded and categorized according to the 13 steps. During the implementation period, we categorized 119 decisions and identified 8 new categories required to complete the project. We provide details on an updated model that outlines all of the steps used to translate CPG knowledge into a CDS integrated with existing health information technology. PMID:28269916

  17. What can Natural Language Processing do for Clinical Decision Support?

    PubMed Central

    Demner-Fushman, Dina; Chapman, Wendy W.; McDonald, Clement J.

    2009-01-01

    Computerized Clinical Decision Support (CDS) aims to aid decision making of health care providers and the public by providing easily accessible health-related information at the point and time it is needed. Natural Language Processing (NLP) is instrumental in using free-text information to drive CDS, representing clinical knowledge and CDS interventions in standardized formats, and leveraging clinical narrative. The early innovative NLP research of clinical narrative was followed by a period of stable research conducted at the major clinical centers and a shift of mainstream interest to biomedical NLP. This review primarily focuses on the recently renewed interest in development of fundamental NLP methods and advances in the NLP systems for CDS. The current solutions to challenges posed by distinct sublanguages, intended user groups, and support goals are discussed. PMID:19683066

  18. Semantic Interoperability in Clinical Decision Support Systems: A Systematic Review.

    PubMed

    Marco-Ruiz, Luis; Bellika, Johan Gustav

    2015-01-01

    The interoperability of Clinical Decision Support (CDS) systems with other health information systems has become one of the main limitations to their broad adoption. Semantic interoperability must be granted in order to share CDS modules across different health information systems. Currently, numerous standards for different purposes are available to enable the interoperability of CDS systems. We performed a literature review to identify and provide an overview of the available standards that enable CDS interoperability in the areas of clinical information, decision logic, terminology, and web service interfaces.

  19. Factors affecting clinical reasoning of occupational therapists: a qualitative study

    PubMed Central

    Shafaroodi, Narges; Kamali, Mohammad; Parvizy, Soroor; Mehraban, Afsoon Hassani; O’Toole, Giyn

    2014-01-01

    Background: Clinical reasoning is generally defined as the numerous modes of thinking that guide clinical practice but little is known about the factors affecting how occupational therapists manage the decision-making process. The aim of this qualitative study was to explore the factors influencing the clinical reasoning of occupational therapists. Methods: Twelve occupational therapy practitioners working in mental and physical dysfunction fields participated in this study. The sampling method was purposeful and interviews were continued until data saturation. All the interviews were recorded and transcribed. The data were analyzed through a qualitative content analysis method. Results: There were three main themes. The first theme: socio-cultural conditions included three subthemes: 1- client beliefs; 2- therapist values and beliefs; 3- social attitude to disability. The second theme: individual attributions included two subthemes 1- client attributions; 2- therapist attributions. The final theme was the workplace environment with the three subthemes: 1- knowledge of the managers of rehabilitation services, 2- working in an inter-professional team; 3- limited clinical facilities and resources. Conclusion: In this study, the influence of the attitudes and beliefs of client, therapist and society about illness, abilities and disabilities upon reasoning was different to previous studies. Understanding these factors, especially the socio-cultural beliefs basis can play a significant role in the quality of occupational therapy services. Accurate understanding of these influential factors requires more extensive qualitative and quantitative studies. PMID:25250253

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

    PubMed Central

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

    2015-01-01

    Background 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. Methods 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. Results 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. Conclusions 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. PMID:26697443

  1. The role of emotions in clinical reasoning and decision making.

    PubMed

    Marcum, James A

    2013-10-01

    What role, if any, should emotions play in clinical reasoning and decision making? Traditionally, emotions have been excluded from clinical reasoning and decision making, but with recent advances in cognitive neuropsychology they are now considered an important component of them. Today, cognition is thought to be a set of complex processes relying on multiple types of intelligences. The role of mathematical logic (hypothetico-deductive thinking) or verbal linguistic intelligence in cognition, for example, is well documented and accepted; however, the role of emotional intelligence has received less attention-especially because its nature and function are not well understood. In this paper, I argue for the inclusion of emotions in clinical reasoning and decision making. To that end, developments in contemporary cognitive neuropsychology are initially examined and analyzed, followed by a review of the medical literature discussing the role of emotions in clinical practice. Next, a published clinical case is reconstructed and used to illustrate the recognition and regulation of emotions played during a series of clinical consultations, which resulted in a positive medical outcome. The paper's main thesis is that emotions, particularly in terms of emotional intelligence as a practical form of intelligence, afford clinical practitioners a robust cognitive resource for providing quality medical care.

  2. Improving Congestive Heart Failure Care with a Clinical Decision Unit.

    PubMed

    Carpenter, Jo Ellen; Short, Nancy; Williams, Tracy E; Yandell, Ben; Bowers, Margaret T

    2015-01-01

    Evidence supporting the development of Clinical Decision Units (CDUs) to impact congestive heart failure readmission rates comes from several categories of the literature. In this study, a pre-post design with comparison group was used to evaluate the impact of the CDU. Early changes in clinical and financial outcome indicators are encouraging. Nurse leaders seek ways to improve clinical outcomes while managing the current financially challenging environment. Implementation of a CDU provides many opportunities for nurse leaders to positively impact clinical care and financial performance within their institutions.

  3. Students' Perceptions of Factors that Affect College Funding Decisions

    ERIC Educational Resources Information Center

    Porter, Julia Y.; Fossey, W. Richard; Davis, William E.; Burnett, Michael F.; Stuhlmann, Janice; Suchy, Patricia A.

    2006-01-01

    This exploratory study examines the factors that college students perceive are important in helping them make good financial decisions about paying for a college education. The study categorizes and summarizes students' self-reported responses to an open-ended survey question about recommendations for changes in financial aid counseling practices.…

  4. Planning horizon affects prophylactic decision-making and epidemic dynamics

    PubMed Central

    Ridenhour, Benjamin J.; Krone, Stephen M.

    2016-01-01

    The spread of infectious diseases can be impacted by human behavior, and behavioral decisions often depend implicitly on a planning horizon—the time in the future over which options are weighed. We investigate the effects of planning horizons on epidemic dynamics. We developed an epidemiological agent-based model (along with an ODE analog) to explore the decision-making of self-interested individuals on adopting prophylactic behavior. The decision-making process incorporates prophylaxis efficacy and disease prevalence with the individuals’ payoffs and planning horizon. Our results show that for short and long planning horizons individuals do not consider engaging in prophylactic behavior. In contrast, individuals adopt prophylactic behavior when considering intermediate planning horizons. Such adoption, however, is not always monotonically associated with the prevalence of the disease, depending on the perceived protection efficacy and the disease parameters. Adoption of prophylactic behavior reduces the epidemic peak size while prolonging the epidemic and potentially generates secondary waves of infection. These effects can be made stronger by increasing the behavioral decision frequency or distorting an individual’s perceived risk of infection. PMID:27843714

  5. Hip Arthroplasty Pseudotumors: Pathogenesis, Imaging, and Clinical Decision Making

    PubMed Central

    Davis, Derik L; Morrison, James J

    2016-01-01

    Pseudotumors are a complication of hip arthroplasty. The goal of this article is to review the clinical presentation, pathogenesis, histology, and the role of diagnostic imaging in clinical decision making for treatment, and surveillance of pseudotumors. We will discuss the multimodal imaging appearances, differential diagnosis, associated complications, treatment, and prognosis of pseudotumors, as an aid to the assessment of orthopedic prostheses at the hip. PMID:27195183

  6. Thinking Processes Used by Nurses in Clinical Decision Making.

    ERIC Educational Resources Information Center

    Higuchi, Kathryn A. Smith; Donald, Janet G.

    2002-01-01

    Interviews with eight medical and surgical nurses and audits of patient charts investigated clinical decision-making processes. Predominant thinking processes were description of facts, selection of information, inference, syntheses, and verification, with differences between medical and surgical specialties. Exemplars of thinking processes…

  7. Key External Influences Affecting Consumers’ Decisions Regarding Food

    PubMed Central

    Martínez-Ruiz, María Pilar; Gómez-Cantó, Carmen María

    2016-01-01

    Among the numerous internal and external forces that compete for consumers’ attention in the context in which they buy their food, this paper will seek to provide a review of the most important external influences, such as the variables related to food itself. To this end, in addition to the food attributes traditionally identified in fields such as consumer behavior, it will give special consideration to the classification of food values. Although the influence of these variables on consumer decisions depends on the individual, analyzing them will undoubtedly increase understanding of consumers’ decisions. Additionally, identifying and describing these variables will enable subsequent research on how they influence both consumer behavior and other key outcomes for producers, manufacturers, and retailers in the food industry, such as satisfaction, trust, and loyalty. PMID:27803686

  8. 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.

  9. Clinical Decision Support Systems for Comorbidity: Architecture, Algorithms, and Applications

    PubMed Central

    Fan, Aihua; Tang, Yu

    2017-01-01

    In this paper, we present the design of a clinical decision support system (CDSS) for monitoring comorbid conditions. Specifically, we address the architecture of a CDSS by characterizing it from three layers and discuss the algorithms in each layer. Also we address the applications of CDSSs in a few real scenarios and analyze the accuracy of a CDSS in consideration of the potential conflicts when using multiple clinical practice guidelines concurrently. Finally, we compare the system performance in our design with that in the other design schemes. Our study shows that our proposed design can achieve a clinical decision in a shorter time than the other designs, while ensuring a high level of system accuracy. PMID:28373881

  10. Improving the implementation of clinical decision support systems.

    PubMed

    Rüping, Stefan; Anguita, Alberto; Bucur, Anca; Cirstea, Traian Cristian; Jacobs, Björn; Torge, Antje

    2013-01-01

    Clinical decision support (CDS) systems promise to improve the quality of clinical care by helping physicians to make better, more informed decisions efficiently. However, the design and testing of CDS systems for practical medical use is cumbersome. It has been recognized that this may easily lead to a problematic mismatch between the developers' idea of the system and requirements from clinical practice. In this paper, we will present an approach to reduce the complexity of constructing a CDS system. The approach is based on an ontological annotation of data resources, which improves standardization and the semantic processing of data. This, in turn, allows to use data mining tools to automatically create hypotheses for CDS models, which reduces the manual workload in the creation of a new model. The approach is implemented in the context of EU research project p-medicine. A proof of concept implementation on data from an existing Leukemia study is presented.

  11. Dynamic clinical data mining: search engine-based decision support.

    PubMed

    Celi, Leo Anthony; Zimolzak, Andrew J; Stone, David J

    2014-06-23

    The research world is undergoing a transformation into one in which data, on massive levels, is freely shared. In the clinical world, the capture of data on a consistent basis has only recently begun. We propose an operational vision for a digitally based care system that incorporates data-based clinical decision making. The system would aggregate individual patient electronic medical data in the course of care; query a universal, de-identified clinical database using modified search engine technology in real time; identify prior cases of sufficient similarity as to be instructive to the case at hand; and populate the individual patient's electronic medical record with pertinent decision support material such as suggested interventions and prognosis, based on prior outcomes. Every individual's course, including subsequent outcomes, would then further populate the population database to create a feedback loop to benefit the care of future patients.

  12. 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.

  13. Clinical Decision Support for Immunizations (CDSi): A Comprehensive, Collaborative Strategy

    PubMed Central

    Arzt, Noam H.

    2016-01-01

    This article focuses on the requirements and current developments in clinical decision support technologies for immunizations (CDSi) in both the public health and clinical communities, with an emphasis on shareable solutions. The requirements of the Electronic Health Record Incentive Programs have raised some unique challenges for the clinical community, including vocabulary mapping, update of changing guidelines, single immunization schedule, and scalability. This article discusses new, collaborative approaches whose long-term goal is to make CDSi more sustainable for both the public and private sectors. PMID:27789956

  14. The Relationship Between the Clinical Orientation of Substance Abuse Professionals and Their Clinical Decisions

    ERIC Educational Resources Information Center

    Toriello, Paul J.; Leierer, Stephen J.

    2005-01-01

    In this study, the authors examined the relationship between the clinical orientations of substance abuse professionals (SAPs) and their clinical decisions. Cluster analysis grouped a sample of 245 SAPs on two clinical orientations that differed in their relative endorsement of traditional versus contemporary substance abuse counseling processes…

  15. Elapsed decision time affects the weighting of prior probability in a perceptual decision task.

    PubMed

    Hanks, Timothy D; Mazurek, Mark E; Kiani, Roozbeh; Hopp, Elisabeth; Shadlen, Michael N

    2011-04-27

    Decisions are often based on a combination of new evidence with prior knowledge of the probable best choice. Optimal combination requires knowledge about the reliability of evidence, but in many realistic situations, this is unknown. Here we propose and test a novel theory: the brain exploits elapsed time during decision formation to combine sensory evidence with prior probability. Elapsed time is useful because (1) decisions that linger tend to arise from less reliable evidence, and (2) the expected accuracy at a given decision time depends on the reliability of the evidence gathered up to that point. These regularities allow the brain to combine prior information with sensory evidence by weighting the latter in accordance with reliability. To test this theory, we manipulated the prior probability of the rewarded choice while subjects performed a reaction-time discrimination of motion direction using a range of stimulus reliabilities that varied from trial to trial. The theory explains the effect of prior probability on choice and reaction time over a wide range of stimulus strengths. We found that prior probability was incorporated into the decision process as a dynamic bias signal that increases as a function of decision time. This bias signal depends on the speed-accuracy setting of human subjects, and it is reflected in the firing rates of neurons in the lateral intraparietal area (LIP) of rhesus monkeys performing this task.

  16. Decisions That Affect Outcomes in the Distant Future.

    DTIC Science & Technology

    1979-12-01

    75-030-0713 and #78-072-0721 NSF Grant #FNn-72-04149-AO1 9. PERFORMING ORGANIZATION NAME AND ADDRESS 10. PROGRAM ELEMENT. PROJECT, TASK The Board of...lng expoctat in- about the. outcomes by charging or rebat in ; i, each cuotomr. P The concept of a social brokerage ftrm i sinilar to that ,f , charity ...contributes to charities . For this reason, we would ask the individual questions about other decisions and tradeoffs 104 .0. -e e ’. ". ’*- . " 0 Lvd 6 . he has

  17. Evaluative decision latencies mediated by induced affective states.

    PubMed

    Hermans, D; De Houwer, J; Eelen, P

    1996-01-01

    Recent priming studies (e.g. Hermans, De Houwer & Eelen, 1994, Cognition and Emotion, 8, 515-533) have demonstrated that response latencies to target stimuli are mediated by the affective relation between prime and target. The time needed to evaluate or pronounce targets is facilitated if preceded by similarly valenced primes, but is inhibited for trials on which prime and target have an opposite affective valence. These data suggest that information stored in memory is associatively linked with similarly evaluated information, through association with some general representation of goodness or badness. To investigate whether affective priming is merely one type of conventional semantic priming, or whether it is mediated by affective responses, the affective context provided by the primes was replaced in this study by the induction of an emotional state using a Musical Mood Induction procedure (Depression/Elation). Subjects had to evaluate target pictures as quickly as possible. The data revealed a significant Mood Change (More Depressed/Less Depressed/No Change) x Target Valence (Positive/Negative) interaction, indicating that emotional states can mediate evaluate response latencies to affectively valenced target stimuli. The results are interpreted in the context of a biphasic emotion theory, and are related to previous research on mood congruency effects on perceptual responses.

  18. Using nursing clinical decision support systems to achieve meaningful use.

    PubMed

    Harrison, Roberta L; Lyerla, Frank

    2012-07-01

    The Health Information Technology and Clinical Health Act (one component of the American Recovery and Reinvestment Act) is responsible for providing incentive payments to hospitals and eligible providers in an effort to support the adoption of electronic health records. Future penalties are planned for electronic health record noncompliance. In order to receive incentives and avoid penalties, hospitals and eligible providers must demonstrate "meaningful use" of their electronic health records. One of the meaningful-use objectives established by the Centers for Medicare & Medicaid Services involves the use of a clinical decision support rule that addresses a hospital-defined, high-priority condition. This article describes the Plan-Do-Study-Act process for creating and implementing a nursing clinical decision support system designed to improve guideline adherence for hypoglycemia management. This project identifies hypoglycemia management as the high-priority area. However, other facilities with different high-priority conditions may find the process presented in this article useful for implementing additional clinical decision support rules geared toward improving outcomes and meeting federal mandates.

  19. 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.

  20. IBM’s Health Analytics and Clinical Decision Support

    PubMed Central

    Sun, J.; Knoop, S.; Shabo, A.; Carmeli, B.; Sow, D.; Syed-Mahmood, T.; Rapp, W.

    2014-01-01

    Summary Objectives This survey explores the role of big data and health analytics developed by IBM in supporting the transformation of healthcare by augmenting evidence-based decision-making. Methods Some problems in healthcare and strategies for change are described. It is argued that change requires better decisions, which, in turn, require better use of the many kinds of healthcare information. Analytic resources that address each of the information challenges are described. Examples of the role of each of the resources are given. Results There are powerful analytic tools that utilize the various kinds of big data in healthcare to help clinicians make more personalized, evidenced-based decisions. Such resources can extract relevant information and provide insights that clinicians can use to make evidence-supported decisions. There are early suggestions that these resources have clinical value. As with all analytic tools, they are limited by the amount and quality of data. Conclusion Big data is an inevitable part of the future of healthcare. There is a compelling need to manage and use big data to make better decisions to support the transformation of healthcare to the personalized, evidence-supported model of the future. Cognitive computing resources are necessary to manage the challenges in employing big data in healthcare. Such tools have been and are being developed. The analytic resources, themselves, do not drive, but support healthcare transformation. PMID:25123736

  1. Clinical decision support systems: data quality management and governance.

    PubMed

    Liaw, Siaw-Teng

    2013-01-01

    This chapter examines data quality management (DQM) and information governance (IG) of electronic decision support (EDS) systems so that they are safe and fit for use by clinicians and patients and their carers. This is consistent with the ISO definition of data quality as being fit for purpose. The scope of DQM & IG should range from data creation and collection in clinical settings, through cleaning and, where obtained from multiple sources, linkage, storage, use by the EDS logic engine and algorithms, knowledge base and guidance provided, to curation and presentation. It must also include protocols and mechanisms to monitor the safety of EDS, which will feedback into DQM & IG activities. Ultimately, DQM & IG must be integrated across the data cycle to ensure that the EDS systems provide guidance that leads to safe and effective clinical decisions and care.

  2. A Preliminary Investigation of Factors Affecting Appraisal of the Decision to Take Early Retirement.

    ERIC Educational Resources Information Center

    Gowan, Mary A.

    1998-01-01

    Examines why individuals elect to take the early retirement package offered by their employer, as well as factors affecting their appraisal of that decision. Results suggest that all early retirement decisions are not voluntary. Individuals who do not wish to retire and who had lower self-esteem, fewer financial resources, and plans to continue…

  3. Factors Perceived to Affect Delinquent Dispositions in Juvenile Court: Putting the Sentencing Decision into Context.

    ERIC Educational Resources Information Center

    Sanborn, Joseph B., Jr.

    1996-01-01

    One hundred workers from rural, urban, and suburban juvenile courts were interviewed to ascertain their perspectives as to factors that should and do influence sentencing decisions. The data demonstrate that the factors perceived to affect these decisions vary among juvenile courts, making it difficult to determine the impact of any single factor.…

  4. Query Modification through External Sources to Support Clinical Decisions

    DTIC Science & Technology

    2014-11-01

    Query Modification through External Sources to Support Clinical Decisions Raymond Wan1, Jannifer Hiu-Kwan Man2, and Ting-Fung Chan1 1School of Life...query modifications that use either external data sources or a domain expert. While each method gave slightly different results, we discovered that...biomedical literature offers many possible paths of investigation, our study focused on modifications to the query using external data sources. We submitted 5

  5. Clinical Decision Support for Vascular Disease in Community Family Practice

    PubMed Central

    Keshavjee, K; Holbrook, AM; Lau, E; Esporlas-Jewer, I; Troyan, S

    2006-01-01

    The COMPETE III Vascular Disease Tracker (C3VT) is a personalized, Web-based, clinical decision support tool that provides patients and physicians access to a patient’s 16 individual vascular risk markers, specific advice for each marker and links to best practices in vascular disease management. It utilizes the chronic care model1 so that physicians can better manage patients with chronic diseases. Over 1100 patients have been enrolled into the COMPETE III study to date.

  6. 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.

  7. Creating Shareable Clinical Decision Support Rules for a Pharmacogenomics Clinical Guideline Using Structured Knowledge Representation

    PubMed Central

    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. PMID:26958298

  8. 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

  9. The Arithmetic of Emotion: Integration of Incidental and Integral Affect in Judgments and Decisions.

    PubMed

    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.

  10. Influence of data display formats on physician investigators’ decisions to stop clinical trials: prospective trial with repeated measures

    PubMed Central

    Elting, Linda S; Martin, Charles G; Cantor, Scott B; Rubenstein, Edward B

    1999-01-01

    Objective To examine the effect of the method of data display on physician investigators’ decisions to stop hypothetical clinical trials for an unplanned statistical analysis. Design Prospective, mixed model design with variables between subjects and within subjects (repeated measures). Setting Comprehensive cancer centre. Participants 34 physicians, stratified by academic rank, who were conducting clinical trials. Interventions Participants were shown tables, pie charts, bar graphs, and icon displays containing hypothetical data from a clinical trial and were asked to decide whether to continue the trial or stop for an unplanned statistical analysis. Main outcome measure Percentage of accurate decisions with each type of display. Results Accuracy of decisions was affected by the type of data display and positive or negative framing of the data. More correct decisions were made with icon displays than with tables, pie charts, and bar graphs (82% v 68%, 56%, and 43%, respectively; P=0.03) and when data were negatively framed rather than positively framed in tables (93% v 47%; P=0.004). Conclusions Clinical investigators’ decisions can be affected by factors unrelated to the actual data. In the design of clinical trials information systems, careful consideration should be given to the method by which data are framed and displayed in order to reduce the impact of these extraneous factors. Key messagesIn clinical trials formal interim monitoring points, at which statistical tests are conducted, are designated a priori, but investigators also conduct informal interim monitoring, when statistical tests are not usedThis study investigated the effect of the method of displaying results on clinical investigators’ decisions to conduct unplanned analyses of a hypothetical clinical trialThe method of displaying results significantly influenced the accuracy of decisions, as did the framing of these results (positive or negative)The display formats preferred by the

  11. Power and conflict in intensive care clinical decision making.

    PubMed

    Coombs, Maureen

    2003-06-01

    It is clear that current government policy places increasing emphasis on the need for flexible team working. This requires a shared understanding of roles and working practices. However, review of the current literature reveals that such a collaborative working environment has not as yet, been fully achieved. Role definitions and power bases based on traditional and historical boundaries continue to exist. This ethnographic study explores decision making between doctors and nurses in the intensive care environment in order to examine contemporary clinical roles in this clinical specialty. Three intensive care units were selected as field sites and data was collected through participant observation, ethnographic interviews and documentation. A key issue arising in this study is that whilst the nursing role in intensive care has changed, this has had little impact on how clinical decisions are made. Both medical and nursing staff identify conflict during patient management discussions. However, it is predominantly nurses who seek to redress this conflict area through developing specific behaviours for this clinical forum. Using this approach to resolve such team issues has grave implications if the government vision of interdisciplinary team working is to be realised.

  12. DYNAMICALLY EVOLVING CLINICAL PRACTICES AND IMPLICATIONS FOR PREDICTING MEDICAL DECISIONS

    PubMed Central

    CHEN, JONATHAN H; GOLDSTEIN, MARY K; ASCH, STEVEN M; ALTMAN, RUSS B

    2015-01-01

    Automatically data-mining clinical practice patterns from electronic health records (EHR) can enable prediction of future practices as a form of clinical decision support (CDS). Our objective is to determine the stability of learned clinical practice patterns over time and what implication this has when using varying longitudinal historical data sources towards predicting future decisions. We trained an association rule engine for clinical orders (e.g., labs, imaging, medications) using structured inpatient data from a tertiary academic hospital. Comparing top order associations per admission diagnosis from training data in 2009 vs. 2012, we find practice variability from unstable diagnoses with rank biased overlap (RBO)<0.35 (e.g., pneumonia) to stable admissions for planned procedures (e.g., chemotherapy, surgery) with comparatively high RBO>0.6. Predicting admission orders for future (2013) patients with associations trained on recent (2012) vs. older (2009) data improved accuracy evaluated by area under the receiver operating characteristic curve (ROC-AUC) 0.89 to 0.92, precision at ten (positive predictive value of the top ten predictions against actual orders) 30% to 37%, and weighted recall (sensitivity) at ten 2.4% to 13%, (P<10−10). Training with more longitudinal data (2009-2012) was no better than only using recent (2012) data. Secular trends in practice patterns likely explain why smaller but more recent training data is more accurate at predicting future practices. PMID:26776186

  13. A highly scalable, interoperable clinical decision support service

    PubMed Central

    Goldberg, Howard S; Paterno, Marilyn D; Rocha, Beatriz H; Schaeffer, Molly; Wright, Adam; Erickson, Jessica L; Middleton, Blackford

    2014-01-01

    Objective To create a clinical decision support (CDS) system that is shareable across healthcare delivery systems and settings over large geographic regions. Materials and methods The enterprise clinical rules service (ECRS) realizes nine design principles through a series of enterprise java beans and leverages off-the-shelf rules management systems in order to provide consistent, maintainable, and scalable decision support in a variety of settings. Results The ECRS is deployed at Partners HealthCare System (PHS) and is in use for a series of trials by members of the CDS consortium, including internally developed systems at PHS, the Regenstrief Institute, and vendor-based systems deployed at locations in Oregon and New Jersey. Performance measures indicate that the ECRS provides sub-second response time when measured apart from services required to retrieve data and assemble the continuity of care document used as input. Discussion We consider related work, design decisions, comparisons with emerging national standards, and discuss uses and limitations of the ECRS. Conclusions ECRS design, implementation, and use in CDS consortium trials indicate that it provides the flexibility and modularity needed for broad use and performs adequately. Future work will investigate additional CDS patterns, alternative methods of data passing, and further optimizations in ECRS performance. PMID:23828174

  14. A Clinical Decision Support System for Breast Cancer Patients

    NASA Astrophysics Data System (ADS)

    Fernandes, Ana S.; Alves, Pedro; Jarman, Ian H.; Etchells, Terence A.; Fonseca, José M.; Lisboa, Paulo J. G.

    This paper proposes a Web clinical decision support system for clinical oncologists and for breast cancer patients making prognostic assessments, using the particular characteristics of the individual patient. This system comprises three different prognostic modelling methodologies: the clinically widely used Nottingham prognostic index (NPI); the Cox regression modelling and a partial logistic artificial neural network with automatic relevance determination (PLANN-ARD). All three models yield a different prognostic index that can be analysed together in order to obtain a more accurate prognostic assessment of the patient. Missing data is incorporated in the mentioned models, a common issue in medical data that was overcome using multiple imputation techniques. Risk group assignments are also provided through a methodology based on regression trees, where Boolean rules can be obtained expressed with patient characteristics.

  15. Clinical decision support for physician order-entry: design challenges.

    PubMed

    Broverman, C A; Clyman, J I; Schlesinger, J M; Want, E

    1996-01-01

    We report on a joint development effort between ALLTEL Information Services Health Care Division and IBM Worldwide Healthcare Industry to demonstrate concurrent clinical decision support using Arden Syntax at order-entry time. The goal of the partnership is to build a high performance CDS toolkit that may be easily customized for multiple health care enterprises. Our work uses and promotes open technologies and health care standards while building a generalizable interface to a legacy patient-care system and clinical database. This paper identifies four areas of design challenges and solutions unique to a concurrent order-entry environment: the clinical information model, the currency of the patient virtual chart, the granularity of event triggers and rule evaluation context, and performance.

  16. Clinical decision making-a functional medicine perspective.

    PubMed

    Pizzorno, Joseph E

    2012-09-01

    As 21st century health care moves from a disease-based approach to a more patient-centric system that can address biochemical individuality to improve health and function, clinical decision making becomes more complex. Accentuating the problem is the lack of a clear standard for this more complex functional medicine approach. While there is relatively broad agreement in Western medicine for what constitutes competent assessment of disease and identification of related treatment approaches, the complex functional medicine model posits multiple and individualized diagnostic and therapeutic approaches, most or many of which have reasonable underlying science and principles, but which have not been rigorously tested in a research or clinical setting. This has led to non-rigorous thinking and sometimes to uncritical acceptance of both poorly documented diagnostic procedures and ineffective therapies, resulting in less than optimal clinical care.

  17. Modeling decision support rule interactions in a clinical setting.

    PubMed

    Sordo, Margarita; Rocha, Beatriz H; Morales, Alfredo A; Maviglia, Saverio M; Oglio, Elisa Dell'Oglio; Fairbanks, Amanda; Aroy, Teal; Dubois, David; Bouyer-Ferullo, Sharon; Rocha, Roberto A

    2013-01-01

    Traditionally, rule interactions are handled at implementation time through rule task properties that control the order in which rules are executed. By doing so, knowledge about the behavior and interactions of decision rules is not captured at modeling time. We argue that this is important knowledge that should be integrated in the modeling phase. In this project, we build upon current work on a conceptual schema to represent clinical knowledge for decision support in the form of if then rules. This schema currently captures provenance of the clinical content, context where such content is actionable (i.e. constraints) and the logic of the rule itself. For this project, we borrowed concepts from both the Semantic Web (i.e., Ontologies) and Complex Adaptive Systems (CAS), to explore a conceptual approach for modeling rule interactions in an enterprise-wide clinical setting. We expect that a more comprehensive modeling will facilitate knowledge authoring, editing and update; foster consistency in rules implementation and maintenance; and develop authoritative knowledge repositories to promote quality, safety and efficacy of healthcare.

  18. Reward-Related Decision Making in Older Adults: Relationship to Clinical Presentation of Depression

    PubMed Central

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

    2015-01-01

    Objective 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. 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 elderly, healthy subjects, depressed, elderly patients would exhibit impaired decision making and that apathetic, depressed patients would show greater impairment in decision making than non-apathetic, depressed patients. Methods We used the Iowa Gambling Task to examine reward-related decision making in 60 non-demented, elderly patients with non-psychotic major depression and 36 elderly, 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. Results Older adults with depression and healthy comparison participants did not differ in their performance on the IGT. However, apathetic, depressed older adults adopted an advantageous strategy and selected cards from the conservative decks compared to 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. Conclusions 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. PMID:25306937

  19. Studying the Vendor Perspective on Clinical Decision Support

    PubMed Central

    Ash, Joan S.; Sittig, Dean F.; McMullen, Carmit K.; McCormack, James L.; Wright, Adam; Bunce, Arwen; Wasserman, Joseph; Mohan, Vishnu; Cohen, Deborah J.; Shapiro, Michael; Middleton, Blackford

    2011-01-01

    In prior work, using a Rapid Assessment Process (RAP), we have investigated clinical decision support (CDS) in ambulatory clinics and hospitals. We realized that individuals in these settings provide only one perspective related to the CDS landscape, which also includes content vendors and electronic health record (EHR) vendors. To discover content vendors’ perspectives and their perceived challenges, we modified RAP for industrial settings. We describe how we employed RAP, and show its utility by describing two illustrative themes. We found that while the content vendors believe they provide unique much-needed services, the amount of labor involved in content development is underestimated by others. We also found that the content vendors believe their products are resources to be used by practitioners, so they are somewhat protected from liability issues. To promote adequate understanding about these issues, we recommend a “three way conversation” among content vendors, EHR vendors, and user organizations. PMID:22195058

  20. Evaluation of RxNorm for Medication Clinical Decision Support

    PubMed Central

    Freimuth, Robert R.; Wix, Kelly; Zhu, Qian; Siska, Mark; Chute, Christopher G.

    2014-01-01

    We evaluated the potential use of RxNorm to provide standardized representations of generic drug name and route of administration to facilitate management of drug lists for clinical decision support (CDS) rules. We found a clear representation of generic drug name but not route of administration. We identified several issues related to data quality, including erroneous or missing defined relationships, and the use of different concept hierarchies to represent the same drug. More importantly, we found extensive semantic precoordination of orthogonal concepts related to route and dose form, which would complicate the use of RxNorm for drug-based CDS. This study demonstrated that while RxNorm is a valuable resource for the standardization of medications used in clinical practice, additional work is required to enhance the terminology so that it can support expanded use cases, such as managing drug lists for CDS. PMID:25954360

  1. Patient management scenario: a framework for clinical decision and prognosis.

    PubMed

    Gospodarowicz, Mary; O'Sullivan, Brian

    2003-01-01

    The depiction of prognosis is one of the main activities and a mainstay in medical practice. In cancer, as in other diseases, the prognosis differs for a variety of situations and evolves with time and with medical interventions. Although most commonly described at diagnosis, prognosis may be defined at any time during the course of the disease and for any endpoint including response to therapy, failure of treatment, survival, or preservation of function, and so forth. To facilitate the accurate portrayal of the future, the prognosis should be defined within a specific setting, referred to as a 'management scenario'. In the concept of a management scenario, the prognosis is defined using systematically considered prognostic factors, interventions and the outcome of interest. A deliberate and careful determination of prognosis is essential to clinical decision making and patient care. We illustrate the use of the concept of management scenario in several clinical examples.

  2. Studying the vendor perspective on clinical decision support.

    PubMed

    Ash, Joan S; Sittig, Dean F; McMullen, Carmit K; McCormack, James L; Wright, Adam; Bunce, Arwen; Wasserman, Joseph; Mohan, Vishnu; Cohen, Deborah J; Shapiro, Michael; Middleton, Blackford

    2011-01-01

    In prior work, using a Rapid Assessment Process (RAP), we have investigated clinical decision support (CDS) in ambulatory clinics and hospitals. We realized that individuals in these settings provide only one perspective related to the CDS landscape, which also includes content vendors and electronic health record (EHR) vendors. To discover content vendors' perspectives and their perceived challenges, we modified RAP for industrial settings. We describe how we employed RAP, and show its utility by describing two illustrative themes. We found that while the content vendors believe they provide unique much-needed services, the amount of labor involved in content development is underestimated by others. We also found that the content vendors believe their products are resources to be used by practitioners, so they are somewhat protected from liability issues. To promote adequate understanding about these issues, we recommend a "three way conversation" among content vendors, EHR vendors, and user organizations.

  3. Evaluation of RxNorm for Medication Clinical Decision Support.

    PubMed

    Freimuth, Robert R; Wix, Kelly; Zhu, Qian; Siska, Mark; Chute, Christopher G

    2014-01-01

    We evaluated the potential use of RxNorm to provide standardized representations of generic drug name and route of administration to facilitate management of drug lists for clinical decision support (CDS) rules. We found a clear representation of generic drug name but not route of administration. We identified several issues related to data quality, including erroneous or missing defined relationships, and the use of different concept hierarchies to represent the same drug. More importantly, we found extensive semantic precoordination of orthogonal concepts related to route and dose form, which would complicate the use of RxNorm for drug-based CDS. This study demonstrated that while RxNorm is a valuable resource for the standardization of medications used in clinical practice, additional work is required to enhance the terminology so that it can support expanded use cases, such as managing drug lists for CDS.

  4. Clinical genomics information management software linking cancer genome sequence and clinical decisions.

    PubMed

    Watt, Stuart; Jiao, Wei; Brown, Andrew M K; Petrocelli, Teresa; Tran, Ben; Zhang, Tong; McPherson, John D; Kamel-Reid, Suzanne; Bedard, Philippe L; Onetto, Nicole; Hudson, Thomas J; Dancey, Janet; Siu, Lillian L; Stein, Lincoln; Ferretti, Vincent

    2013-09-01

    Using sequencing information to guide clinical decision-making requires coordination of a diverse set of people and activities. In clinical genomics, the process typically includes sample acquisition, template preparation, genome data generation, analysis to identify and confirm variant alleles, interpretation of clinical significance, and reporting to clinicians. We describe a software application developed within a clinical genomics study, to support this entire process. The software application tracks patients, samples, genomic results, decisions and reports across the cohort, monitors progress and sends reminders, and works alongside an electronic data capture system for the trial's clinical and genomic data. It incorporates systems to read, store, analyze and consolidate sequencing results from multiple technologies, and provides a curated knowledge base of tumor mutation frequency (from the COSMIC database) annotated with clinical significance and drug sensitivity to generate reports for clinicians. By supporting the entire process, the application provides deep support for clinical decision making, enabling the generation of relevant guidance in reports for verification by an expert panel prior to forwarding to the treating physician.

  5. Clinical decision rules to distinguish between bacterial and aseptic meningitis

    PubMed Central

    Dubos, F; Lamotte, B; Bibi‐Triki, F; Moulin, F; Raymond, J; Gendrel, D; Bréart, G; Chalumeau, M

    2006-01-01

    Background Clinical decision rules have been derived to distinguish between bacterial and aseptic meningitis in the emergency room to avoid unnecessary antibiotic treatments and hospitalisations. Aims To evaluate the reproducibility and to compare the diagnostic performance of five clinical decision rules. Methods All children hospitalised for bacterial meningitis between 1995 and 2004 or aseptic meningitis between 2000 and 2004 have been included in a retrospective cohort study. Sensitivity and specificity were calculated by applying each rule to the patients. The best rule was a priori defined as the one yielding 100% sensitivity for bacterial meningitis, the highest specificity, and the greatest simplicity for a bedside application. Results Among the 166 patients included, 20 had bacterial meningitis and 146 had aseptic meningitis. Although three rules achieved 100% sensitivity (95% CI 84–100), one had a significantly lower specificity (13%, 95% CI 8–19) than those of the other two rules (57%, 95% CI 48–65; and 66%, 95% CI 57–73), which were not statistically different. The ease of manual computation of the rule developed by Nigrovic et al (a simple list of five items: seizure, blood neutrophil count, cerebrospinal fluid (CSF) Gram stain, CSF protein, CSF neutrophil count) was higher than the one developed by Bonsu and Harper. Conclusion On our population, the rule derived by Nigrovic et al had the best balance between accuracy and simplicity of manual computation and could help to avoid two thirds of unnecessary antibiotic treatments and hospitalisations. PMID:16595647

  6. Affecting others: social appraisal and emotion contagion in everyday decision making.

    PubMed

    Parkinson, Brian; Simons, Gwenda

    2009-08-01

    In a diary study of interpersonal affect transfer, 41 participants reported on decisions involving other people over 3 weeks. Reported anxiety and excitement were reliably related to the perceived anxiety and excitement of another person who was present during decision making. Risk and importance appraisals partially mediated effects of other's anxiety on own anxiety as predicted by social appraisal theory. However, other's emotion remained a significant independent predictor of own emotion after controlling for appraisals, supporting the additional impact of more direct forms of affect transfer such as emotion contagion. Significant affect-transfer effects remained even after controlling for participants' perceptions of the other's emotion in addition to all measured appraisals, confirming that affect transfer does not require explicit registration of someone else's feelings. This research provides some of the clearest evidence for the operation of both social appraisal and automatic affect transfer in everyday social life.

  7. Can patient decision aids help people make good decisions about participating in clinical trials? A study protocol

    PubMed Central

    Brehaut, Jamie C; Lott, Alison; Fergusson, Dean A; Shojania, Kaveh G; Kimmelman, Jonathan; Saginur, Raphael

    2008-01-01

    Background Evidence shows that the standard process for obtaining informed consent in clinical trials can be inadequate, with study participants frequently not understanding even basic information fundamental to giving informed consent. Patient decision aids are effective decision support tools originally designed to help patients make difficult treatment or screening decisions. We propose that incorporating decision aids into the informed consent process will improve the extent to which participants make decisions that are informed and consistent with their preferences. A mixed methods study will test this proposal. Methods Phase one of this project will involve assessment of a stratified random sample of 50 consent documents from recently completed investigator-initiated clinical trials, according to existing standards for supporting good decision making. Phase two will involve interviews of a purposive sample of 50 trial participants (10 participants from each of five different clinical areas) about their experience of the informed consent process, and how it could be improved. In phase three, we will convert consent forms for two completed clinical trials into decision aids and pilot test these new tools using a user-centered design approach, an iterative development process commonly employed in computer usability literature. In phase four, we will conduct a pilot observational study comparing the new tools to standard consent forms, with potential recruits to two hypothetical clinical trials. Outcomes will include knowledge of key aspects of the decision, knowledge of the probabilities of different outcomes, decisional conflict, the hypothetical participation decision, and qualitative impressions of the experience. Discussion This work will provide initial evidence about whether a patient decision aid can improve the informed consent process. The larger goal of this work is to examine whether study recruitment can be improved from (barely) informed consent

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

    PubMed

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

    2011-04-01

    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.

  9. 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

  10. Biostatistics in clinical decision making for cardiothoracic radiologists.

    PubMed

    Zurakowski, David; Johnson, Victor M; Lee, Edward Y

    2013-11-01

    Cardiothoracic radiologists are intuitively aware of sensitivity and specificity as they pertain to diagnostic tests involving clinical information. However, many cardiothoracic radiologists are unfamiliar with odds ratios, likelihood ratios, predictive values, and receiver operating characteristic (ROC) curves, which provide more information about the performance of a test. Our article will first review the fundamental concepts of sensitivity, specificity, predictive values, and likelihood ratios. The ROC curve methodology will be covered with an emphasis on creating a look-up table, a straightforward table that communicates important information to the clinician to aid in diagnosis. The article reviews sensitivity and specificity, as well as predictive values, logistic regression, and ROC curves, using conceptual principles without unnecessary mathematical rigor. We will apply principles of sensitivity and specificity to continuous measurements by constructing ROC curves in order to tie together key ideas in diagnostic decision making. Three clinical examples are presented to illustrate these fundamental statistical concepts: predictors of pulmonary embolism in children, use of dobutamine-cardiac magnetic resonance imaging to identify impaired ventricular function in patients who have suffered a myocardial infarction, and diagnostic accuracy of 64-multidetector row computed tomography to identify occluded vessels in adult patients with suspected coronary artery disease. In addition, a glossary is provided at the end of the article with key terms important in diagnostic imaging. An understanding of the concepts presented will assist cardiothoracic radiologists in critically discerning the usefulness of diagnostic tests and how these statistics can be applied to make judgments and decisions that are essential to clinical practice.

  11. Clinical decision support for perioperative information management systems.

    PubMed

    Wanderer, Jonathan P; Ehrenfeld, Jesse M

    2013-12-01

    Clinical decision support (CDS) systems are being used to optimize the increasingly complex care that our health care system delivers. These systems have become increasingly important in the delivery of perioperative care for patients undergoing cardiac, thoracic, and vascular procedures. The adoption of perioperative information management systems (PIMS) has allowed these technologies to enter the operating room and support the clinical work flow of anesthesiologists and operational processes. Constructing effective CDS systems necessitates an understanding of operative work flow and technical considerations as well as achieving integration with existing information systems. In this review, we describe published examples of CDS for PIMS, including support for cardiopulmonary bypass separation physiological alarms, β-blocker guideline adherence, enhanced revenue capture for arterial line placement, and detection of hemodynamic monitoring gaps. Although these and other areas are amenable to CDS systems, the challenges of latency and data reliability represent fundamental limitations on the potential application of these tools to specific types of clinical issues. Ultimately, we expect that CDS will remain an important tool in our efforts to optimize the quality of care delivered.

  12. A Four-Phase Model of the Evolution of Clinical Decision Support Architectures

    PubMed Central

    Wright, Adam; Sittig, Dean F.

    2008-01-01

    Background A large body of evidence over many years suggests that clinical decision support systems can be helpful in improving both clinical outcomes and adherence to evidence-based guidelines. However, to this day, clinical decision support systems are not widely used outside of a small number of sites. One reason why decision support systems are not widely used is the relative difficulty of integrating such systems into clinical workflows and computer systems. Purpose To review and synthesize the history of clinical decision support systems, and to propose a model of various architectures for integrating clinical decision support systems with clinical systems. Methods The authors conducted an extensive review of the clinical decision support literature since 1959, sequenced the systems and developed a model. Results The model developed consists of four phases: standalone decision support systems, decision support integrated into clinical systems, standards for sharing clinical decision support content and service models for decision support. These four phases have not heretofore been identified, but they track remarkably well with the chronological history of clinical decision support, and show evolving and increasingly sophisticated attempts to ease integrating decision support systems into clinical workflows and other clinical systems. Conclusions Each of the four evolutionary approaches to decision support architecture has unique advantages and disadvantages. A key lesson was that there were common limitations that almost all the approaches faced, and no single approach has been able to entirely surmount: 1) fixed knowledge representation systems inherently circumscribe the type of knowledge that can be represented in them, 2) there are serious terminological issues, 3) patient data may be spread across several sources with no single source having a complete view of the patient, and 4) major difficulties exist in transferring successful interventions from one

  13. 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.

  14. Doctors' attitudes to risk in difficult clinical decisions: application of decision analysis in hepatobiliary disease.

    PubMed

    Theodossi, A; Spiegelhalter, D J; McFarlane, I G; Williams, R

    1984-07-28

    Twelve doctors with special training in hepatology independently reviewed two to five cases each from a group of seven cases of complicated hepatobiliary problems. A doctor's willingness to take risks to improve his patients' health was quantified by a wagering technique based on the probability of achieving a successful intervention. These probabilities were then used to calculate "utilities," which represented the average opinion of the doctors about the relative worth of each of six predefined states of health. The results showed that, in the context of risky decisions for severely ill patients, a year of life was considered by the doctors to be worth 44% of a full recovery; being mobile for that year increased this value to 57%. Survival for up to five years with restricted mobility was considered to be worth 70% of a full recovery and the ability to work during that period increased this value to 85%. It is concluded that in clinical decision making the uncertainty and preferences implicit in a course of action can be quantified and thus made explicit.

  15. Clinical Decision Support for Early Recognition of Sepsis.

    PubMed

    Amland, Robert C; Hahn-Cover, Kristin E

    2016-01-01

    Sepsis is an inflammatory response triggered by infection, with a high in-hospital mortality rate. Early recognition and treatment can reverse the inflammatory response, with evidence of improved patient outcomes. One challenge clinicians face is identifying the inflammatory syndrome against the background of the patient's infectious illness and comorbidities. An approach to this problem is implementation of computerized early warning tools for sepsis. This multicenter retrospective study sought to determine clinimetric performance of a cloud-based computerized sepsis clinical decision support system (CDS), understand the epidemiology of sepsis, and identify opportunities for quality improvement. Data encompassed 6200 adult hospitalizations from 2012 through 2013. Of 13% patients screened-in, 51% were already suspected to have an infection when the system activated. This study focused on a patient cohort screened-in before infection was suspected; median time from arrival to CDS activation was 3.5 hours, and system activation to diagnostic collect was another 8.6 hours.

  16. SANDS: An Architecture for Clinical Decision Support in a National Health Information Network

    PubMed Central

    Wright, Adam; Sittig, Dean F.

    2007-01-01

    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. PMID:18693950

  17. An Overview of Federal Court Decisions Affecting Equal Rights for Women in Education. Report No. 70.

    ERIC Educational Resources Information Center

    Pearson, William

    This publication is a study of federal court decisions as they affect the equal rights of women in education. Because the majority of such cases have involved employment, the main focus of the study is on that area. Primary objective of the study is to derive from relevant federal cases the basic judicial principles applicable to the concept of…

  18. Factors Affecting Christian Parents' School Choice Decision Processes: A Grounded Theory Study

    ERIC Educational Resources Information Center

    Prichard, Tami G.; Swezey, James A.

    2016-01-01

    This study identifies factors affecting the decision processes for school choice by Christian parents. Grounded theory design incorporated interview transcripts, field notes, and a reflective journal to analyze themes. Comparative analysis, including open, axial, and selective coding, was used to reduce the coded statements to five code families:…

  19. Relation of Depression and Affectivity to Career Decision Status and Self-Efficacy in College Students

    ERIC Educational Resources Information Center

    Rottinghaus, Patrick J.; Jenkins, Nicholas; Jantzer, Amanda M.

    2009-01-01

    Further investigations are necessary to explore the interface between personal-emotional and career-related factors. The authors examined links between participants' emotional life, including depression and positive/negative affect, and career decision status and average level of vocationally relevant self-efficacy in a sample of 388 university…

  20. Support Systems which Affect the Hispanic and Anglo Adolescent Mother's Decision To Continue Her Education.

    ERIC Educational Resources Information Center

    Wilson, Ruth D.

    For an ethnographic study of the personal and educational needs of Hispanic and Anglo adolescent mothers and the services affecting their decision to remain in school, researchers interviewed eight teenage mothers--four in a special high school teen parents' program and four who had dropped out of the program. Two young women in each group were…

  1. Factors, Correlates, Problem Areas Affecting Career Decision Making of a Cross-Sectional Sample of Students.

    ERIC Educational Resources Information Center

    O'Neil, James M.; And Others

    A study was conducted to investigate the effects of the correlates and problem areas affecting career decision making and specifically to test the validity of the O'Neil, Meeker & Borgers' (1978) model. A cross-sectional sample of high school, undergraduate, and graduate students (N=1,436) responded to the Career Factor Checklist (CFC) and…

  2. Factors Affecting Career Decision Making of Mexican and Mexican-American Students.

    ERIC Educational Resources Information Center

    Newlon, Betty J.; Borboa, Roman

    The purpose of this research was to identify the self-reported factors affecting the career decision making of Mexican and Mexican-American students. It was hypothesized that the factor clusters would differ between the two sample populations, Mexican and Mexican-American. It was also hypothesized that these clusters would differ from six clusters…

  3. Factors Affecting Individuals' Decisions to Enter Music Teacher Education Doctoral Programs

    ERIC Educational Resources Information Center

    Teachout, David J.

    2004-01-01

    The present study is one of the first investigations into the music teacher educator shortage. The purpose was to identify factors that affect music teachers' decisions about entering music education doctoral programs. Practicing music educators, identified as being outstanding candidates for doctoral studies (PME) (n = 22), and recent doctoral…

  4. Virtual Characters: Visual Realism Affects Response Time and Decision-Making

    ERIC Educational Resources Information Center

    Sibuma, Bernadette

    2012-01-01

    This study integrates agent research with a neurocognitive technique to study how character faces affect cognitive processing. The N170 event-related potential (ERP) was used to study face processing during simple decision-making tasks. Twenty-five adults responded to facial expressions (fear/neutral) presented in three designs…

  5. [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.

  6. Clinical decision analysis using microcomputers. A case of coexistent hepatocellular carcinoma and abdominal aortic aneurysm.

    PubMed

    Wong, J B; Moskowitz, A J; Pauker, S G

    1986-12-01

    Many difficult medical decisions involve uncertainty. Decision analysis-an explicit, normative and analytic approach to making decisions under uncertainty-provides a probabilistic framework for exploring difficult problems in nondeterministic domains. As the methodology has advanced, clinical decision analysis has been applied to increasingly complex medical problems and disseminated widely in the medical literature. Unfortunately, this approach imposes a heavy computational burden on analysts. Microcomputer-based decision-support software can ease this burden.

  7. Exploration Clinical Decision Support System: Medical Data Architecture

    NASA Technical Reports Server (NTRS)

    Lindsey, Tony; Shetye, Sandeep; Shaw, Tianna (Editor)

    2016-01-01

    The Exploration Clinical Decision Support (ECDS) System project is intended to enhance the Exploration Medical Capability (ExMC) Element for extended duration, deep-space mission planning in HRP. A major development guideline is the Risk of "Adverse Health Outcomes & Decrements in Performance due to Limitations of In-flight Medical Conditions". ECDS attempts to mitigate that Risk by providing crew-specific health information, actionable insight, crew guidance and advice based on computational algorithmic analysis. The availability of inflight health diagnostic computational methods has been identified as an essential capability for human exploration missions. Inflight electronic health data sources are often heterogeneous, and thus may be isolated or not examined as an aggregate whole. The ECDS System objective provides both a data architecture that collects and manages disparate health data, and an active knowledge system that analyzes health evidence to deliver case-specific advice. A single, cohesive space-ready decision support capability that considers all exploration clinical measurements is not commercially available at present. Hence, this Task is a newly coordinated development effort by which ECDS and its supporting data infrastructure will demonstrate the feasibility of intelligent data mining and predictive modeling as a biomedical diagnostic support mechanism on manned exploration missions. The initial step towards ground and flight demonstrations has been the research and development of both image and clinical text-based computer-aided patient diagnosis. Human anatomical images displaying abnormal/pathological features have been annotated using controlled terminology templates, marked-up, and then stored in compliance with the AIM standard. These images have been filtered and disease characterized based on machine learning of semantic and quantitative feature vectors. The next phase will evaluate disease treatment response via quantitative linear

  8. A rule-based clinical decision model to support interpretation of multiple data in health examinations.

    PubMed

    Kuo, Kuan-Liang; Fuh, Chiou-Shann

    2011-12-01

    Health examinations can obtain relatively complete health information and thus are important for the personal and public health management. For clinicians, one of the most important works in the health examinations is to interpret the health examination results. Continuously interpreting numerous health examination results of healthcare receivers is tedious and error-prone. This paper proposes a clinical decision support system to assist solving above problems. In order to customize the clinical decision support system intuitively and flexibly, this paper also proposes the rule syntax to implement computer-interpretable logic for health examinations. It is our purpose in this paper to describe the methodology of the proposed clinical decision support system. The evaluation was performed by the implementation and execution of decision rules on health examination results and a survey on clinical decision support system users. It reveals the efficiency and user satisfaction of proposed clinical decision support system. Positive impact of clinical data interpretation is also noted.

  9. A clinical decision rule for streptococcal pharyngitis management: An update

    PubMed Central

    Nasirian, Hosain; TarvijEslami, Saeedeh; Matini, Esfandiar; Bayesh, Seyedehsara; Omaraee, Yasaman

    2017-01-01

    PURPOSE: Group A streptococcal (GAS) pharyngitis is a common disease worldwide. We aimed to establish a pragmatic program as a clinical decision rule for GAS pharyngitis diagnosis. MATERIALS AND METHODS: This article derived from a research project on children aged 6–15 years. Five hundred and seventy-one children met the enrollment criteria on whom throat culture and validities of clinical findings were assessed in positive and negative throat culture groups. RESULTS: Positive GAS throat culture group included 99 (17.3%) patients with a positive culture. Negative GAS throat culture group included 472 (82.6%) patients. Exudate or enlarged tender nodes each one had 63% and 68% sensitivity and 31.5% and 37.5% specificity with a high percentage of negative predictive value (NPV) 80.54% and 85.09%, respectively. Sequence test revealed validities of exudate plus enlarged nodes at 43.62% sensitivity and 57.19% specificity with 83% NPV. CONCLUSIONS: High NPV of 83% indicated that similar prevalence in the absence of either exudate or enlarged tender lymph nodes. Probability of GAS negative throat cultures among children suspected of GAS pharyngitis was 83% and would correctly not receive inopportune antibiotics. PMID:28367027

  10. Clinical Decision Support Systems (CDSS) in GRID Environments.

    PubMed

    Blanquer, Ignacio; Hernández, Vicente; Segrelles, Damià; Robles, Montserrat; García, Juan Miguel; Robledo, Javier Vicente

    2005-01-01

    This paper presents an architecture defined for searching and executing Clinical Decision Support Systems (CDSS) in a LCG2/GT2 Grid environment, using web-based protocols. A CDSS is a system that provides a classification of the patient illness according to the knowledge extracted from clinical practice and using the patient's information in a structured format. The CDSS classification engines can be installed in any site and can be used by different medical users from a Virtual Organization (VO). All users in a VO can consult and execute different classification engines that have been installed in the Grid independently of the platform, architecture or site where the engines are installed or the users are located. The present paper present a solution to requirements such as short-job execution, reducing the response delay on LCG2 environments and providing grid-enabled authenticated access through web portals. Resource discovering and job submission is performed through web services, which are also described in the article.

  11. To push or not to push? Affective influences on moral judgment depend on decision frame.

    PubMed

    Pastötter, Bernhard; Gleixner, Sabine; Neuhauser, Theresa; Bäuml, Karl-Heinz T

    2013-03-01

    People's moods can influence moral judgment. Such influences may arise because moods affect moral emotion, or because moods affect moral thought. The present study provides evidence that, at least in the footbridge dilemma, moods affect moral thought. The results of two experiments are reported in which, after induction of positive, negative, or neutral moods and presentation of the footbridge scenario, participants were asked one of two differentially framed closing questions. In the active frame, participants were asked whether they would be active and push the man, making thoughts about pushing accessible; in the passive frame, they were asked whether they would be passive and not push the man, making thoughts about not pushing accessible. The results show that affective influences on moral judgment depended on participants' decision frame. Compared to neutral moods, positive moods induced utilitarian responding - i.e., deciding to push - in the active decision frame, but induced nonutilitarian responding - i.e., deciding to not push - in the passive decision frame; in negative moods, exactly the opposite picture arose. The results suggest that people's moods affect moral judgment by conferring value on moral thought. Positive moods promote and negative moods inhibit accessible thoughts.

  12. 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

  13. 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

  14. Using Data Mining Strategies in Clinical Decision Making: A Literature Review.

    PubMed

    Chen, Lu-Yen A; Fawcett, Tonks N

    2016-10-01

    Several data-mining models have been embedded in the clinical environment to improve decision making and patient safety. Consequently, it is crucial to survey the principal data-mining strategies currently used in clinical decision making and to determine the disadvantages and advantages of using these strategies in data mining in clinical decision making. A literature review was conducted, which identified 21 relevant articles. The article findings showed that multiple models of data mining were used in clinical decision making. Although data mining is efficient and accurate, the models are limited with respect to disease and condition.

  15. 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.

  16. Affect and psychiatric symptoms in a veteran polytrauma clinic.

    PubMed

    Kraal, A Zarina; Waldron-Perrine, Brigid; Pangilinan, Percival H; Bieliauskas, Linas A

    2015-02-01

    Although the relationship between negative affect and psychiatric symptoms has been well-demonstrated in research, less is known about positive affect relative to negative affect, and its relationship to psychiatric symptoms, especially among veterans. This study examined how levels of positive and negative affect are associated with symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD). Data were collected in a veteran polytrauma clinic; analyses were conducted using data from 94 veterans (87 males) with and without a mild traumatic brain injury (mTBI) diagnosis. Results demonstrate that positive and negative affect were separate dimensions and that both were independently related to each symptom measure. After removing the contribution of negative affect from symptom reports, strong relationships remained between positive affect and psychiatric symptoms. Furthermore, the magnitude of the associations for positive affect and for negative affect with symptoms of depression, anxiety, and PTSD were not impacted by a mTBI diagnosis. Altogether, findings suggest that both positive and negative affect should be uniquely considered when conceptualizing, assessing, and treating returning service members; in addition, positive affect may be an appropriate target of assessment and interventions of persons who have experienced polytrauma.

  17. Multiple contributions to clinical presentation of flat affect in schizophrenia.

    PubMed

    Mayer, M; Alpert, M; Stastny, P; Perlick, D; Empfield, M

    1985-01-01

    Flat affect has long been recognized as a central manifestation of schizophrenia, and has more recently been appreciated as a stable and prognostically important attribute of this disorder. Yet, because it is thought to be difficult to evaluate, flat affect has been deemphasized in criterion-based diagnostic systems. Results of this study suggest that the clinical evaluation of flat affect may be contaminated by a number of behaviorally similar processes. The components we identified included right hemisphere dysfunction, retardation and extrapyramidal effects, as well as the sequelae of hospitalization. Thus, in the clinical evaluation of flat affect, a multivariate approach in which these different components are considered separately might improve the reliability of evaluation and make this important sign more useful.

  18. Older and wiser? An affective science perspective on age-related challenges in financial decision making

    PubMed Central

    Kensinger, Elizabeth A.; Munnell, Alicia H.; Sass, Steven A.; Dickerson, Brad C.; Wright, Christopher I.; Barrett, Lisa Feldman

    2011-01-01

    Financial planning decisionss are fundamentally affective in nature; they are decisions related to money, longevity and quality of life. Over the next several decades people will be increasingly responsible for managing their own assets and investments, and they will be subject to the affective influences on active, personal decision-making. Many of these crucial decisions are made and revised across the lifespan, including when to buy or sell a home, how to save for childrens’ education, how to manage healthcare costs, when to retire, how much to save for retirement and how to allocate retirement funds. As average life expectancy increases, many retirees will be faced with inadequate savings to live comfortably until the end of their lives. In the current article, we examine the problems of and potential solutions to inadequate financial planning through the lens of affective science, with an emphasis on how brain-based changes in affective processing with age might contribute to the challenge of financial planning. PMID:20587596

  19. Transient emotional events and individual affective traits affect emotion recognition in a perceptual decision-making task

    PubMed Central

    Garcia Quesada, Maria; Antico, Lia; Bavelier, Daphne; Vuilleumier, Patrik; Pichon, Swann

    2017-01-01

    Both affective states and personality traits shape how we perceive the social world and interpret emotions. The literature on affective priming has mostly focused on brief influences of emotional stimuli and emotional states on perceptual and cognitive processes. Yet this approach does not fully capture more dynamic processes at the root of emotional states, with such states lingering beyond the duration of the inducing external stimuli. Our goal was to put in perspective three different types of affective states (induced affective states, more sustained mood states and affective traits such as depression and anxiety) and investigate how they may interact and influence emotion perception. Here, we hypothesized that absorption into positive and negative emotional episodes generate sustained affective states that outlast the episode period and bias the interpretation of facial expressions in a perceptual decision-making task. We also investigated how such effects are influenced by more sustained mood states and by individual affect traits (depression and anxiety) and whether they interact. Transient emotional states were induced using movie-clips, after which participants performed a forced-choice emotion classification task with morphed facial expressions ranging from fear to happiness. Using a psychometric approach, we show that negative (vs. neutral) clips increased participants’ propensity to classify ambiguous faces as fearful during several minutes. In contrast, positive movies biased classification toward happiness only for those clips perceived as most absorbing. Negative mood, anxiety and depression had a stronger effect than transient states and increased the propensity to classify ambiguous faces as fearful. These results provide the first evidence that absorption and different temporal dimensions of emotions have a significant effect on how we perceive facial expressions. PMID:28151976

  20. 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

  1. 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…

  2. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success

    PubMed Central

    Kawamoto, Kensaku; Houlihan, Caitlin A; Balas, E Andrew; Lobach, David F

    2005-01-01

    Objective To identify features of clinical decision support systems critical for improving clinical practice. Design Systematic review of randomised controlled trials. Data sources Literature searches via Medline, CINAHL, and the Cochrane Controlled Trials Register up to 2003; and searches of reference lists of included studies and relevant reviews. Study selection Studies had to evaluate the ability of decision support systems to improve clinical practice. Data extraction Studies were assessed for statistically and clinically significant improvement in clinical practice and for the presence of 15 decision support system features whose importance had been repeatedly suggested in the literature. Results Seventy studies were included. Decision support systems significantly improved clinical practice in 68% of trials. Univariate analyses revealed that, for five of the system features, interventions possessing the feature were significantly more likely to improve clinical practice than interventions lacking the feature. Multiple logistic regression analysis identified four features as independent predictors of improved clinical practice: automatic provision of decision support as part of clinician workflow (P < 0.00001), provision of recommendations rather than just assessments (P = 0.0187), provision of decision support at the time and location of decision making (P = 0.0263), and computer based decision support (P = 0.0294). Of 32 systems possessing all four features, 30 (94%) significantly improved clinical practice. Furthermore, direct experimental justification was found for providing periodic performance feedback, sharing recommendations with patients, and requesting documentation of reasons for not following recommendations. Conclusions Several features were closely correlated with decision support systems' ability to improve patient care significantly. Clinicians and other stakeholders should implement clinical decision support systems that incorporate these

  3. The Fox and the Grapes—How Physical Constraints Affect Value Based Decision Making

    PubMed Central

    Strobel, Martin

    2015-01-01

    One fundamental question in decision making research is how humans compute the values that guide their decisions. Recent studies showed that people assign higher value to goods that are closer to them, even when physical proximity should be irrelevant for the decision from a normative perspective. This phenomenon, however, seems reasonable from an evolutionary perspective. Most foraging decisions of animals involve the trade-off between the value that can be obtained and the associated effort of obtaining. Anticipated effort for physically obtaining a good could therefore affect the subjective value of this good. In this experiment, we test this hypothesis by letting participants state their subjective value for snack food while the effort that would be incurred when reaching for it was manipulated. Even though reaching was not required in the experiment, we find that willingness to pay was significantly lower when subjects wore heavy wristbands on their arms. Thus, when reaching was more difficult, items were perceived as less valuable. Importantly, this was only the case when items were physically in front of the participants but not when items were presented as text on a computer screen. Our results suggest automatic interactions of motor and valuation processes which are unexplored to this date and may account for irrational decisions that occur when reward is particularly easy to reach. PMID:26061087

  4. Clinical Decision Support for Early Recognition of Sepsis

    PubMed Central

    Amland, Robert C.; Hahn-Cover, Kristin E.

    2014-01-01

    Sepsis is an inflammatory response triggered by infection, with a high in-hospital mortality rate. Early recognition and treatment can reverse the inflammatory response, with evidence of improved patient outcomes. One challenge clinicians face is identifying the inflammatory syndrome against the background of the patient’s infectious illness and comorbidities. An approach to this problem is implementation of computerized early warning tools for sepsis. This multicenter retrospective study sought to determine clinimetric performance of a cloud-based computerized sepsis clinical decision support system (CDS), understand the epidemiology of sepsis, and identify opportunities for quality improvement. Data encompassed 6200 adult hospitalizations from 2012 through 2013. Of 13% patients screened-in, 51% were already suspected to have an infection when the system activated. This study focused on a patient cohort screened-in before infection was suspected; median time from arrival to CDS activation was 3.5 hours, and system activation to diagnostic collect was another 8.6 hours. PMID:25385815

  5. Factors, Correlates, and Problem Areas Affecting Career Decision Making of a Cross-Sectional Sample of Students.

    ERIC Educational Resources Information Center

    O'Neil, James M.; And Others

    1980-01-01

    Examined the self-reported impact of factors affecting career decision making and tested the validity of the Career Factor Checklist (CFC) developed from O'Neil, Meeker, and Borgers' model. Results provide evidence of the factorial validity of the CFC, and support the O'Neil model and hypothesized factors affecting career decision making.…

  6. [Affective temperaments: from neurobiological roots to clinical application].

    PubMed

    Eory, Ajándék; Gonda, Xénia; Torzsa, Péter; Kalabay, László; Rihmer, Zoltán

    2011-11-20

    The Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) has grown to be a clinically important outcome measure in the diagnosis and the clinical course of mood disorders. However, temperaments, which represent the biologically stable core of personality, are not just antecedents of major affective disorders, but also serve as a reservoir of genetically advantageous traits for the survival of different cultures. The rapidly growing body of research in psychiatric and non-psychiatric fields even raises the question of temperament as a common root in psychiatric and somatic disorders, providing a new meaning for the construct of psychosomatic disorders. In this review we aim to summarize current knowledge on both the neurobiological background and clinical importance of affective temperaments including implications for future research.

  7. Population-based clinical decision support: a clinical and economic evaluation.

    PubMed

    Eisenstein, Eric L; Anstrom, Kevin J; Edwards, Rex; Willis, Janese M; Simo, Jessica; Lobach, David F

    2012-01-01

    Governments are investing in health information technologies (HIT) to improve care quality and reduce medical costs. However, evidence of these benefits is limited. We conducted a randomized trial of three clinical decision support (CDS) interventions in 20,180 patients: email to care managers (n=3329), reports to primary care administrators (n=3368), letters to patients (n=3401), and controls (10,082). At 7-month follow-up, the letters to patients group had greater use of outpatient services and higher outpatient and total medical costs; whereas, the other groups had no change in clinical events or medical costs. As our CDS interventions were associated with no change or an increase in medical costs, it appears that investments in HIT without consideration for organizational context may not be sufficient to achieve improvements in clinical and economic outcomes.

  8. Human and nature-caused hazards: the affect heuristic causes biased decisions.

    PubMed

    Siegrist, Michael; Sütterlin, Bernadette

    2014-08-01

    People are more concerned about the negative consequences of human hazards compared with natural hazards. Results of four experiments show that the same negative outcome (e.g., number of birds killed by an oil spill) was more negatively evaluated when caused by humans than when caused by nature. Results further show that when identical risk information was provided, participants evaluated nuclear power more negatively compared with solar power. The affect associated with the hazard per se influenced the interpretation of the new information. Furthermore, the affect experienced in the situation fully mediated the evaluation of the negative outcomes of a hazard. People's reliance on the affect heuristic is a challenge for acceptance of cost-benefit analyses because equally negative outcomes are differently evaluated depending on the cause. Symbolically significant information and the affect evoked by this information may result in biased and riskier decisions.

  9. Analysis of Community Practice Clinical Decision-Making Skills in Pharmacy Students.

    ERIC Educational Resources Information Center

    Greer, Marianne L.; Kirk, Kenneth W.

    1988-01-01

    A computerized, simulation-based instrument, consisting of four community practice clinical scenarios, collected information-searching data and the students' decisions. The appropriateness of the decisions, assessed by three clinical judges, and the focus of information search, based on the computer-collected process data, were the dependent…

  10. Social Status-Dependent Shift in Neural Circuit Activation Affects Decision Making.

    PubMed

    Miller, Thomas H; Clements, Katie; Ahn, Sungwoo; Park, Choongseok; Hye Ji, Eoon; Issa, Fadi A

    2017-02-22

    In a social group, animals make behavioral decisions that fit their social ranks. These behavioral choices are dependent on the various social cues experienced during social interactions. In vertebrates, little is known of how social status affects the underlying neural mechanisms regulating decision-making circuits that drive competing behaviors. Here, we demonstrate that social status in zebrafish (Danio rerio) influences behavioral decisions by shifting the balance in neural circuit activation between two competing networks (escape and swim). We show that socially dominant animals enhance activation of the swim circuit. Conversely, social subordinates display a decreased activation of the swim circuit, but an enhanced activation of the escape circuit. In an effort to understand how social status mediates these effects, we constructed a neurocomputational model of the escape and swim circuits. The model replicates our findings and suggests that social status-related shift in circuit dynamics could be mediated by changes in the relative excitability of the escape and swim networks. Together, our results reveal that changes in the excitabilities of the Mauthner command neuron for escape and the inhibitory interneurons that regulate swimming provide a cellular mechanism for the nervous system to adapt to changes in social conditions by permitting the animal to select a socially appropriate behavioral response.SIGNIFICANCE STATEMENT Understanding how social factors influence nervous system function is of great importance. Using zebrafish as a model system, we demonstrate how social experience affects decision making to enable animals to produce socially appropriate behavior. Based on experimental evidence and computational modeling, we show that behavioral decisions reflect the interplay between competing neural circuits whose activation thresholds shift in accordance with social status. We demonstrate this through analysis of the behavior and neural circuit

  11. 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:

  12. Surrogate decision making: reconciling ethical theory and clinical practice.

    PubMed

    Berger, Jeffrey T; DeRenzo, Evan G; Schwartz, Jack

    2008-07-01

    The care of adult patients without decision-making abilities is a routine part of medical practice. Decisions for these patients are typically made by surrogates according to a process governed by a hierarchy of 3 distinct decision-making standards: patients' known wishes, substituted judgments, and best interests. Although this framework offers some guidance, it does not readily incorporate many important considerations of patients and families and does not account for the ways in which many patients and surrogates prefer to make decisions. In this article, the authors review the research on surrogate decision making, compare it with normative standards, and offer ways in which the 2 can be reconciled for the patient's benefit.

  13. Assessing the sensibility of two clinical decision support systems.

    PubMed

    Graham, Timothy A D; Bullard, Michael J; Kushniruk, Andre W; Holroyd, Brian R; Rowe, Brian H

    2008-10-01

    Clinicians in Emergency Medicine (EM) are increasingly exposed to guidelines and treatment recommendations. To help access and recall these recommendations, electronic Clinical Decision Support Systems (CDSS) have been developed. This study examined the use and sensibility of two CDSS designed for emergency physicians. CDDS for community acquired pneumonia (CAP) and neutropenic fever (NF) were developed by multidisciplinary teams and have been accessed via an intranet-based homepage (eCPG) for several years. Sensibility is a term coined by Feinstein that describes common sense aspects of a survey instrument. It was modified by emergency researchers to include four main headings: (1) Appropriateness; (2) Objectivity; (3) Content; and (4) Discriminative Power. Sensibility surveys were developed using an iterative approach for both the CAP and NF CDSS and distributed to all 25 emergency physicians at one Canadian site. The overall response rate was 88%. Respondents were 88% male and 83% were less than 40; all were attending EM physicians with specialty designations. A number reported never having used the CAP (21%) or NF (33%) CDSS; 54% (CAP) and 21% (NF) of respondents had used the respective CDSS less than 10 times. Overall, both CDSS were rated highly by users with a mean response of 4.95 (SD 0.56) for CAP and 5.62 (SD 0.62) for NF on a seven-point Likert scale. The majority or respondents (CAP 59%, NF 80%) felt that the NF CDSS was more likely than the CAP CDSS to decrease the chances of making a medical error in medication dose, antibiotic choice or patient disposition (4.61 vs. 5.81, p=0.008). Despite being in place for several years, CDSS for CAP and NF are not used by all EM clinicians. Users were generally satisfied with the CDSS and felt that the NF was more likely than the CAP CDSS to decrease medical errors. Additional research is required to determine the barriers to CDSS use.

  14. System-Agnostic Clinical Decision Support Services: Benefits and Challenges for Scalable Decision Support

    PubMed Central

    Kawamoto, Kensaku; Del Fiol, Guilherme; Orton, Charles; Lobach, David F

    2010-01-01

    System-agnostic clinical decision support (CDS) services provide patient evaluation capabilities that are independent of specific CDS systems and system implementation contexts. While such system-agnostic CDS services hold great potential for facilitating the widespread implementation of CDS systems, little has been described regarding the benefits and challenges of their use. In this manuscript, the authors address this need by describing potential benefits and challenges of using a system-agnostic CDS service. This analysis is based on the authors’ formal assessments of, and practical experiences with, various approaches to developing, implementing, and maintaining CDS capabilities. In particular, the analysis draws on the authors’ experience developing and leveraging a system-agnostic CDS Web service known as SEBASTIAN. A primary potential benefit of using a system-agnostic CDS service is the relative ease and flexibility with which the service can be leveraged to implement CDS capabilities across applications and care settings. Other important potential benefits include facilitation of centralized knowledge management and knowledge sharing; the potential to support multiple underlying knowledge representations and knowledge resources through a common service interface; improved simplicity and componentization; easier testing and validation; and the enabling of distributed CDS system development. Conversely, important potential challenges include the increased effort required to develop knowledge resources capable of being used in many contexts and the critical need to standardize the service interface. Despite these challenges, our experiences to date indicate that the benefits of using a system-agnostic CDS service generally outweigh the challenges of using this approach to implementing and maintaining CDS systems. PMID:21603281

  15. System-agnostic clinical decision support services: benefits and challenges for scalable decision support.

    PubMed

    Kawamoto, Kensaku; Del Fiol, Guilherme; Orton, Charles; Lobach, David F

    2010-01-01

    System-agnostic clinical decision support (CDS) services provide patient evaluation capabilities that are independent of specific CDS systems and system implementation contexts. While such system-agnostic CDS services hold great potential for facilitating the widespread implementation of CDS systems, little has been described regarding the benefits and challenges of their use. In this manuscript, the authors address this need by describing potential benefits and challenges of using a system-agnostic CDS service. This analysis is based on the authors' formal assessments of, and practical experiences with, various approaches to developing, implementing, and maintaining CDS capabilities. In particular, the analysis draws on the authors' experience developing and leveraging a system-agnostic CDS Web service known as SEBASTIAN. A primary potential benefit of using a system-agnostic CDS service is the relative ease and flexibility with which the service can be leveraged to implement CDS capabilities across applications and care settings. Other important potential benefits include facilitation of centralized knowledge management and knowledge sharing; the potential to support multiple underlying knowledge representations and knowledge resources through a common service interface; improved simplicity and componentization; easier testing and validation; and the enabling of distributed CDS system development. Conversely, important potential challenges include the increased effort required to develop knowledge resources capable of being used in many contexts and the critical need to standardize the service interface. Despite these challenges, our experiences to date indicate that the benefits of using a system-agnostic CDS service generally outweigh the challenges of using this approach to implementing and maintaining CDS systems.

  16. Clinical care paths: a role for finance in clinical decision-making.

    PubMed

    Abrams, Michael N; Cummings, Simone; Hage, Dana

    2012-12-01

    Care paths map the critical actions and decision points across a patient's course of medical treatment; their purpose is to guide physicians in the delivery of high-quality care while reducing care costs by avoiding services that do not contribute meaningfully to positive outcomes. Each care path development initiative should be led by a respected physician champion, whose specialty is in the area of the care episode being mapped, with the support of a clinician project manager. Once the care path has been developed and implemented, the finance leader's role begins in earnest with the tracking of financial and clinical data against care paths.

  17. Affective judgment and beneficial decision making: ventromedial prefrontal activity correlates with performance in the Iowa Gambling Task.

    PubMed

    Northoff, Georg; Grimm, Simone; Boeker, Heinz; Schmidt, Conny; Bermpohl, Felix; Heinzel, Alexander; Hell, Daniel; Boesiger, Peter

    2006-07-01

    Damasio proposes in his somatic marker theory that not only cognitive but also affective components are critical for decision making. Since affective judgment requires an interplay between affective and cognitive components, it might be considered a key process in decision making that has been linked to neural activity in ventromedial prefrontal cortex (VMPFC). Using functional magnetic resonance imaging (fMRI), we examined the relationship between VMPFC, emotionally (unexpected)- and cognitively (expected)-accentuated affective judgment, and beneficial decision making (Iowa Gambling Task; IGT) in healthy subjects. Neuronal activity in the VMPFC during unexpected affective judgment significantly correlated with both global and final performance in the IGT task. These findings suggest that the degree to which subjects recruit the VMPFC during affective judgment is related to beneficial performance in decision making in gambling.

  18. Representation of Clinical Practice Guidelines in Conventional and Augmented Decision Tables

    PubMed Central

    Shiffman, Richard N.

    1997-01-01

    Abstract Objective: To develop a knowledge representation model for clinical practice guidelines that is linguistically adequate, comprehensible, reusable, and maintainable. Design: Decision tables provide the basic framework for the proposed knowledge representation model. Guideline logic is represented as rules in conventional decision tables. These tables are augmented by layers where collateral information is recorded in slots beneath the logic. Results: Decision tables organize rules into cohesive rule sets wherein complex logic is clarified. Decision table rule sets may be verified to assure completeness and consistency. Optimization and display of rule sets as sequential decision trees may enhance the comprehensibility of the logic. The modularity of the rule formats may facilitate maintenance. The augmentation layers provide links to descriptive language, information sources, decision variable characteristics, costs and expected values of policies, and evidence sources and quality. Conclusion: Augmented decision tables can serve as a unifying knowledge representation for developers and implementers of clinical practice guidelines. PMID:9292844

  19. Influence of affective words on lexical decision task in major depression.

    PubMed Central

    Stip, E; Lecours, A R; Chertkow, H; Elie, R; O'Connor, K

    1994-01-01

    In cognitive science, lexical decision task is used to investigate visual word recognition and lexical access. The issue of whether or not individuals who are depressed differ in their access to affectively laden words and specifically to words that have negative affect was examined. Based on some aspects of the Resource Allocation Model (Ellis), it was postulated that patients suffering from depression take more time to recognize items from an affective-loaded list. In order to compare their behavior in a lexical decision task, patients suffering from depression and healthy controls were studied. We hoped to find an interaction between the mood state of subjects and the categories (affective or neutral) of words. Two groups of right-handed adults served as subjects in our experiment. The first group consisted of 11 patients suffering from depression (mean age: 40.2; sd: 6.8). All of this group met the DSM-III-R and the Research Diagnostic Criteria for major depressive disorder. Severity of their disease was rated using the 24-item Hamilton Depressive Rating Scale. All patients suffering from depression were without psychotropic medication. The control group was composed of 24 subjects (mean age: 32.7; sd: 7.9). A depressive word-list and a neutral word-list were built and a computer was used for the lexical-decision task. A longer reaction time to detect the non-word stimuli (F1,33 = 11.19, p < 0.01) was observed with the patients by comparison to the normal subjects. In the analysis of the word stimuli, a group by list interaction (F1,33 = 7.18, p < 0.01) was found.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:8031744

  20. Disaster dilemma: factors affecting decision to come to work during a natural disaster.

    PubMed

    Davidson, Judy E; Sekayan, Ani; Agan, Donna; Good, Linda; Shaw, David; Smilde, Renee

    2009-01-01

    Natural disasters threaten the ability to staff a hospital. The objective of this study was to identify factors influencing decision to come to work during a fire disaster. The authors' hospital experienced a 17-fold increase in no-shows during a fire. Phenomenography was used to explore staff experiences immediately following wildfires. Factors affecting decision to work during a disaster included vulnerability of family, personal safety, and fire proximity. Modifiable factors were identified as follows: past experience with disasters, perceived importance, relationship with the organization, and caring connection with the organization. Employees experienced tension between obligations to family, community, and organization. Pets were seen as family and as important as biological family. Further research is indicated to determine predictive modeling and generalizability. Hospital leaders may influence disaster response by establishing a caring connection, providing resources for family members/pets, and promoting perceived importance of the employee.

  1. Microcomputer-Based Expert System for Clinical Decision-Making

    PubMed Central

    Hudson, Donna L.; Estrin, Thelma

    1981-01-01

    A computerized rule-based expert system for chest pain analysis in the emergency room has been developed as a medical decision-making tool. The rules are based on a previously established criteria mapping procedure developed for evaluating emergency room decisions. The system is implemented in PASCAL, a standardized language, and hence is machine-independent, and also has modest memory requirements. The overall design permits usage by those unfamiliar with computers.

  2. Extracting clinical information to support medical decision based on standards.

    PubMed

    Gomoi, Valentin; Vida, Mihaela; Stoicu-Tivadar, Lăcrămioara; Stoicu-Tivadar, Vasile

    2011-01-01

    The paper presents a method connecting medical databases to a medical decision system, and describes a service created to extract the necessary information that is transferred based on standards. The medical decision can be improved based on many inputs from different medical locations. The developed solution is described for a concrete case concerning the management for chronic pelvic pain, based on the information retrieved from diverse healthcare databases.

  3. The role of current affect, anticipated affect and spontaneous self-affirmation in decisions to receive self-threatening genetic risk information.

    PubMed

    Ferrer, Rebecca A; Taber, Jennifer M; Klein, William M P; Harris, Peter R; Lewis, Katie L; Biesecker, Leslie G

    2015-01-01

    One reason for not seeking personally threatening information may be negative current and anticipated affective responses. We examined whether current (e.g., worry) and anticipated negative affect predicted intentions to seek sequencing results in the context of an actual genomic sequencing trial (ClinSeq®; n = 545) and whether spontaneous self-affirmation mitigated any (negative) association between affect and intentions. Anticipated affective response negatively predicted intentions to obtain and share results pertaining to both medically actionable and non-actionable disease, whereas current affect was only a marginal predictor. The negative association between anticipated affect and intentions to obtain results pertaining to non-actionable disease was weaker in individuals who were higher in spontaneous self-affirmation. These results have implications for the understanding of current and anticipated affect, self-affirmation and consequential decision-making and contribute to a growing body of evidence on the role of affect in medical decisions.

  4. A Representation for Gaining Insight into Clinical Decision Models

    PubMed Central

    Jimison, Holly B.

    1988-01-01

    For many medical domains uncertainty and patient preferences are important components of decision making. Decision theory is useful as a representation for such medical models in computer decision aids, but the methodology has typically had poor performance in the areas of explanation and user interface. The additional representation of probabilities and utilities as random variables serves to provide a framework for graphical and text insight into complicated decision models. The approach allows for efficient customization of a generic model that describes the general patient population of interest to a patient- specific model. Monte Carlo simulation is used to calculate the expected value of information and sensitivity for each model variable, thus providing a metric for deciding what to emphasize in the graphics and text summary. The computer-generated explanation includes variables that are sensitive with respect to the decision or that deviate significantly from what is typically observed. These techniques serve to keep the assessment and explanation of the patient's decision model concise, allowing the user to focus on the most important aspects for that patient.

  5. Chest pain for coronary heart disease in general practice: clinical judgement and a clinical decision rule

    PubMed Central

    Haasenritter, Jörg; Donner-Banzhoff, Norbert; Bösner, Stefan

    2015-01-01

    Background The Marburg Heart Score (MHS) is a simple, valid, and robust clinical decision rule assisting GPs in ruling out coronary heart disease (CHD) in patients presenting with chest pain. Aim To investigate whether using the rule adds to the GP’s clinical judgement. Design and setting A comparative diagnostic accuracy study was conducted using data from 832 consecutive patients with chest pain in general practice. Method Three diagnostic strategies were defined using the MHS: diagnosis based solely on the MHS; using the MHS as a triage test; and GP’s clinical judgement aided by the MHS. Their accuracy was compared with the GPs’ unaided clinical judgement. Results Sensitivity and specificity of the GPs’ unaided clinical judgement was 82.9% (95% confidence interval [CI] = 72.4 to 89.9) and 61.0% (95% CI = 56.7 to 65.2), respectively. In comparison, the sensitivity of the MHS was higher (difference 8.5%, 95% CI = −2.4 to 19.6) and the specificity was similar (difference −0.4%, 95% CI = −5.3 to 4.5); the sensitivity of the triage was similar (difference −1.5%, 95% CI = −9.8 to 7.0) and the specificity was higher (difference 11.6%, 95% CI = 7.8 to 15.4); and both the sensitivity and specificity of the aided clinical judgement were higher (difference 8.0%, 95% CI = −6.9 to 23.0 and 5.8%, 95% CI = −1.6 to 13.2, respectively). Conclusion Using the Marburg Heart Score for initial triage can improve the clinical diagnosis of CHD in general practice. PMID:26500322

  6. 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.

  7. 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

  8. Quantitative Framework for Retrospective Assessment of Interim Decisions in Clinical Trials.

    PubMed

    Stanev, Roger

    2016-11-01

    This article presents a quantitative way of modeling the interim decisions of clinical trials. While statistical approaches tend to focus on the epistemic aspects of statistical monitoring rules, often overlooking ethical considerations, ethical approaches tend to neglect the key epistemic dimension. The proposal is a second-order decision-analytic framework. The framework provides means for retrospective assessment of interim decisions based on a clear and consistent set of criteria that combines both ethical and epistemic considerations. The framework is broadly Bayesian and addresses a fundamental question behind many concerns about clinical trials: What does it take for an interim decision (e.g., whether to stop the trial or continue) to be a good decision? Simulations illustrating the modeling of interim decisions counterfactually are provided.

  9. Critical care outreach: the need for effective decision-making in clinical practice (part 2).

    PubMed

    Hancock, Helen C; Durham, Lesley

    2007-04-01

    As the extension of nursing into roles previously within the domain of medicine and the demand for evidence based practice continue to increase, the quality of decision making becomes imperative. Making accurate decisions is essential, both for the practitioner and for the patient, especially in the provision of critical care outreach (CCOR), to improve outcomes of care. With changes in health care delivery and increased accountability for practitioners' decisions, it is important to understand more about how clinical decisions are made and what factors influence them in order to inform practice. The previous paper outlined the theoretical background of clinical decision making and the knowledge that underpins practice in CCOR. In this paper, the authors, a Nurse Consultant in CCOR and a research fellow, examine the process of a practitioner's decision making in the practice of CCOR, through a collaborative reflective account of a case study. From this, recommendations are made about the future development of CCOR practitioners and services.

  10. Quantitative Framework for Retrospective Assessment of Interim Decisions in Clinical Trials

    PubMed Central

    Stanev, Roger

    2016-01-01

    This article presents a quantitative way of modeling the interim decisions of clinical trials. While statistical approaches tend to focus on the epistemic aspects of statistical monitoring rules, often overlooking ethical considerations, ethical approaches tend to neglect the key epistemic dimension. The proposal is a second-order decision-analytic framework. The framework provides means for retrospective assessment of interim decisions based on a clear and consistent set of criteria that combines both ethical and epistemic considerations. The framework is broadly Bayesian and addresses a fundamental question behind many concerns about clinical trials: What does it take for an interim decision (e.g., whether to stop the trial or continue) to be a good decision? Simulations illustrating the modeling of interim decisions counterfactually are provided. PMID:27353825

  11. How do strategic decisions and operative practices affect operating room productivity?

    PubMed

    Peltokorpi, Antti

    2011-12-01

    Surgical operating rooms are cost-intensive parts of health service production. Managing operating units efficiently is essential when hospitals and healthcare systems aim to maximize health outcomes with limited resources. Previous research about operating room management has focused on studying the effect of management practices and decisions on efficiency by utilizing mainly modeling approach or before-after analysis in single hospital case. The purpose of this research is to analyze the synergic effect of strategic decisions and operative management practices on operating room productivity and to use a multiple case study method enabling statistical hypothesis testing with empirical data. 11 hypotheses that propose connections between the use of strategic and operative practices and productivity were tested in a multi-hospital study that included 26 units. The results indicate that operative practices, such as personnel management, case scheduling and performance measurement, affect productivity more remarkably than do strategic decisions that relate to, e.g., units' size, scope or academic status. Units with different strategic positions should apply different operative practices: Focused hospital units benefit most from sophisticated case scheduling and parallel processing whereas central and ambulatory units should apply flexible working hours, incentives and multi-skilled personnel. Operating units should be more active in applying management practices which are adequate for their strategic orientation.

  12. Need for Cognitive Closure Modulates How Perceptual Decisions Are Affected by Task Difficulty and Outcome Relevance

    PubMed Central

    Viola, Vanda; Tosoni, Annalisa; Brizi, Ambra; Salvato, Ilaria; Kruglanski, Arie W.; Galati, Gaspare; Mannetti, Lucia

    2015-01-01

    The aim of this study was to assess the extent to which Need for Cognitive Closure (NCC), an individual-level epistemic motivation, can explain inter-individual variability in the cognitive effort invested on a perceptual decision making task (the random motion task). High levels of NCC are manifested in a preference for clarity, order and structure and a desire for firm and stable knowledge. The study evaluated how NCC moderates the impact of two variables known to increase the amount of cognitive effort invested on a task, namely task ambiguity (i.e., the difficulty of the perceptual discrimination) and outcome relevance (i.e., the monetary gain associated with a correct discrimination). Based on previous work and current design, we assumed that reaction times (RTs) on our motion discrimination task represent a valid index of effort investment. Task ambiguity was associated with increased cognitive effort in participants with low or medium NCC but, interestingly, it did not affect the RTs of participants with high NCC. A different pattern of association was observed for outcome relevance; high outcome relevance increased cognitive effort in participants with moderate or high NCC, but did not affect the performance of low NCC participants. In summary, the performance of individuals with low NCC was affected by task difficulty but not by outcome relevance, whereas individuals with high NCC were influenced by outcome relevance but not by task difficulty; only participants with medium NCC were affected by both task difficulty and outcome relevance. These results suggest that perceptual decision making is influenced by the interaction between context and NCC. PMID:26716987

  13. Can decision-making skills affect responses to psychological stress in healthy women?

    PubMed

    Santos-Ruiz, Ana; Garcia-Rios, M Carmen; Fernandez-Sanchez, José Carlos; Perez-Garcia, Miguel; Muñoz-García, Miguel Angel; Peralta-Ramirez, Maria Isabel

    2012-12-01

    In recent studies showing how stress can affect an individual's decision-making process, the cognitive component of decision-making could also be considered a coping resource available to individuals when faced with a stressful situation. The Iowa Gambling Task (IGT) constitutes the standard test for the assessment of decision-making skills under conditions of uncertainty. Responses of the hypothalamic-pituitary-adrenal (HPA) axis to psychosocial stress, in turn, have been estimated by means of cortisol measurements. Our main objective in this study was to test if good and bad IGT performers show distinct HPA axis responses, when challenged in a classic psychosocial stress test. Because women have been shown to outperform men on the IGT under the influence of psychosocial stress, we chose a sample of 40 women to take the IGT before they were exposed to a public speaking task in a virtual environment. The activation of the HPA axis, involved in the stress response, was assessed by examining the levels of cortisol in the subjects' saliva at the following four stages: before the challenge, after the challenge, and 10 and 20 min after the task. Participants were divided into two groups according to their level of performance, good or poor, on the IGT. Results showed statistically significant differences between the groups for pre-exposure cortisol levels and for cortisol levels 20 min after exposure. Overall cortisol levels were significantly higher in the group with poor performance on the IGT. It appears that good decision-making, which may be an important resource for coping with stress, is associated with a lower HPA axis response to a psychosocial stressor.

  14. Factors affecting decision making of low-income young women with unplanned pregnancies in Bangkok, Thailand.

    PubMed

    Naravage, Wanapa; Vichit-Vadakan, Nuntavarn; Sakulbumrungsil, Rungpetch C; Van der Putten, Marc

    2005-05-01

    Unplanned pregnancy is one of the most difficult life experiences for young women. Women are often confused and seek help and support. When the problem occurs, a woman has three choices: parenting the baby, planning for adoption, or terminating the pregnancy. Choosing one of these three options is often difficult. This study aimed to identify the factors (variables) influencing women's decision making when choosing the options available to them. The study was conducted in five shelters and low-income communities in the Bangkok area. Data were collected for five months, November 2003 to March 2004. Young women, age 13-24, who experienced an unplanned pregnancy at least once, or currently experiencing an unplanned pregnancy, were recruited into the study. One hundred and twenty volunteer cases were recruited. Discriminant analysis was used to determine the factors that affecting the choices of young women with unplanned pregnancies. There were 6 potential influencing variables, in three broad categories of factors that influenced their choices. In this study, the influencing factors from the personal history variables were, age of the most recent unplanned pregnancy. The individual psychosocial variables were: attitude towards unplanned pregnancy, attitude towards contraception, and making a decision without consultation. The relationship variables were: relationship with partner, and consulting partner when having a problem. The results from discriminant analysis yielded 68.3% predictive accuracy. This result was satisfactory compared with a 33% chance of accuracy (classified as chance alone would yield a 33% accuracy). Knowing the influencing factors for the choices of young women with unplanned pregnancies allows us to understand the women's decisions and their utilization of services with some degree of confidence. The program managers or implementers should do as much as possible to support the decision making process in these young women in order to provide

  15. The professional medical ethics model of decision making under conditions of clinical uncertainty.

    PubMed

    McCullough, Laurence B

    2013-02-01

    The professional medical ethics model of decision making may be applied to decisions clinicians and patients make under the conditions of clinical uncertainty that exist when evidence is low or very low. This model uses the ethical concepts of medicine as a profession, the professional virtues of integrity and candor and the patient's virtue of prudence, the moral management of medical uncertainty, and trial of intervention. These features combine to justifiably constrain clinicians' and patients' autonomy with the goal of preventing nondeliberative decisions of patients and clinicians. To prevent biased recommendations by the clinician that promote such nondeliberative decisions, medically reasonable alternatives supported by low or very low evidence should be offered but not recommended. The professional medical ethics model of decision making aims to improve the quality of decisions by reducing the unacceptable variation that can result from nondeliberative decision making by patients and clinicians when evidence is low or very low.

  16. The Clinical Intuition Exploration Guide: A Decision-Making Tool for Counselors and Supervisors

    ERIC Educational Resources Information Center

    Jeffrey, Aaron

    2012-01-01

    Clinical intuition is a common experience among counselors, yet many do not know what to do with intuition when it occurs. This article reviews the role intuition plays in clinical work and presents the research-based Clinical Intuition Exploration Guide to help counselors navigate the decision-making process. The guide consists of self-reflection…

  17. Factors Predicting Oncology Care Providers' Behavioral Intention to Adopt Clinical Decision Support Systems

    ERIC Educational Resources Information Center

    Wolfenden, Andrew

    2012-01-01

    The purpose of this quantitative correlation study was to examine the predictors of user behavioral intention on the decision of oncology care providers to adopt or reject the clinical decision support system. The Unified Theory of Acceptance and Use of Technology (UTAUT) formed the foundation of the research model and survey instrument. The…

  18. An Examination of Accelerated and Basic Baccalaureate Nursing Students' Perceptions of Clinical Decision Making

    ERIC Educational Resources Information Center

    Krumwiede, Kelly A.

    2010-01-01

    Developing decision-making skills is essential in education in order to be a competent nurse. The purpose of this study was to examine and compare the perceptions of clinical decision-making skills of students enrolled in accelerated and basic baccalaureate nursing programs. A comparative descriptive research design was used for this study.…

  19. Mental Workload as a Key Factor in Clinical Decision Making

    ERIC Educational Resources Information Center

    Byrne, Aidan

    2013-01-01

    The decision making process is central to the practice of a clinician and has traditionally been described in terms of the hypothetico-deductive model. More recently, models adapted from cognitive psychology, such as the dual process and script theories have proved useful in explaining patterns of practice not consistent with purely cognitive…

  20. Clinical trials involving cats: What factors affect owner 1 participation?

    PubMed Central

    Gruen, Margaret E; Jiamachello, Katrina N; Thomson, Andrea; Lascelles, BDX

    2014-01-01

    Clinical trials are frequently hindered by difficulty recruiting eligible participants, increasing the timeline and limiting generalizability of results. In veterinary medicine, where proxy enrollment is required, no studies have detailed what factors influence owner participation in studies involving cats. We aimed to investigate these factors through a survey of owners at first opinion practices. The survey was designed using feedback from a pilot study and input from clinical researchers. Owners were asked demographic questions and whether they would, would not, or were unsure about participating in a clinical trial with their cat. They then ranked the importance and influence of various factors on participation using a 5-point Likert-type scale, and incentives from most to least encouraging. A total of 413 surveys were distributed to cat owners at four hospitals, two feline-only and two multi-species; 88.6% were completed. Data for importance and influence factors as well as incentive rankings were analyzed overall, by hospital type, location and whether owners would consider participating. The most influential factors were trust in the organization, benefit to the cat and veterinarian recommendation. Importance and influence factors varied by willingness to participate. Ranked incentives were not significantly different across groups, with “Free Services” ranked highest. This study provides a first look at what factors influence participation in clinical trials with cats. Given the importance placed in the recommendation of veterinarians, continued work is needed to determine veterinarian related factors affecting clinical trial participation. The results provide guidance towards improved clinical trial design, promotion and education. PMID:24938313

  1. 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

  2. Individual dispersal decisions affect fitness via maternal rank effects in male rhesus macaques

    PubMed Central

    Weiß, Brigitte M.; Kulik, Lars; Ruiz-Lambides, Angelina V.; Widdig, Anja

    2016-01-01

    Natal dispersal may have considerable social, ecological and evolutionary consequences. While species-specific dispersal strategies have received much attention, individual variation in dispersal decisions and its fitness consequences remain poorly understood. We investigated causes and consequences of natal dispersal age in rhesus macaques (Macaca mulatta), a species with male dispersal. Using long-term demographic and genetic data from a semi-free ranging population on Cayo Santiago, Puerto Rico, we analysed how the social environment such as maternal family, group and population characteristics affected the age at which males leave their natal group. While natal dispersal age was unrelated to most measures of group or population structure, our study confirmed earlier findings that sons of high-ranking mothers dispersed later than sons of low-ranking ones. Natal dispersal age did not affect males’ subsequent survival, but males dispersing later were more likely to reproduce. Late dispersers were likely to start reproducing while still residing in their natal group, frequently produced extra-group offspring before natal dispersal and subsequently dispersed to the group in which they had fathered offspring more likely than expected. Hence, the timing of natal dispersal was affected by maternal rank and influenced male reproduction, which, in turn affected which group males dispersed to. PMID:27576465

  3. Evaluating ambivalence: social-cognitive and affective brain regions associated with ambivalent decision-making.

    PubMed

    Nohlen, Hannah U; van Harreveld, Frenk; Rotteveel, Mark; Lelieveld, Gert-Jan; Crone, Eveline A

    2014-07-01

    Ambivalence is a state of inconsistency that is often experienced as affectively aversive. In this functional magnetic resonance imaging study, we investigated the role of cognitive and social-affective processes in the experience of ambivalence and coping with its negative consequences. We examined participants' brain activity during the dichotomous evaluation (pro vs contra) of pretested ambivalent (e.g. alcohol), positive (e.g. happiness) and negative (e.g. genocide) word stimuli. We manipulated evaluation relevance by varying the probability of evaluation consequences, under the hypothesis that ambivalence is experienced as more negative when outcomes are relevant. When making ambivalent evaluations, more activity was found in the anterior cingulate cortex, the insula, the temporal parietal junction (TPJ) and the posterior cingulate cortex (PCC)/precuneus, for both high and low evaluation relevance. After statistically conservative corrections, activity in the TPJ and PCC/precuneus was negatively correlated with experienced ambivalence after scanning, as measured by Priester and Petty's felt ambivalence scale (1996). The findings show that cognitive and social-affective brain areas are involved in the experience of ambivalence. However, these networks are differently associated with subsequent reduction of ambivalence, thus highlighting the importance of understanding both cognitive and affective processes involved in ambivalent decision-making.

  4. A patient with a large pulmonary saddle embolus eluding both clinical gestalt and validated decision rules.

    PubMed

    Hennessey, Adam; Setyono, Devy A; Lau, Wayne Bond; Fields, Jason Matthew

    2012-06-01

    We report a patient with chest pain who was classified as having low risk for pulmonary embolism with clinical gestalt and accepted clinical decision rules. An inadvertently ordered D-dimer and abnormal result, however, led to the identification of a large saddle embolus. This case illustrates the fallibility of even well-validated decision aids and that an embolism missed by these tools is not necessarily low risk or indicative of a low clot burden.

  5. Use of Simulation to Study Nurses' Acceptance and Nonacceptance of Clinical Decision Support Suggestions.

    PubMed

    Sousa, Vanessa E C; Lopez, Karen Dunn; Febretti, Alessandro; Stifter, Janet; Yao, Yingwei; Johnson, Andrew; Wilkie, Diana J; Keenan, Gail M

    2015-10-01

    Our long-term goal was to ensure nurse clinical decision support works as intended before full deployment in clinical practice. As part of a broader effort, this pilot project explored factors influencing acceptance/nonacceptance of eight clinical decision support suggestions displayed in an electronic health record-based nursing plan of care software prototype. A diverse sample of 21 nurses participated in this high-fidelity clinical simulation experience and completed a questionnaire to assess reasons for accepting/not accepting the clinical decision support suggestions. Of 168 total suggestions displayed during the experiment (eight for each of the 21 nurses), 123 (73.2%) were accepted, and 45 (26.8%) were not accepted. The mode number of acceptances by nurses was seven of eight, with only two of 21 nurses accepting all. The main reason for clinical decision support acceptance was the nurse's belief that the suggestions were good for the patient (100%), with other features providing secondary reinforcement. Reasons for nonacceptance were less clear, with fewer than half of the subjects indicating low confidence in the evidence. This study provides preliminary evidence that high-quality simulation and targeted questionnaires about specific clinical decision support selections offer a cost-effective means for testing before full deployment in clinical practice.

  6. Decision analysis in clinical cardiology: When is coronary angiography required in aortic stenosis

    SciTech Connect

    Georgeson, S.; Meyer, K.B.; Pauker, S.G. )

    1990-03-15

    Decision analysis offers a reproducible, explicit approach to complex clinical decisions. It consists of developing a model, typically a decision tree, that separates choices from chances and that specifies and assigns relative values to outcomes. Sensitivity analysis allows exploration of alternative assumptions. Cost-effectiveness analysis shows the relation between dollars spent and improved health outcomes achieved. In a tutorial format, this approach is applied to the decision whether to perform coronary angiography in a patient who requires aortic valve replacement for critical aortic stenosis.

  7. Helping Health Care Providers and Clinical Scientists Understand Apparently Irrational Policy Decisions

    PubMed Central

    2016-01-01

    Health care providers (HCP) and clinical scientists (CS) are generally most comfortable using evidence-based rational decision-making models. They become very frustrated when policymakers make decisions that, on the surface, seem irrational and unreasonable. However, such decisions usually make sense when analysed properly. The goal of this paper to provide a basic theoretical understanding of major policy models, to illustrate which models are most prevalent in publicly funded health care systems, and to propose a policy analysis framework to better understand the elements that drive policy decision-making. The proposed policy framework will also assist HCP and CS achieve greater success with their own proposals. PMID:28123917

  8. Hip fractures and dementia: clinical decisions for the future.

    PubMed

    Waran, Eswaran; William, Leeroy

    2016-02-01

    Severe dementia is a life-limiting condition; hip fractures are more common in patients who have dementia. This study outlines the case of a 92-year-old female with severe dementia who sustained a hip fracture. Despite having a terminal diagnosis (severe dementia and hip fracture) and poor premorbid quality of life, she had a life-prolonging surgery. The report outlines issues around treatment options in such circumstances, informed consent and substitute decision-making. The authors propose a 'goals of care' approach to manage patients in whom the best treatment is unclear, during their attendance to the emergency department. It is suggested that utilization of such a model may help with substitute decision-making and true informed consent.

  9. Clinical data warehousing for evidence based decision making.

    PubMed

    Narra, Lekha; Sahama, Tony; Stapleton, Peta

    2015-01-01

    Large volumes of heterogeneous health data silos pose a big challenge when exploring for information to allow for evidence based decision making and ensuring quality outcomes. In this paper, we present a proof of concept for adopting data warehousing technology to aggregate and analyse disparate health data in order to understand the impact various lifestyle factors on obesity. We present a practical model for data warehousing with detailed explanation which can be adopted similarly for studying various other health issues.

  10. Development of a scalable pharmacogenomic clinical decision support service.

    PubMed

    Fusaro, Vincent A; Brownstein, Catherine; Wolf, Wendy; Clinton, Catherine; Savage, Sarah; Mandl, Kenneth D; Margulies, David; Manzi, Shannon

    2013-01-01

    Advances in sequencing technology are making genomic data more accessible within the healthcare environment. Published pharmacogenetic guidelines attempt to provide a clinical context for specific genomic variants; however, the actual implementation to convert genomic data into a clinical report integrated within an electronic medical record system is a major challenge for any hospital. We created a two-part solution that integrates with the medical record system and converts genetic variant results into an interpreted clinical report based on published guidelines. We successfully developed a scalable infrastructure to support TPMT genetic testing and are currently testing approximately two individuals per week in our production version. We plan to release an online variant to clinical interpretation reporting system in order to facilitate translation of pharmacogenetic information into clinical practice.

  11. Shared decision making: examining key elements and barriers to adoption into routine clinical practice.

    PubMed

    Légaré, France; Witteman, Holly O

    2013-02-01

    For many patients, the time spent meeting with their physician-the clinical encounter-is the most opportune moment for them to become engaged in their own health through the process of shared decision making. In the United States shared decision making is being promoted for its potential to improve the health of populations and individual patients, while also helping control care costs. In this overview we describe the three essential elements of shared decision making: recognizing and acknowledging that a decision is required; knowing and understanding the best available evidence; and incorporating the patient's values and preferences into the decision. To achieve the promise of shared decision making, more physicians need training in the approach, and more practices need to be reorganized around the principles of patient engagement. Additional research is also needed to identify the interventions that are most effective.

  12. Exploring Factors Affecting Emergency Medical Services Staffs' Decision about Transporting Medical Patients to Medical Facilities

    PubMed Central

    Seyedin, Hesam; Jamshidi-Orak, Roohangiz

    2014-01-01

    Transfer of patients in medical emergency situations is one of the most important missions of emergency medical service (EMS) staffs. So this study was performed to explore affecting factors in EMS staffs' decision during transporting of patients in medical situations to medical facilities. The participants in this qualitative study consisted of 18 EMS staffs working in prehospital care facilities in Tehran, Iran. Data were gathered through semistructured interviews. The data were analyzed using a content analysis approach. The data analysis revealed the following theme: “degree of perceived risk in EMS staffs and their patients.” This theme consisted of two main categories: (1) patient's condition' and (2) the context of the EMS mission'. The patent's condition category emerged from “physical health statuses,” “socioeconomic statuses,” and “cultural background” subcategories. The context of the EMS mission also emerged from two subcategories of “characteristics of the mission” and EMS staffs characteristics'. EMS system managers can consider adequate technical, informational, financial, educational, and emotional supports to facilitate the decision making of their staffs. Also, development of an effective and user-friendly checklist and scoring system was recommended for quick and easy recognition of patients' needs for transportation in a prehospital situation. PMID:24891953

  13. Exploring Factors Affecting Emergency Medical Services Staffs' Decision about Transporting Medical Patients to Medical Facilities.

    PubMed

    Ebrahimian, Abbasali; Seyedin, Hesam; Jamshidi-Orak, Roohangiz; Masoumi, Gholamreza

    2014-01-01

    Transfer of patients in medical emergency situations is one of the most important missions of emergency medical service (EMS) staffs. So this study was performed to explore affecting factors in EMS staffs' decision during transporting of patients in medical situations to medical facilities. The participants in this qualitative study consisted of 18 EMS staffs working in prehospital care facilities in Tehran, Iran. Data were gathered through semistructured interviews. The data were analyzed using a content analysis approach. The data analysis revealed the following theme: "degree of perceived risk in EMS staffs and their patients." This theme consisted of two main categories: (1) patient's condition' and (2) the context of the EMS mission'. The patent's condition category emerged from "physical health statuses," "socioeconomic statuses," and "cultural background" subcategories. The context of the EMS mission also emerged from two subcategories of "characteristics of the mission" and EMS staffs characteristics'. EMS system managers can consider adequate technical, informational, financial, educational, and emotional supports to facilitate the decision making of their staffs. Also, development of an effective and user-friendly checklist and scoring system was recommended for quick and easy recognition of patients' needs for transportation in a prehospital situation.

  14. Factors Affecting Women's Autonomous Decision Making In Research Participation Amongst Yoruba Women Of Western Nigeria.

    PubMed

    Princewill, Chitu Womehoma; Jegede, Ayodele S; Nordström, Karin; Lanre-Abass, Bolatito; Elger, Bernice Simone

    2017-04-01

    Research is a global enterprise requiring participation of both genders for generalizable knowledge; advancement of science and evidence based medical treatment. Participation of women in research is necessary to reduce the current bias that most empirical evidence is obtained from studies with men to inform health care and related policy interventions. Various factors are assumed to limit autonomy amongst the Yoruba women of western Nigeria. This paper seeks to explore the experience and understanding of autonomy by the Yoruba women in relation to research participation. Focus is on factors that affect women's autonomous decision making in research participation. An exploratory qualitative approach comprising four focus group discussions, 42 in-depth interviews and 14 key informant interviews was used. The study permits a significant amount of triangulation, as opinions of husbands and religious leaders are also explored. Interviews and discussions were audiotaped and transcribed verbatim. Content analysis was employed for data analysis. Findings show that concepts of autonomy varied amongst the Yoruba women. Patriarchy, religion and culture are conceived to have negative impact on the autonomy of women in respect to research participation. Among the important findings are: 1) male dominance is strongly emphasized by religious leaders who should teach equality, 2) while men feel that by making decisions for women, they are protecting them, the women on the other hand see this protection as a way of limiting their autonomy. We recommend further studies to develop culturally appropriate and workable recruitment methods to increase women's participation in research.

  15. Marrow-inspired matrix cues rapidly affect early fate decisions of hematopoietic stem and progenitor cells

    PubMed Central

    Choi, Ji Sun; Harley, Brendan A. C.

    2017-01-01

    Hematopoiesis is the physiological process where hematopoietic stem cells (HSCs) continuously generate the body’s complement of blood and immune cells within unique regions of the bone marrow termed niches. Although previous investigations have revealed gradients in cellular and extracellular matrix (ECM) content across the marrow, and matrix elasticity and ligand type are believed to be strong regulators of stem cell fate, the impact of biophysical signals on HSC response is poorly understood. Using marrow-inspired ECM ligand–coated polyacrylamide substrates that present defined stiffness and matrix ligand cues, we demonstrate that the interplay between integrin engagement and myosin II activation processes affects the morphology, proliferation, and myeloid lineage specification of primary murine HSCs within 24 hours ex vivo. Notably, the impact of discrete biophysical signals on HSC fate decisions appears to be correlated to known microenvironmental transitions across the marrow. The combination of fibronectin and marrow matrix-associated stiffness was sufficient to maintain hematopoietic progenitor populations, whereas collagen and laminin enhanced proliferation and myeloid differentiation, respectively. Inhibiting myosin II–mediated contraction or adhesion to fibronectin via specific integrins (α5β1 and ανβ3) selectively abrogated the impact of the matrix environment on HSC fate decisions. Together, these findings indicate that adhesive interactions and matrix biophysical properties are critical design considerations in the development of biomaterials to direct HSC behavior in vitro. PMID:28070554

  16. Voting for a personality: Do first impressions and self-evaluations affect voting decisions?

    PubMed

    Koppensteiner, Markus; Stephan, Pia

    2014-08-01

    Participants were asked to assess their own personality (i.e. Big Five scales), the personality of politicians shown in brief silent video clips, and the probability that they would vote for these politicians. Response surface analyses (RSA) revealed noteworthy effects of self-ratings and observer-ratings of openness, agreeableness, and emotional stability on voting probability. Furthermore, the participants perceived themselves as being more open, more agreeable, more emotionally stable, and more extraverted than the average politician. The study supports previous findings that first impressions affect decision making on important issues. Results also indicate that when only nonverbal information is available people prefer political candidates they perceive as having personality traits they value in themselves.

  17. Can computerized clinical decision support systems improve practitioners' diagnostic test ordering behavior? A decision-maker-researcher partnership systematic review

    PubMed Central

    2011-01-01

    Background Underuse and overuse of diagnostic tests have important implications for health outcomes and costs. Decision support technology purports to optimize the use of diagnostic tests in clinical practice. The objective of this review was to assess whether computerized clinical decision support systems (CCDSSs) are effective at improving ordering of tests for diagnosis, monitoring of disease, or monitoring of treatment. The outcome of interest was effect on the diagnostic test-ordering behavior of practitioners. Methods We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews database, Inspec, and reference lists for eligible articles published up to January 2010. We included randomized controlled trials comparing the use of CCDSSs to usual practice or non-CCDSS controls in clinical care settings. Trials were eligible if at least one component of the CCDSS gave suggestions for ordering or performing a diagnostic procedure. We considered studies 'positive' if they showed a statistically significant improvement in at least 50% of test ordering outcomes. Results Thirty-five studies were identified, with significantly higher methodological quality in those published after the year 2000 (p = 0.002). Thirty-three trials reported evaluable data on diagnostic test ordering, and 55% (18/33) of CCDSSs improved testing behavior overall, including 83% (5/6) for diagnosis, 63% (5/8) for treatment monitoring, 35% (6/17) for disease monitoring, and 100% (3/3) for other purposes. Four of the systems explicitly attempted to reduce test ordering rates and all succeeded. Factors of particular interest to decision makers include costs, user satisfaction, and impact on workflow but were rarely investigated or reported. Conclusions Some CCDSSs can modify practitioner test-ordering behavior. To better inform development and implementation efforts, studies should describe in more detail potentially important factors such

  18. Evaluation of a novel electronic genetic screening and clinical decision support tool in prenatal clinical settings.

    PubMed

    Edelman, Emily A; Lin, Bruce K; Doksum, Teresa; Drohan, Brian; Edelson, Vaughn; Dolan, Siobhan M; Hughes, Kevin; O'Leary, James; Vasquez, Lisa; Copeland, Sara; Galvin, Shelley L; DeGroat, Nicole; Pardanani, Setul; Gregory Feero, W; Adams, Claire; Jones, Renee; Scott, Joan

    2014-07-01

    "The Pregnancy and Health Profile" (PHP) is a free prenatal genetic screening and clinical decision support (CDS) software tool for prenatal providers. PHP collects family health history (FHH) during intake and provides point-of-care risk assessment for providers and education for patients. This pilot study evaluated patient and provider responses to PHP and effects of using PHP in practice. PHP was implemented in four clinics. Surveys assessed provider confidence and knowledge and patient and provider satisfaction with PHP. Data on the implementation process were obtained through semi-structured interviews with administrators. Quantitative survey data were analyzed using Chi square test, Fisher's exact test, paired t tests, and multivariate logistic regression. Open-ended survey questions and interviews were analyzed using qualitative thematic analysis. Of the 83% (513/618) of patients that provided feedback, 97% felt PHP was easy to use and 98% easy to understand. Thirty percent (21/71) of participating physicians completed both pre- and post-implementation feedback surveys [13 obstetricians (OBs) and 8 family medicine physicians (FPs)]. Confidence in managing genetic risks significantly improved for OBs on 2/6 measures (p values ≤0.001) but not for FPs. Physician knowledge did not significantly change. Providers reported value in added patient engagement and reported mixed feedback about the CDS report. We identified key steps, resources, and staff support required to implement PHP in a clinical setting. To our knowledge, this study is the first to report on the integration of patient-completed, electronically captured and CDS-enabled FHH software into primary prenatal practice. PHP is acceptable to patients and providers. Key to successful implementation in the future will be customization options and interoperability with electronic health records.

  19. 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

  20. Clinical decision-making and therapeutic approaches in osteopathy - a qualitative grounded theory study.

    PubMed

    Thomson, Oliver P; Petty, Nicola J; Moore, Ann P

    2014-02-01

    There is limited understanding of how osteopaths make decisions in relation to clinical practice. The aim of this research was to construct an explanatory theory of the clinical decision-making and therapeutic approaches of experienced osteopaths in the UK. Twelve UK registered osteopaths participated in this constructivist grounded theory qualitative study. Purposive and theoretical sampling was used to select participants. Data was collected using semi-structured interviews which were audio-recorded and transcribed. As the study approached theoretical sufficiency, participants were observed and video-recorded during a patient appointment, which was followed by a video-prompted interview. Constant comparative analysis was used to analyse and code data. Data analysis resulted in the construction of three qualitatively different therapeutic approaches which characterised participants and their clinical practice, termed; Treater, Communicator and Educator. Participants' therapeutic approach influenced their approach to clinical decision-making, the level of patient involvement, their interaction with patients, and therapeutic goals. Participants' overall conception of practice lay on a continuum ranging from technical rationality to professional artistry, and contributed to their therapeutic approach. A range of factors were identified which influenced participants' conception of practice. The findings indicate that there is variation in osteopaths' therapeutic approaches to practice and clinical decision-making, which are influenced by their overall conception of practice. This study provides the first explanatory theory of the clinical decision-making and therapeutic approaches of osteopaths.

  1. Clinical-decision support based on medical literature: A complex network approach

    NASA Astrophysics Data System (ADS)

    Jiang, Jingchi; Zheng, Jichuan; Zhao, Chao; Su, Jia; Guan, Yi; Yu, Qiubin

    2016-10-01

    In making clinical decisions, clinicians often review medical literature to ensure the reliability of diagnosis, test, and treatment because the medical literature can answer clinical questions and assist clinicians making clinical decisions. Therefore, finding the appropriate literature is a critical problem for clinical-decision support (CDS). First, the present study employs search engines to retrieve relevant literature about patient records. However, the result of the traditional method is usually unsatisfactory. To improve the relevance of the retrieval result, a medical literature network (MLN) based on these retrieved papers is constructed. Then, we show that this MLN has small-world and scale-free properties of a complex network. According to the structural characteristics of the MLN, we adopt two methods to further identify the potential relevant literature in addition to the retrieved literature. By integrating these potential papers into the MLN, a more comprehensive MLN is built to answer the question of actual patient records. Furthermore, we propose a re-ranking model to sort all papers by relevance. We experimentally find that the re-ranking model can improve the normalized discounted cumulative gain of the results. As participants of the Text Retrieval Conference 2015, our clinical-decision method based on the MLN also yields higher scores than the medians in most topics and achieves the best scores for topics: #11 and #12. These research results indicate that our study can be used to effectively assist clinicians in making clinical decisions, and the MLN can facilitate the investigation of CDS.

  2. Empirically and Clinically Useful Decision Making in Psychotherapy: Differential Predictions with Treatment Response Models

    ERIC Educational Resources Information Center

    Lutz, Wolfgang; Saunders, Stephen M.; Leon, Scott C.; Martinovich, Zoran; Kosfelder, Joachim; Schulte, Dietmar; Grawe, Klaus; Tholen, Sven

    2006-01-01

    In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patient's response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research…

  3. Computer Decision Support to Improve Autism Screening and Care in Community Pediatric Clinics

    ERIC Educational Resources Information Center

    Bauer, Nerissa S.; Sturm, Lynne A.; Carroll, Aaron E.; Downs, Stephen M.

    2013-01-01

    An autism module was added to an existing computer decision support system (CDSS) to facilitate adherence to recommended guidelines for screening for autism spectrum disorders in primary care pediatric clinics. User satisfaction was assessed by survey and informal feedback at monthly meetings between clinical staff and the software team. To assess…

  4. 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

  5. Clinical characteristics affecting motor recovery and ambulation in stroke patients

    PubMed Central

    Yetisgin, Alparslan

    2017-01-01

    [Purpose] To describe the clinical characteristics affecting motor recovery and ambulation in stroke patients. [Subjects and Methods] Demographic and clinical characteristics of 53 stroke patients (31 M, 22 F), such as age, gender, etiology, hemiplegic side, Brunnstrom stage, functional ambulation scale scores, history of rehabilitation, and presence of shoulder pain and complex regional pain syndrome were evaluated. [Results] The etiology was ischemic in 79.2% of patients and hemorrhagic in 20.8%. Brunnstrom hand and upper extremity values in females were lower than in males. Complex regional pain syndrome was observed at a level of 18.9% in all patients (more common in females). Brunnstrom hand stage was lower in complex regional pain syndrome patients than in those without the syndrome. Shoulder pain was present in 44.4% of patients. Brunnstrom lower extremity values and functional ambulation scale scores were higher in rehabilitated than in non-rehabilitated cases. [Conclusion] Brunnstrom stages of hand and upper extremity were lower and complex regional pain syndrome was more common in female stroke patients. Shoulder pain and lower Brunnstrom hand stages were related to the presence of complex regional pain syndrome. PMID:28265142

  6. "Thinking aloud" as a strategy to improve clinical decision making.

    PubMed

    Corcoran, S; Narayan, S; Moreland, H

    1988-09-01

    Although "thinking aloud" has been used as a research method to collect data about nurses' knowledge and cognitive processes, it has not been used widely for instruction. We suggest that thinking aloud can be an effective teaching strategy for staff development. Two techniques are described for incorporating thinking aloud into dialogue among experienced nurses and into mentoring activities between experts and novices. An excerpt from a transcript of one nurse's thinking aloud while making a triage decision is presented to illustrate the types of knowledge and cognitive processes that can be elicited and revealed by using this strategy. Potential educational benefits are identified, along with suggestions for implementing thinking aloud as an instructional method.

  7. A Three-Question Framework to Facilitate Clinical Decision Making

    ERIC Educational Resources Information Center

    Sibold, Jeremy

    2012-01-01

    Context: Highly developed critical thinking and the ability to discriminate among many possible therapeutic interventions is a core behavior for the practicing athletic trainer. However, while athletic training students receive a great deal of clinically applicable information, many are not explicitly trained in efficient methods for channeling…

  8. [Knowledge management system for laboratory work and clinical decision support].

    PubMed

    Inada, Masanori; Sato, Mayumi; Yoneyama, Akiko

    2011-05-01

    This paper discusses a knowledge management system for clinical laboratories. In the clinical laboratory of Toranomon Hospital, we receive about 20 questions relevant to laboratory tests per day from medical doctors or co-medical staff. These questions mostly involve the essence to appropriately accomplish laboratory tests. We have to answer them carefully and suitably because an incorrect answer may cause a medical accident. Up to now, no method has been in place to achieve a rapid response and standardized answers. For this reason, the laboratory staff have responded to various questions based on their individual knowledge. We began to develop a knowledge management system to promote the knowledge of staff working for the laboratory. This system is a type of knowledge base for assisting the work, such as inquiry management, laboratory consultation, process management, and clinical support. It consists of several functions: guiding laboratory test information, managing inquiries from medical staff, reporting results of patient consultation, distributing laboratory staffs notes, and recording guidelines for laboratory medicine. The laboratory test information guide has 2,000 records of medical test information registered in the database with flexible retrieval. The inquiry management tool provides a methos to record all questions, answer easily, and retrieve cases. It helps staff to respond appropriately in a short period of time. The consulting report system treats patients' claims regarding medical tests. The laboratory staffs notes enter a file management system so they can be accessed to aid in clinical support. Knowledge sharing using this function can achieve the transition from individual to organizational learning. Storing guidelines for laboratory medicine will support EBM. Finally, it is expected that this system will support intellectual activity concerning laboratory work and contribute to the practice of knowledge management for clinical work support.

  9. 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…

  10. Should triple-negative breast cancer (TNBC) subtype affect local-regional therapy decision making?

    PubMed

    Moran, Meena S

    2014-01-01

    The more aggressive biologic characteristics and the current lack of targeted therapy for triple-negative breast cancer (TNBC) make local-regional management decisions challenging for physicians. TNBC is associated with patients of younger age, black race and BRCA1 mutation carriers. Distinctions between BRCA1-associated and sporadic TNBC include increased lifetime risk of ipsilateral and contralateral breast cancer after breast cancer therapy (BCT) for BRCA carriers, which is not shared by sporadic TNBC. However, the presence of a BRCA mutation should not preclude a breast-conservation approach in patients who are otherwise appropriate candidates for BCT. Data suggest that local-regional relapse (LRR) at baseline after BCT appears to be comparable for TNBC and the HER2-positive subgroups, but is about 50% greater than luminal tumors. LRR appears to be similarly increased after mastectomy; thus, TNBC should not be a contra-indication for BCT. Recent hypothesis-generating data suggest less LRR after BCT (where radiation is routinely delivered) than with mastectomy for early-stage TNBC. To date, no specific local-regional guideline recommendations for TNBC exist. Level I outcome data for TNBC using accelerated partial breast irradiation (APBI) and hypofractionated whole-breast irradiation (hWBRT) are lacking. TNBC should be treated with APBI only on clinical trials. Although hWBRT may be considered in TNBC, its association with younger age, advanced disease and use of systemic chemotherapy often precludes its use for this subtype. Until definitive treatment strategies are validated in large datasets and confirmed in randomized trials, TNBC subtype, in and of itself, should not direct local-regional management treatment decisions.

  11. Clinical judgment and decision-making in wound assessment and management: is experience enough?

    PubMed

    Logan, Gemma

    2015-03-01

    The assessment and management of wounds forms a large proportion of community nurses' workload, often requiring judgment and decision-making in complex, challenging and uncertain circumstances. The processes through which nurses form judgments and make decisions within this context are reviewed in this article against existing theories on these subjects. There is variability in wound assessment and management practice which may be attributed to uncertainties within the context, a lack of knowledge in appropriate treatment choices and the inability to correctly value the importance of the clinical information presented. Nurses may be required to draw on intuition to guide their judgments and decision-making by association with experience and expertise. In addition, a step-by-step analytical approach underpinned by an evidence base may be required to ensure accuracy in practice. Developing an understanding of the different theories of judgment and decision-making may facilitate nurses' abilities to reflect on their own decision tasks, thereby enhancing the care provided.

  12. Managing risk: clinical decision-making in mental health services.

    PubMed

    Muir-Cochrane, Eimear; Gerace, Adam; Mosel, Krista; O'Kane, Debra; Barkway, Patricia; Curren, David; Oster, Candice

    2011-01-01

    Risk assessment and management is a major component of contemporary mental health practice. Risk assessment in health care exists within contemporary perspectives of management and risk aversive practices in health care. This has led to much discussion about the best approach to assessing possible risks posed by people with mental health problems. In addition, researchers and commentators have expressed concern that clinical practice is being dominated by managerial models of risk management at the expense of meeting the patient's health and social care needs. The purpose of the present study is to investigate the risk assessment practices of a multidisciplinary mental health service. Findings indicate that mental health professionals draw on both managerial and therapeutic approaches to risk management, integrating these approaches into their clinical practice. Rather than being dominated by managerial concerns regarding risk, the participants demonstrate professional autonomy and concern for the needs of their clients.

  13. GELLO: An Object-Oriented Query and Expression Language for Clinical Decision Support

    PubMed Central

    Sordo, Margarita; Ogunyemi, Omolola; Boxwala, Aziz A.; Greenes, Robert A.

    2003-01-01

    GELLO is a purpose-specific, object-oriented (OO) query and expression language [1]. GELLO is the result of a concerted effort of the Decision Systems Group (DSG) working with the HL7 Clinical Decision Support Technical Committee (CDSTC) to provide the HL7 community with a common format for data encoding and manipulation. GELLO will soon be submitted for ballot to the HL7 CDSTC for consideration as a standard. PMID:14728515

  14. Clinical pearls: factors affecting reported contraceptive efficacy rates in clinical studies.

    PubMed

    Burkman, Ronald T

    2002-01-01

    Current combination oral contraceptives (OCs) are among the most popular, safe, and effective methods of reversible contraception. There are, however, many factors that can affect contraceptive failure rates as reported in clinical trials, including subject characteristics, factors related to study methodology and data analysis, and publication biases. The variability of these factors among clinical trials makes meaningful comparisons of contraceptive efficacy data across studies difficult, if not misleading or erroneous. It is even more difficult to reconcile the differences between clinical trial efficacy rates and everyday use rates; for instance, the National Survey of Family Growth reported that the rate of OC failure is close to 8% in the United States, which is higher than rates reported in clinical trials. Thus, it is important for the clinician to consider the many factors that can influence reporting of contraceptive failure rates in clinical trials and be aware of the limitations in differentiating OCs on the basis of contraceptive efficacy derived from clinical trial data. Furthermore, clinical trial data may not accurately predict contraceptive efficacy in everyday use.

  15. [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.

  16. Implementing an integrative multi-agent clinical decision support system with open source software.

    PubMed

    Sayyad Shirabad, Jelber; Wilk, Szymon; Michalowski, Wojtek; Farion, Ken

    2012-02-01

    Clinical decision making is a complex multi-stage process. Decision support can play an important role at each stage of this process. At present, the majority of clinical decision support systems have been focused on supporting only certain stages. In this paper we present the design and implementation of MET3-a prototype multi-agent system providing an integrative decision support that spans over the entire decision making process. The system helps physicians with data collection, diagnosis formulation, treatment planning and finding supporting evidence. MET3 integrates with external hospital information systems via HL7 messages and runs on various computing platforms available at the point of care (e.g., tablet computers, mobile phones). Building MET3 required sophisticated and reliable software technologies. In the past decade the open source software movement has produced mature, stable, industrial strength software systems with a large user base. Therefore, one of the decisions that should be considered before developing or acquiring a decision support system is whether or not one could use open source technologies instead of proprietary ones. We believe MET3 shows that the answer to this question is positive.

  17. Feasibility of Extracting Key Elements from ClinicalTrials.gov to Support Clinicians’ Patient Care Decisions

    PubMed Central

    Kim, Heejun; Bian, Jiantao; Mostafa, Javed; Jonnalagadda, Siddhartha; Del Fiol, Guilherme

    2016-01-01

    Motivation: Clinicians need up-to-date evidence from high quality clinical trials to support clinical decisions. However, applying evidence from the primary literature requires significant effort. Objective: To examine the feasibility of automatically extracting key clinical trial information from ClinicalTrials.gov. Methods: We assessed the coverage of ClinicalTrials.gov for high quality clinical studies that are indexed in PubMed. Using 140 random ClinicalTrials.gov records, we developed and tested rules for the automatic extraction of key information. Results: The rate of high quality clinical trial registration in ClinicalTrials.gov increased from 0.2% in 2005 to 17% in 2015. Trials reporting results increased from 3% in 2005 to 19% in 2015. The accuracy of the automatic extraction algorithm for 10 trial attributes was 90% on average. Future research is needed to improve the algorithm accuracy and to design information displays to optimally present trial information to clinicians. PMID:28269867

  18. Feasibility of Extracting Key Elements from ClinicalTrials.gov to Support Clinicians' Patient Care Decisions.

    PubMed

    Kim, Heejun; Bian, Jiantao; Mostafa, Javed; Jonnalagadda, Siddhartha; Del Fiol, Guilherme

    2016-01-01

    Motivation: Clinicians need up-to-date evidence from high quality clinical trials to support clinical decisions. However, applying evidence from the primary literature requires significant effort. Objective: To examine the feasibility of automatically extracting key clinical trial information from ClinicalTrials.gov. Methods: We assessed the coverage of ClinicalTrials.gov for high quality clinical studies that are indexed in PubMed. Using 140 random ClinicalTrials.gov records, we developed and tested rules for the automatic extraction of key information. Results: The rate of high quality clinical trial registration in ClinicalTrials.gov increased from 0.2% in 2005 to 17% in 2015. Trials reporting results increased from 3% in 2005 to 19% in 2015. The accuracy of the automatic extraction algorithm for 10 trial attributes was 90% on average. Future research is needed to improve the algorithm accuracy and to design information displays to optimally present trial information to clinicians.

  19. A clinical recruiting management system for complex multi-site clinical trials using qualification decision support systems.

    PubMed

    Vahabzadeh, Massoud; Lin, Jia-Ling; Mezghanni, Mustapha; Contoreggi, Carlo; Leff, Michelle

    2007-10-11

    A clinical recruiting management system with qualification decision support systems was developed to increase the efficiency of screening and evaluation of participants during a recruiting process whereby recruiting for various protocols are conducted at multiple sites by different groups with process interdependencies. This system is seamlessly integrated into our enterprise-scale Human Research Information System (HuRIS), encompassing research participants' electronic health records (EHR), with real-time access to the clinical trial data.

  20. Knowledge bases, clinical decision support systems, and rapid learning in oncology.

    PubMed

    Yu, Peter Paul

    2015-03-01

    One of the most important benefits of health information technology is to assist the cognitive process of the human mind in the face of vast amounts of health data, limited time for decision making, and the complexity of the patient with cancer. Clinical decision support tools are frequently cited as a technologic solution to this problem, but to date useful clinical decision support systems (CDSS) have been limited in utility and implementation. This article describes three unique sources of health data that underlie fundamentally different types of knowledge bases which feed into CDSS. CDSS themselves comprise a variety of models which are discussed. The relationship of knowledge bases and CDSS to rapid learning health systems design is critical as CDSS are essential drivers of rapid learning in clinical care.

  1. Workflow Technology to Enrich a Computerized Clinical Chart with Decision Support Facilities

    PubMed Central

    Panzarasa, Silvia; Quaglini, Silvana; Cavallini, Anna; Micieli, Giuseppe; Pernice, Corrado; Pessina, Mauro; Stefanelli, Mario

    2006-01-01

    Literature results and personal experience show that intrusive modalities of presenting suggestions of computerized clinical practice guidelines are detrimental to the routine use of an information system. This paper describes a solution for smoothly integrating a guideline-based decision support system into an existing computerized clinical chart for patients admitted to a Stroke Unit. Since many years, the healthcare personnel were using a commercial product for the ordinary patients’ data management, and they were satisfied with it. Thus, the decision support system has been integrated keeping attention to minimize changes and preserve existing human-computer interaction. Our decision support system is based on workflow technology. The paper illustrates the middleware layer developed to allow communication between the workflow management system and the clinical chart. At the same time, the consequent modification of the graphical users' interface is illustrated. PMID:17238415

  2. Clinical decision making in seizures and status epilepticus.

    PubMed

    Teran, Felipe; Harper-Kirksey, Katrina; Jagoda, Andy

    2015-01-01

    Seizures and status epilepticus are frequent neurologic emergencies in the emergency department, accounting for 1% of all emergency department visits. The management of this time-sensitive and potentially life-threatening condition is challenging for both prehospital providers and emergency clinicians. The approach to seizing patients begins with differentiating seizure activity from mimics and follows with identifying potential secondary etiologies, such as alcohol-related seizures. The approach to the patient in status epilepticus and the patient with nonconvulsive status epilepticus constitutes a special clinical challenge. This review summarizes the best available evidence and recommendations regarding diagnosis and resuscitation of the seizing patient in the emergency setting.

  3. Teleconsultation and Clinical Decision Making: a Systematic Review

    PubMed Central

    Deldar, Kolsoum; Bahaadinbeigy, Kambiz; Tara, Seyed Mahmood

    2016-01-01

    Background: The goal of teleconsultation is to omit geographical and functional distance between two or more geographically separated health care providers. The purpose of present study is to review and analyze physician-physician teleconsultations. Method: The PubMed electronic database was searched. The primary search was done on January 2015 and was updated on December 2015. A fetch and tag plan was designed by the researchers using an online Zotero library. Results: 174 full-text articles of 1702 records met inclusion criteria. Teleconsultation for pediatric patients accounts for 14.36 percent of accepted articles. Surgery and general medicine were the most prevalent medical fields in the adults and pediatrics, respectively. Most teleconsultations were inland experiences (no=135), and the USA, Italy and Australia were the three top countries in this group. Non-specialists health care providers/centers were the dominant group who requested teleconsultation (no=130). Real time, store and forward, and hybrid technologies were used in 50, 31, and 16.7 percent of articles, respectively. The teleconsultation were reported to result in change in treatment plan, referral or evacuation rate, change in diagnosis, educational effects, and rapid decision making. Use of structured or semi-structured template had been noticed only in a very few articles. Conclusion: The present study focused on the recent ten years of published articles on physician-physician teleconsultations. Our findings showed that although there are positive impacts of teleconsultation as improving patient management, still have gaps that need to be repaired. PMID:27708494

  4. A social-technological epistemology of clinical decision-making as mediated by imaging.

    PubMed

    van Baalen, Sophie; Carusi, Annamaria; Sabroe, Ian; Kiely, David G

    2016-10-03

    In recent years there has been growing attention to the epistemology of clinical decision-making, but most studies have taken the individual physicians as the central object of analysis. In this paper we argue that knowing in current medical practice has an inherently social character and that imaging plays a mediating role in these practices. We have analyzed clinical decision-making within a medical expert team involved in diagnosis and treatment of patients with pulmonary hypertension (PH), a rare disease requiring multidisciplinary team involvement in diagnosis and management. Within our field study, we conducted observations, interviews, video tasks, and a panel discussion. Decision-making in the PH clinic involves combining evidence from heterogeneous sources into a cohesive framing of a patient, in which interpretations of the different sources can be made consistent with each other. Because pieces of evidence are generated by people with different expertise and interpretation and adjustments take place in interaction between different experts, we argue that this process is socially distributed. Multidisciplinary team meetings are an important place where information is shared, discussed, interpreted, and adjusted, allowing for a collective way of seeing and a shared language to be developed. We demonstrate this with an example of image processing in the PH service, an instance in which knowledge is distributed over multiple people who play a crucial role in generating an evaluation of right heart function. Finally, we argue that images fulfill a mediating role in distributed knowing in 3 ways: first, as enablers or tools in acquiring information; second, as communication facilitators; and third, as pervasively framing the epistemic domain. With this study of clinical decision-making in diagnosis and treatment of PH, we have shown that clinical decision-making is highly social and mediated by technologies. The epistemology of clinical decision-making needs

  5. Power to Punish Norm Violations Affects the Neural Processes of Fairness-Related Decision Making

    PubMed Central

    Cheng, Xuemei; Zheng, Li; Li, Lin; Guo, Xiuyan; Wang, Qianfeng; Lord, Anton; Hu, Zengxi; Yang, Guang

    2015-01-01

    Punishing norm violations is considered an important motive during rejection of unfair offers in the ultimatum game (UG). The present study investigates the impact of the power to punish norm violations on people’s responses to unfairness and associated neural correlates. In the UG condition participants had the power to punish norm violations, while an alternate condition, the impunity game (IG), was presented where participants had no power to punish norm violations since rejection only reduced the responder’s income to zero. Results showed that unfair offers were rejected more often in UG compared to IG. At the neural level, anterior insula and dorsal anterior cingulate cortex were more active when participants received and rejected unfair offers in both UG and IG. Moreover, greater dorsolateral prefrontal cortex activity was observed when participants rejected than accepted unfair offers in UG but not in IG. Ventromedial prefrontal cortex activation was higher in UG than IG when unfair offers were accepted as well as when rejecting unfair offers in IG as opposed to UG. Taken together, our results demonstrate that the power to punish norm violations affects not only people’s behavioral responses to unfairness but also the neural correlates of the fairness-related social decision-making process. PMID:26696858

  6. Anterior and posterior subareas of the dorsolateral frontal cortex in socially relevant decisions based on masked affect expressions

    PubMed Central

    Prochnow, Denise; Brunheim, Sascha; Kossack, Hannes; Eickhoff, Simon B.; Markowitsch, Hans J.; Seitz, Rüdiger J.

    2015-01-01

    Socially-relevant decisions are based on clearly recognizable but also not consciously accessible affective stimuli. We studied the role of the dorsolateral frontal cortex (DLFC) in decision-making on masked affect expressions using functional magnetic resonance imaging. Our paradigm permitted us to capture brain activity during a pre-decision phase when the subjects viewed emotional expressions below the threshold of subjective awareness, and during the decision phase, which was based on verbal descriptions as the choice criterion. Using meta-analytic connectivity modeling, we found that the preparatory phase of the decision was associated with activity in a right-posterior portion of the DLFC featuring co-activations in the left-inferior frontal cortex. During the subsequent decision a right-anterior and more dorsal portion of the DLFC became activated, exhibiting a different co-activation pattern. These results provide evidence for partially independent sub-regions within the DLFC, supporting the notion of dual associative processes in intuitive judgments. PMID:26236464

  7. Designing an automated clinical decision support system to match clinical practice guidelines for opioid therapy for chronic pain

    PubMed Central

    2010-01-01

    Background Opioid prescribing for chronic pain is common and controversial, but recommended clinical practices are followed inconsistently in many clinical settings. Strategies for increasing adherence to clinical practice guideline recommendations are needed to increase effectiveness and reduce negative consequences of opioid prescribing in chronic pain patients. Methods Here we describe the process and outcomes of a project to operationalize the 2003 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Non-Cancer Pain into a computerized decision support system (DSS) to encourage good opioid prescribing practices during primary care visits. We based the DSS on the existing ATHENA-DSS. We used an iterative process of design, testing, and revision of the DSS by a diverse team including guideline authors, medical informatics experts, clinical content experts, and end-users to convert the written clinical practice guideline into a computable algorithm to generate patient-specific recommendations for care based upon existing information in the electronic medical record (EMR), and a set of clinical tools. Results The iterative revision process identified numerous and varied problems with the initially designed system despite diverse expert participation in the design process. The process of operationalizing the guideline identified areas in which the guideline was vague, left decisions to clinical judgment, or required clarification of detail to insure safe clinical implementation. The revisions led to workable solutions to problems, defined the limits of the DSS and its utility in clinical practice, improved integration into clinical workflow, and improved the clarity and accuracy of system recommendations and tools. Conclusions Use of this iterative process led to development of a multifunctional DSS that met the approval of the clinical practice guideline authors, content experts, and clinicians involved in testing. The process and experiences described

  8. A service oriented approach for guidelines-based clinical decision support using BPMN.

    PubMed

    Rodriguez-Loya, Salvador; Aziz, Ayesha; Chatwin, Chris

    2014-01-01

    Evidence-based medical practice requires that clinical guidelines need to be documented in such a way that they represent a clinical workflow in its most accessible form. In order to optimize clinical processes to improve clinical outcomes, we propose a Service Oriented Architecture (SOA) based approach for implementing clinical guidelines that can be accessed from an Electronic Health Record (EHR) application with a Web Services enabled communication mechanism with the Enterprise Service Bus. We have used Business Process Modelling Notation (BPMN) for modelling and presenting the clinical pathway in the form of a workflow. The aim of this study is to produce spontaneous alerts in the healthcare workflow in the diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The use of BPMN as a tool to automate clinical guidelines has not been previously employed for providing Clinical Decision Support (CDS).

  9. Emotion and decision-making: affect-driven belief systems in anxiety and depression

    PubMed Central

    Paulus, Martin P.; Yu, Angela J.

    2012-01-01

    Emotion processing and decision-making are integral aspects of daily life. However, our understanding of the interaction between these constructs is limited. In this review, we summarize theoretical approaches to the link between emotion and decision-making, and focus on research with anxious or depressed individuals that reveals how emotions can interfere with decision-making. We integrate the emotional framework based on valence and arousal with a Bayesian approach to decision-making in terms of probability and value processing. We then discuss how studies of individuals with emotional dysfunctions provide evidence that alterations of decision-making can be viewed in terms of altered probability and value computation. We argue that the probabilistic representation of belief states in the context of partially observable Markov decision processes provides a useful approach to examine alterations in probability and value representation in individuals with anxiety and depression and outline the broader implications of this approach. PMID:22898207

  10. Hemispheric activation differences in novice and expert clinicians during clinical decision making.

    PubMed

    Hruska, Pam; Hecker, Kent G; Coderre, Sylvain; McLaughlin, Kevin; Cortese, Filomeno; Doig, Christopher; Beran, Tanya; Wright, Bruce; Krigolson, Olav

    2016-12-01

    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 were reflected in terms of differences in neural areas of activation. Novice and expert clinicians diagnosed simple or complex (easy, hard) cases while functional magnetic resonance imaging (fMRI) data were collected. Our results highlight key differences in the neural areas activated in novices and experts during the clinical decision-making process. fMRI data were collected from ten second year medical students (novices) and ten practicing gastroenterologists (experts) while they diagnosed sixteen (eight easy and eight hard) clinical cases via multiple-choice questions. Behavioral data were collected for diagnostic accuracy (correct/incorrect diagnosis) and time taken to assign a clinical diagnosis. Two analyses were performed with the fMRI data. First, data from easy and hard cases were compared within respective groups (easy > hard, hard > easy). Second, neural differences between novices and experts (novice > expert, expert > novice) were assessed. Experts correctly diagnosed more cases than novices and made their diagnoses faster than novices on both easy and hard cases (all p's < 0.05). Time taken to diagnose hard cases took significantly longer for both novices and experts. While similar neural areas were activated in both novices and experts during the decision making process, we identified significant hemispheric activation differences between novice and expert clinicians when diagnosing hard clinical cases. Specifically, novice clinicians had greater activations in the left anterior temporal cortex and left ventral lateral prefrontal cortex whereas expert clinicians had greater activations in the right

  11. The interaction of patient race, provider bias, and clinical ambiguity on pain management decisions

    PubMed Central

    Hirsh, Adam T.; Hollingshead, Nicole A.; Ashburn-Nardo, Leslie; Kroenke, Kurt

    2015-01-01

    Although racial disparities in pain care are widely reported, much remains to be known about the role of provider and contextual factors. We used computer-simulated patients to examine the influence of patient race, provider racial bias, and clinical ambiguity on pain decisions. One hundred twenty nine medical residents/fellows made assessment (pain intensity) and treatment (opioid and non-opioid analgesics) decisions for 12 virtual patients with acute pain. Race (Black/White) and clinical ambiguity (high/low) were manipulated across vignettes. Participants completed the Implicit Association Test and feeling thermometers, which assess implicit and explicit racial biases, respectively. Individual- and group-level analyses indicated that race and ambiguity had an interactive effect on providers’ decisions, such that decisions varied as a function of ambiguity for White but not Black patients. Individual differences across providers were observed for the effect of race and ambiguity on decisions; however providers’ implicit and explicit biases did not account for this variability. These data highlight the complexity of racial disparities and suggest that differences in care between White and Black patients are, in part, attributable to the nature (i.e., ambiguity) of the clinical scenario. The current study suggests that interventions to reduce disparities should differentially target patient, provider, and contextual factors. PMID:25828370

  12. Potential Role of Methylation Marker in Glioma Supporting Clinical Decisions

    PubMed Central

    Roszkowski, Krzysztof; Furtak, Jacek; Zurawski, Bogdan; Szylberg, Tadeusz; Lewandowska, Marzena A.

    2016-01-01

    The IDH1/2 gene mutations, ATRX loss/mutation, 1p/19q status, and MGMT promoter methylation are increasingly used as prognostic or predictive biomarkers of gliomas. However, the effect of their combination on radiation therapy outcome is discussable. Previously, we demonstrated that the IDH1 c.G395A; p.R132H mutation was associated with longer survival in grade II astrocytoma and GBM (Glioblastoma). Here we analyzed the MGMT promoter methylation status in patients with a known mutation status in codon 132 of IDH1, followed by clinical and genetic data analysis based on the two statuses. After a subtotal tumor resection, the patients were treated using IMRT (Intensity-Modulated Radiation Therapy) with 6 MeV photons. The total dose was: 54 Gy for astrocytoma II, 60 Gy for astrocytoma III, 60 Gy for glioblastoma, 2 Gy per day, with 24 h intervals, five days per week. The patients with MGMT promoter methylation and IDH1 somatic mutation (OS = 40 months) had a better prognosis than those with MGMT methylation alone (OS = 18 months). In patients with astrocytoma anaplasticum (n = 7) with the IDH1 p.R132H mutation and hypermethylated MGMT, the prognosis was particularly favorable (median OS = 47 months). In patients with astrocytoma II meeting the above criteria, the prognosis was also better than in those not meeting those criteria. The IDH1 mutation appears more relevant for the prognosis than MGMT methylation. The IDH1 p.R132H mutation combined with MGMT hypermethylation seems to be the most advantageous for treatment success. Patients not meeting those criteria may require more aggressive treatments. PMID:27834917

  13. Mobile clinical decision support systems and applications: a literature and commercial review.

    PubMed

    Martínez-Pérez, Borja; de la Torre-Díez, Isabel; López-Coronado, Miguel; Sainz-de-Abajo, Beatriz; Robles, Montserrat; García-Gómez, Juan Miguel

    2014-01-01

    The latest advances in eHealth and mHealth have propitiated the rapidly creation and expansion of mobile applications for health care. One of these types of applications are the clinical decision support systems, which nowadays are being implemented in mobile apps to facilitate the access to health care professionals in their daily clinical decisions. The aim of this paper is twofold. Firstly, to make a review of the current systems available in the literature and in commercial stores. Secondly, to analyze a sample of applications in order to obtain some conclusions and recommendations. Two reviews have been done: a literature review on Scopus, IEEE Xplore, Web of Knowledge and PubMed and a commercial review on Google play and the App Store. Five applications from each review have been selected to develop an in-depth analysis and to obtain more information about the mobile clinical decision support systems. Ninety-two relevant papers and 192 commercial apps were found. Forty-four papers were focused only on mobile clinical decision support systems. One hundred seventy-one apps were available on Google play and 21 on the App Store. The apps are designed for general medicine and 37 different specialties, with some features common in all of them despite of the different medical fields objective. The number of mobile clinical decision support applications and their inclusion in clinical practices has risen in the last years. However, developers must be careful with their interface or the easiness of use, which can impoverish the experience of the users.

  14. Negative and Positive Pretrial Publicity Affect Juror Memory and Decision Making

    ERIC Educational Resources Information Center

    Ruva, Christine L.; McEvoy, Cathy

    2008-01-01

    The experiment examined the effects of exposure to pretrial publicity (PTP) and delay on juror memory and decision-making. Mock jurors read news articles containing negative PTP, positive PTP, or unrelated articles. Five days later, they viewed a videotaped murder trial, after which they made decisions about guilt. Finally, all participants…

  15. Factors Affecting Parental Decision-Making Regarding Interventions for Their Child with Autism

    ERIC Educational Resources Information Center

    Hebert, Elizabeth Baltus

    2014-01-01

    Due to the numerous interventions available for children with autism, parents are faced with challenging decisions regarding treatments from the time of diagnosis and throughout their child's life. This exploratory qualitative study investigated the reasons behind parents' decisions about interventions for their child with autism. In-depth…

  16. The role of dynamic renal scintigraphy on clinical decision making in hydronephrotic children.

    PubMed

    Çamlar, Seçil Arslansoyu; Deveci, Nazlı; Soylu, Alper; Türkmen, Mehmet Atilla; Özmen, Derya; Çapakaya, Gamze; Kavukçu, Salih

    2017-01-01

    Hydronephrosis may be related to an obstructive cause, ureteropelvic/uretero-vesical junction obstruction or nonobstructive [vesicoureteral reflux (VUR)]. When an obstructive pathology is considered, dynamic renal scintigraphy may help to predict whether it is a true obstruction or not. In this study, we aimed to determine the contribution of dynamic renal scintigraphy with [99] mTc-MAG-3 to the clinical decision-making for surgery in hydronephrotic children. Files of the patients evaluated by MAG-3 scintigraphy for antenatal (AH)/postnatal (PH) hydronephrosis between 1992 and 2014 were reviewed. Gender, age, hydronephrosis (HN) grade by ultrasound (US), presence of VUR, MAG-3 result (obstructive vs. nonobstructive), ultimate diagnosis, and need for surgery were assessed. Cases with double collecting system and neurogenic bladder were excluded from the study. All of the patients had normal serum creatinine and eGFR. There were a total of 178 patients with 218 hydronephrotic renal units (mean age 34.7 ± 52.7 months; male/ female = 121/57, AH of 62%). MAG-3 was nonobstructive in 134 and obstructive in 84 hydronephrotic renal units. MAG-3 was obstructive in 47 of 121 (39%) males and 30 of 57 (53%) females (P = 0.058, odds ratio (OR) for obstruction was 1.9 for girls). MAG-3 was obstructive in 47 of 135 (35%) units with AH and 37 of 83 (45%) units with PH (P = 0.137). In 81 units with the society of fetal urology-4 HN by US, MAG-3 was obstructive in 55 (68%), and surgery was required in 52 of 55 (95%). Surgery was required for only two (7%) of the remaining 26 units with nonobstructive dilatation (P <0.001, sensitivity 96%, specificity 89%, OR 208). Antero-posterior diameter >16.5 mm was the best cutoff level for predicting obstruction by MAG-3 (sensitivity 75.2%; specificity 71%; OR 3.8). MAG-3 significantly affects clinical decision for surgery in HN. Hydronephrotic girls have more risk in terms of true obstruction. Combining MAG-3 with US improves the

  17. Knowledge of risk factors and the periodontal disease-systemic link in dental students' clinical decisions.

    PubMed

    Friesen, Lynn Roosa; Walker, Mary P; Kisling, Rebecca E; Liu, Ying; Williams, Karen B

    2014-09-01

    This study evaluated second-, third-, and fourth-year dental students' ability to identify systemic conditions associated with periodontal disease, risk factors most important for referral, and medications with an effect on the periodontium and their ability to apply this knowledge to make clinical decisions regarding treatment and referral of periodontal patients. A twenty-one question survey was administered at one U.S. dental school in the spring semester of 2012 to elicit the students' knowledge and confidence regarding clinical reasoning. The response rate was 86 percent. Periodontal risk factors were accurately selected by at least 50 percent of students in all three classes; these were poorly controlled diabetes, ≥6 mm pockets posteriorly, and lack of response to previous non-surgical therapy. Confidence in knowledge, knowledge of risk factors, and knowledge of medications with an effect on the periodontium improved with training and were predictive of better referral decision making. The greatest impact of training was seen on the students' ability to make correct decisions about referral and treatment for seven clinical scenarios. Although the study found a large increase in the students' abilities from the second through fourth years, the mean of 4.6 (out of 7) for the fourth-year students shows that, on average, those students missed correct treatment or referral on more than two of seven clinical cases. These results suggest that dental curricula should emphasize more critical decision making with respect to referral and treatment criteria in managing the periodontal patient.

  18. Improving Emergency Department Triage Classification with Computerized Clinical Decision Support at a Pediatric Hospital

    ERIC Educational Resources Information Center

    Kunisch, Joseph Martin

    2012-01-01

    Background: The Emergency Severity Index (ESI) is an emergency department (ED) triage classification system based on estimated patient-specific resource utilization. Rules for a computerized clinical decision support (CDS) system based on a patient's chief complaint were developed and tested using a stochastic model for predicting ESI scores.…

  19. 78 FR 35937 - Food and Drug Administration Decisions for Investigational Device Exemption Clinical...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-06-14

    ... revised and is being reissued for comment because the Food and Drug Administration Safety and Innovation... HUMAN SERVICES Food and Drug Administration Food and Drug Administration Decisions for Investigational Device Exemption Clinical Investigations; Draft Guidance for Industry and Food and Drug...

  20. Teaching metacognition in clinical decision-making using a novel mnemonic checklist: an exploratory study

    PubMed Central

    Chew, Keng Sheng; Durning, Steven J; van Merriënboer, Jeroen JG

    2016-01-01

    INTRODUCTION Metacognition is a cognitive debiasing strategy that clinicians can use to deliberately detach themselves from the immediate context of a clinical decision, which allows them to reflect upon the thinking process. However, cognitive debiasing strategies are often most needed when the clinician cannot afford the time to use them. A mnemonic checklist known as TWED (T = threat, W = what else, E = evidence and D = dispositional factors) was recently created to facilitate metacognition. This study explores the hypothesis that the TWED checklist improves the ability of medical students to make better clinical decisions. METHODS Two groups of final-year medical students from Universiti Sains Malaysia, Malaysia, were recruited to participate in this quasi-experimental study. The intervention group (n = 21) received educational intervention that introduced the TWED checklist, while the control group (n = 19) received a tutorial on basic electrocardiography. Post-intervention, both groups received a similar assessment on clinical decision-making based on five case scenarios. RESULTS The mean score of the intervention group was significantly higher than that of the control group (18.50 ± 4.45 marks vs. 12.50 ± 2.84 marks, p < 0.001). In three of the five case scenarios, students in the intervention group obtained higher scores than those in the control group. CONCLUSION The results of this study support the use of the TWED checklist to facilitate metacognition in clinical decision-making. PMID:26778635

  1. Evaluating the Effectiveness of Nurse-Focused Computerized Clinical Decision Support on Urinary Catheter Practice Guidelines

    ERIC Educational Resources Information Center

    Lang, Robin Lynn Neal

    2012-01-01

    A growing national emphasis has been placed on health information technology (HIT) with robust computerized clinical decision support (CCDS) integration into health care delivery. Catheter-associated urinary tract infection is the most frequent health care-associated infection in the United States and is associated with high cost, high volumes and…

  2. May tropospheric noise in satellite radar data affect decision making results?

    NASA Astrophysics Data System (ADS)

    Bloutsos, Aristeidis; Bekri, Eleni; Moschas, Fanis; Saltogianni, Vasso; Stiros, Stathis; Yannopoulos, Panayotis

    2015-04-01

    Meteorological and air pollution conditions affect the satellite positioning signals. To investigate the uncertainty introduced in these signals in various meteorological and air pollution conditions, an array of GPS/GNSS stations and another of meteorological and air pollution stations has been established. The study area is expanded next to Patraikos and Corinth Gulf (NW Peloponnisos, Greece), which is characterized by high variability sequences from hot to cold weather, low to high relative humidity and clear to cloudy or/and Sahara dusty atmosphere, as a result of the particular geographical and topographical features of the study area. The GNSS recordings from several stations with very high vertical separation (with altitude up to 1600m and with a gradient of up to 20%) are analyzed in order to control in some extend both the vertical and the horizontal variability of the atmospheric effects, as well as the noise of geodetic recordings. Then, the GPS results will be combined with meteorological and atmospheric pollution data, as well as satellite radar data, in order to evaluate the enhanced troposphere noise in satellite radar and to estimate the magnitude of uncertainty that may cause alterations to decision making results in the management of water and other natural resources. This project takes advantage of GPS stations established in wider study area in the framework of the Corinth Rift Laboratory (http://crlab.eu/) in conjunction to the air pollution and meteorological monitoring stations of the Environmental Engineering Laboratory of the Department of Civil Engineering of the University of Patras. Regarding GPS stations, the project has been partly funded by the PLATO Project of the Greek Secretariat for Research and Technology.

  3. The doctor-patient relationship as a toolkit for uncertain clinical decisions.

    PubMed

    Diamond-Brown, Lauren

    2016-06-01

    how the doctor-patient relationship and model of care affect physician decision-making, and for forming policy on the optimal structure of medical work.

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

    PubMed Central

    Gilou, Sotiria; Billis, Antonis; Karagianni, Maria; Bratsas, Charalampos D.

    2016-01-01

    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. PMID:27222732

  5. 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.

  6. Deciding how to decide: ventromedial frontal lobe damage affects information acquisition in multi-attribute decision making.

    PubMed

    Fellows, Lesley K

    2006-04-01

    Ventromedial frontal lobe (VMF) damage is associated with impaired decision making. Recent efforts to understand the functions of this brain region have focused on its role in tracking reward, punishment and risk. However, decision making is complex, and frontal lobe damage might be expected to affect it at other levels. This study used process-tracing techniques to explore the effect of VMF damage on multi-attribute decision making under certainty. Thirteen subjects with focal VMF damage were compared with 11 subjects with frontal damage that spared the VMF and 21 demographically matched healthy control subjects. Participants chose rental apartments in a standard information board task drawn from the literature on normal decision making. VMF subjects performed the decision making task in a way that differed markedly from all other groups, favouring an 'alternative-based' information acquisition strategy (i.e. they organized their information search around individual apartments). In contrast, both healthy control subjects and subjects with damage predominantly involving dorsal and/or lateral prefrontal cortex pursued primarily 'attribute-based' search strategies (in which information was acquired about categories such as rent and noise level across several apartments). This difference in the pattern of information acquisition argues for systematic differences in the underlying decision heuristics and strategies employed by subjects with VMF damage, which in turn may affect the quality of their choices. These findings suggest that the processes supported by ventral and medial prefrontal cortex need to be conceptualized more broadly, to account for changes in decision making under conditions of certainty, as well as uncertainty, following damage to these areas.

  7. 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

  8. 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.

  9. Take a stand on your decisions, or take a sit: posture does not affect risk preferences in an economic task

    PubMed Central

    O’Brien, Megan K.

    2014-01-01

    Physiological and emotional states can affect our decision-making processes, even when these states are seemingly insignificant to the decision at hand. We examined whether posture and postural threat affect decisions in a non-related economic domain. Healthy young adults made a series of choices between economic lotteries in various conditions, including changes in body posture (sitting vs. standing) and changes in elevation (ground level vs. atop a 0.8-meter-high platform). We compared three metrics between conditions to assess changes in risk-sensitivity: frequency of risky choices, and parameter fits of both utility and probability weighting parameters using cumulative prospect theory. We also measured skin conductance level to evaluate physiological response to the postural threat. Our results demonstrate that body posture does not significantly affect decision making. Secondly, despite increased skin conductance level, economic risk-sensitivity was unaffected by increased threat. Our findings indicate that economic choices are fairly robust to the physiological and emotional changes that result from posture or postural threat. PMID:25083345

  10. Herding: a new phenomenon affecting medical decision-making in multiple sclerosis care? Lessons learned from DIScUTIR MS

    PubMed Central

    Saposnik, Gustavo; Maurino, Jorge; Sempere, Angel P; Ruff, Christian C; Tobler, Philippe N

    2017-01-01

    Purpose Herding is a phenomenon by which individuals follow the behavior of others rather than deciding independently on the basis of their own private information. A herding-like phenomenon can occur in multiple sclerosis (MS) when a neurologist follows a therapeutic recommendation by a colleague even though it is not supported by best practice clinical guidelines. Limited information is currently available on the role of herding in medical care. The objective of this study was to determine the prevalence (and its associated factors) of herding in the management of MS. Methods We conducted a study among neurologists with expertise in MS care throughout Spain. Participants answered questions regarding the management of 20 case scenarios commonly encountered in clinical practice and completed 3 surveys and 4 experimental paradigms based on behavioral economics. The herding experiment consisted of a case scenario of a 40-year-old woman who has been stable for 3 years on subcutaneous interferon and developed a self-limited neurological event. There were no new magnetic resonance imaging (MRI) lesions. Her neurological examination and disability scores were unchanged. She was advised by an MS neurologist to switch from interferon to fingolimod against best practice guidelines. Multivariable logistic regression analysis was conducted to evaluate factors associated with herding. Results Out of 161 neurologists who were invited to participate, 96 completed the study (response rate: 60%). Herding was present in 75 (78.1%), having a similar prevalence in MS experts and general neurologists (68.8% vs 82.8%; P=0.12). In multivariate analyses, the number of MS patients seen per week was positively associated with herding (odds ratio [OR] 1.08, 95% CI 1.01–1.14). Conversely, physician’s age, gender, years of practice, setting of practice, or risk preferences were not associated with herding. Conclusion Herding was a common phenomenon affecting nearly 8 out of 10

  11. [A computerised clinical decision-support system for the management of depression in Primary Care].

    PubMed

    Aragonès, Enric; Comín, Eva; Cavero, Myriam; Pérez, Víctor; Molina, Cristina; Palao, Diego

    2017-01-09

    Despite its clinical relevance and its importance as a public health problem, there are major gaps in the management of depression. Evidence-based clinical guidelines are useful to improve processes and clinical outcomes. In order to make their implementation easier these guidelines have been transformed into computerised clinical decision support systems. In this article, a description is presented on the basics and characteristics of a new computerised clinical guideline for the management of major depression, developed in the public health system in Catalonia. This tool helps the clinician to establish reliable and accurate diagnoses of depression, to choose the best treatment a priori according to the disease and the patient characteristics. It also emphasises the importance of systematic monitoring to assess the clinical course, and to adjust therapeutic interventions to the patient's needs at all times.

  12. A meta-analysis of confidence and judgment accuracy in clinical decision making.

    PubMed

    Miller, Deborah J; Spengler, Elliot S; Spengler, Paul M

    2015-10-01

    The overconfidence bias occurs when clinicians overestimate the accuracy of their clinical judgments. This bias is thought to be robust leading to an almost universal recommendation by clinical judgment scholars for clinicians to temper their confidence in clinical decision making. An extension of the Meta-Analysis of Clinical Judgment (Spengler et al., 2009) project, the authors synthesized over 40 years of research from 36 studies, from 1970 to 2011, in which the confidence ratings of 1,485 clinicians were assessed in relation to the accuracy of their judgments about mental health (e.g., diagnostic decision making, violence risk assessment, prediction of treatment failure) or psychological issues (e.g., personality assessment). Using a random effects model a small but statistically significant effect (r = .15; CI = .06, .24) was found showing that confidence is better calibrated with accuracy than previously assumed. Approximately 50% of the total variance between studies was due to heterogeneity and not to chance. Mixed effects and meta-regression moderator analyses revealed that confidence is calibrated with accuracy least when there are repeated judgments, and more when there are higher base rate problems, when decisions are made with written materials, and for earlier published studies. Sensitivity analyses indicate a bias toward publishing smaller sample studies with smaller or negative confidence-accuracy effects. Implications for clinical judgment research and for counseling psychology training and practice are discussed.

  13. Workshop on using natural language processing applications for enhancing clinical decision making: an executive summary.

    PubMed

    Pai, Vinay M; Rodgers, Mary; Conroy, Richard; Luo, James; Zhou, Ruixia; Seto, Belinda

    2014-02-01

    In April 2012, the National Institutes of Health organized a two-day workshop entitled 'Natural Language Processing: State of the Art, Future Directions and Applications for Enhancing Clinical Decision-Making' (NLP-CDS). This report is a summary of the discussions during the second day of the workshop. Collectively, the workshop presenters and participants emphasized the need for unstructured clinical notes to be included in the decision making workflow and the need for individualized longitudinal data tracking. The workshop also discussed the need to: (1) combine evidence-based literature and patient records with machine-learning and prediction models; (2) provide trusted and reproducible clinical advice; (3) prioritize evidence and test results; and (4) engage healthcare professionals, caregivers, and patients. The overall consensus of the NLP-CDS workshop was that there are promising opportunities for NLP and CDS to deliver cognitive support for healthcare professionals, caregivers, and patients.

  14. Design and application of a generic clinical decision support system for multiscale data.

    PubMed

    Mattila, Jussi; Koikkalainen, Juha; Virkki, Arho; van Gils, Mark; Lötjönen, Jyrki

    2012-01-01

    Medical research and clinical practice are currently being redefined by the constantly increasing amounts of multiscale patient data. New methods are needed to translate them into knowledge that is applicable in healthcare. Multiscale modeling has emerged as a way to describe systems that are the source of experimental data. Usually, a multiscale model is built by combining distinct models of several scales, integrating, e.g., genetic, molecular, structural, and neuropsychological models into a composite representation. We present a novel generic clinical decision support system, which models a patient's disease state statistically from heterogeneous multiscale data. Its goal is to aid in diagnostic work by analyzing all available patient data and highlighting the relevant information to the clinician. The system is evaluated by applying it to several medical datasets and demonstrated by implementing a novel clinical decision support tool for early prediction of Alzheimer's disease.

  15. Fuzzy-Arden-Syntax-based, Vendor-agnostic, Scalable Clinical Decision Support and Monitoring Platform.

    PubMed

    Adlassnig, Klaus-Peter; Fehre, Karsten; Rappelsberger, Andrea

    2015-01-01

    This study's objective is to develop and use a scalable genuine technology platform for clinical decision support based on Arden Syntax, which was extended by fuzzy set theory and fuzzy logic. Arden Syntax is a widely recognized formal language for representing clinical and scientific knowledge in an executable format, and is maintained by Health Level Seven (HL7) International and approved by the American National Standards Institute (ANSI). Fuzzy set theory and logic permit the representation of knowledge and automated reasoning under linguistic and propositional uncertainty. These forms of uncertainty are a common feature of patients' medical data, the body of medical knowledge, and deductive clinical reasoning.

  16. Advancing clinical decision support using lessons from outside of healthcare: an interdisciplinary systematic review

    PubMed Central

    2012-01-01

    Background Greater use of computerized decision support (DS) systems could address continuing safety and quality problems in healthcare, but the healthcare field has struggled to implement DS technology. This study surveys DS experience across multiple non-healthcare disciplines for new insights that are generalizable to healthcare provider decisions. In particular, it sought design principles and lessons learned from the other disciplines that could inform efforts to accelerate the adoption of clinical decision support (CDS). Methods Our systematic review drew broadly from non-healthcare databases in the basic sciences, social sciences, humanities, engineering, business, and defense: PsychINFO, BusinessSource Premier, Social Sciences Abstracts, Web of Science, and Defense Technical Information Center. Because our interest was in DS that could apply to clinical decisions, we selected articles that (1) provided a review, overview, discussion of lessons learned, or an evaluation of design or implementation aspects of DS within a non-healthcare discipline and (2) involved an element of human judgment at the individual level, as opposed to decisions that can be fully automated or that are made at the organizational level. Results Clinical decisions share some similarities with decisions made by military commanders, business managers, and other leaders: they involve assessing new situations and choosing courses of action with major consequences, under time pressure, and with incomplete information. We identified seven high-level DS system design features from the non-healthcare literature that could be applied to CDS: providing broad, system-level perspectives; customizing interfaces to specific users and roles; making the DS reasoning transparent; presenting data effectively; generating multiple scenarios covering disparate outcomes (e.g., effective; effective with side effects; ineffective); allowing for contingent adaptations; and facilitating collaboration. The

  17. Decision theory and the evaluation of risks and benefits of clinical trials.

    PubMed

    Bernabe, Rosemarie D C; van Thiel, Ghislaine J M W; Raaijmakers, Jan A M; van Delden, Johannes J M

    2012-12-01

    Research ethics committees (RECs) are tasked to assess the risks and the benefits of a clinical trial. In previous studies, it was shown that RECs find this task difficult, if not impossible, to do. The current approaches to benefit-risk assessment (i.e. Component Analysis and the Net Risk Test) confound the various risk-benefit tasks, and as such, make balancing impossible. In this article, we show that decision theory, specifically through the expected utility theory and multiattribute utility theory, enable for an explicit and ethically weighted risk-benefit evaluation. This makes a balanced ethical justification possible, and thus a more rationally defensible decision making.

  18. Clinical Decision Support Systems (CDSS) for preventive management of COPD patients

    PubMed Central

    2014-01-01

    Background The use of information and communication technologies to manage chronic diseases allows the application of integrated care pathways, and the optimization and standardization of care processes. Decision support tools can assist in the adherence to best-practice medicine in critical decision points during the execution of a care pathway. Objectives The objectives are to design, develop, and assess a clinical decision support system (CDSS) offering a suite of services for the early detection and assessment of chronic obstructive pulmonary disease (COPD), which can be easily integrated into a healthcare providers' work-flow. Methods The software architecture model for the CDSS, interoperable clinical-knowledge representation, and inference engine were designed and implemented to form a base CDSS framework. The CDSS functionalities were iteratively developed through requirement-adjustment/development/validation cycles using enterprise-grade software-engineering methodologies and technologies. Within each cycle, clinical-knowledge acquisition was performed by a health-informatics engineer and a clinical-expert team. Results A suite of decision-support web services for (i) COPD early detection and diagnosis, (ii) spirometry quality-control support, (iii) patient stratification, was deployed in a secured environment on-line. The CDSS diagnostic performance was assessed using a validation set of 323 cases with 90% specificity, and 96% sensitivity. Web services were integrated in existing health information system platforms. Conclusions Specialized decision support can be offered as a complementary service to existing policies of integrated care for chronic-disease management. The CDSS was able to issue recommendations that have a high degree of accuracy to support COPD case-finding. Integration into healthcare providers' work-flow can be achieved seamlessly through the use of a modular design and service-oriented architecture that connect to existing health

  19. Development of a clinical decision support system for diabetes care: A pilot study.

    PubMed

    Sim, Livvi Li Wei; Ban, Kenneth Hon Kim; Tan, Tin Wee; Sethi, Sunil Kumar; Loh, Tze Ping

    2017-01-01

    Management of complex chronic diseases such as diabetes requires the assimilation and interpretation of multiple laboratory test results. Traditional electronic health records tend to display laboratory results in a piecemeal and segregated fashion. This makes the assembly and interpretation of results related to diabetes care challenging. We developed a diabetes-specific clinical decision support system (Diabetes Dashboard) interface for displaying glycemic, lipid and renal function results, in an integrated form with decision support capabilities, based on local clinical practice guidelines. The clinical decision support system included a dashboard feature that graphically summarized all relevant laboratory results and displayed them in a color-coded system that allowed quick interpretation of the metabolic control of the patients. An alert module informs the user of tests that are due for repeat testing. An interactive graph module was also developed for better visual appreciation of the trends of the laboratory results of the patient. In a pilot study involving case scenarios administered via an electronic questionnaire, the Diabetes Dashboard, compared to the existing laboratory reporting interface, significantly improved the identification of abnormal laboratory results, of the long-term trend of the laboratory tests and of tests due for repeat testing. However, the Diabetes Dashboard did not significantly improve the identification of patients requiring treatment adjustment or the amount of time spent on each case scenario. In conclusion, we have developed and shown that the use of the Diabetes Dashboard, which incorporates several decision support features, can improve the management of diabetes. It is anticipated that this dashboard will be most helpful when deployed in an outpatient setting, where physicians can quickly make clinical decisions based on summarized information and be alerted to pertinent areas of care that require additional attention.

  20. Development of a clinical decision support system for diabetes care: A pilot study

    PubMed Central

    Sim, Livvi Li Wei; Ban, Kenneth Hon Kim; Tan, Tin Wee; Sethi, Sunil Kumar; Loh, Tze Ping

    2017-01-01

    Management of complex chronic diseases such as diabetes requires the assimilation and interpretation of multiple laboratory test results. Traditional electronic health records tend to display laboratory results in a piecemeal and segregated fashion. This makes the assembly and interpretation of results related to diabetes care challenging. We developed a diabetes-specific clinical decision support system (Diabetes Dashboard) interface for displaying glycemic, lipid and renal function results, in an integrated form with decision support capabilities, based on local clinical practice guidelines. The clinical decision support system included a dashboard feature that graphically summarized all relevant laboratory results and displayed them in a color-coded system that allowed quick interpretation of the metabolic control of the patients. An alert module informs the user of tests that are due for repeat testing. An interactive graph module was also developed for better visual appreciation of the trends of the laboratory results of the patient. In a pilot study involving case scenarios administered via an electronic questionnaire, the Diabetes Dashboard, compared to the existing laboratory reporting interface, significantly improved the identification of abnormal laboratory results, of the long-term trend of the laboratory tests and of tests due for repeat testing. However, the Diabetes Dashboard did not significantly improve the identification of patients requiring treatment adjustment or the amount of time spent on each case scenario. In conclusion, we have developed and shown that the use of the Diabetes Dashboard, which incorporates several decision support features, can improve the management of diabetes. It is anticipated that this dashboard will be most helpful when deployed in an outpatient setting, where physicians can quickly make clinical decisions based on summarized information and be alerted to pertinent areas of care that require additional attention. PMID

  1. Improving Decision Making about Genetic Testing in the Clinic: An Overview of Effective Knowledge Translation Interventions

    PubMed Central

    Légaré, France; Robitaille, Hubert; Gane, Claire; Hébert, Jessica; Labrecque, Michel; Rousseau, François

    2016-01-01

    Background Knowledge translation (KT) interventions are attempts to change behavior in keeping with scientific evidence. While genetic tests are increasingly available to healthcare consumers in the clinic, evidence about their benefits is unclear and decisions about genetic testing are thus difficult for all parties. Objective We sought to identify KT interventions that involved decisions about genetic testing in the clinical context and to assess their effectiveness for improving decision making in terms of behavior change, increased knowledge and wellbeing. Methods We searched for trials assessing KT interventions in the context of genetic testing up to March 2014 in all systematic reviews (n = 153) published by two Cochrane review groups: Effective Practice and Organisation of Care (EPOC) and Consumers and Communication. Results We retrieved 2473 unique trials of which we retained only 28 (1%). Two EPOC reviews yielded two trials of KT interventions: audit and feedback (n = 1) and educational outreach (n = 1). Both targeted health professionals and the KT intervention they assessed was found to be effective. Four Consumers and Communication reviews yielded 26 trials: decision aids (n = 15), communication of DNA-based disease risk estimates (n = 7), personalized risk communication (n = 3) and mobile phone messaging (n = 1). Among these, 25 trials targeted only health consumers or patients and the KT interventions were found to be effective in four trials, partly effective in seven, and ineffective in four. Lastly, only one trial targeted both physicians and patients and was found to be effective. Conclusions More research on the effectiveness of KT interventions regarding genetic testing in the clinical context may contribute to patients making informed value-based decisions and drawing the maximum benefit from clinical applications of genetic and genomic innovations. PMID:26938633

  2. Trait anxiety affects decision-making differently in healthy men and women: towards gender-specific endophenotypes of anxiety.

    PubMed

    de Visser, L; van der Knaap, L J; van de Loo, A J A E; van der Weerd, C M M; Ohl, F; van den Bos, R

    2010-05-01

    Excessive levels of trait anxiety are a risk factor for psychiatric conditions, including anxiety disorders and substance abuse. High trait anxiety has been associated with altered cognitive functioning, in particular with an attentional bias towards aversive stimuli. Decision-making is a crucial aspect of cognitive functioning that relies on the correct processing and control of emotional stimuli. Interestingly, anxiety and decision-making share underlying neural substrates, involving cortico-limbic pathways, including the amygdala, striatum and medial and dorsolateral prefrontal cortices. In the present study, we investigated the relationship between trait anxiety, measured by the State-Trait Anxiety Inventory, and complex decision-making, measured by the Iowa Gambling Task, in healthy male and female volunteers. The main focus of this study was the inclusion of gender as a discriminative factor. Indeed, we found distinct gender-specific effects of trait anxiety: in men, both low and high anxiety groups showed impaired decision-making compared to medium anxiety individuals, whereas in women only high anxiety individuals performed poorly. Furthermore, anxiety affected decision-making in men early in the task, i.e. the exploration phase, as opposed to an effect on performance in women during the second part of the test, i.e. the exploitation phase. These findings were related to different profiles of trait anxiety in men and women, and were independent of performance in the Wisconsin Card Sorting Test and cortisol levels. Our data show gender-specific effects of trait anxiety on emotional decision-making. We suggest gender-specific endophenotypes of anxiety to exist, that differentially affect cognitive functioning.

  3. Risks, dangers and competing clinical decisions on venous thromboembolism prophylaxis in hospital care.

    PubMed

    Boiko, Olga; Sheaff, Rod; Child, Susan; Gericke, Christian A

    2014-07-01

    Drawing on wider sociologies of risk, this article examines the complexity of clinical risks and their management, focusing on risk management systems, expert decision-making and safety standards in health care. At the time of this study preventing venous thromboembolism (VTE) among in-patients was one of the top priorities for hospital safety in the English National Health Service (NHS). An analysis of 50 interviews examining hospital professionals' perceptions about VTE risks and prophylaxis illuminates how National Institute for Health and Clinical Excellence (NICE) guidelines influenced clinical decision-making in four hospitals in one NHS region. We examine four themes: the identification of new risks, the institutionalisation and management of risk, the relationship between risk and danger and the tensions between risk management systems and expert decision-making. The implementation of NICE guidelines for VTE prevention extended managerial control over risk management but some irreducible clinical dangers remained that were beyond the scope of the new VTE risk management systems. Linking sociologies of risk with the realities of hospital risk management reveals the capacity of these theories to illuminate both the possibilities and the limits of managerialism in health care.

  4. Multi-site evaluation of a clinical decision support system for radiation therapy

    NASA Astrophysics Data System (ADS)

    Deshpande, Ruchi; DeMarco, John; Kessel, Kerstin; Liu, Brent J.

    2016-03-01

    We have developed an imaging informatics based decision support system that learns from retrospective treatment plans to provide recommendations for healthy tissue sparing to prospective incoming patients. This system incorporates a model of best practices from previous cases, specific to tumor anatomy. Ultimately, our hope is to improve clinical workflow efficiency, patient outcomes and to increase clinician confidence in decision-making. The success of such a system depends greatly on the training dataset, which in this case, is the knowledge base that the data-mining algorithm employs. The size and heterogeneity of the database is essential for good performance. Since most institutions employ standard protocols and practices for treatment planning, the diversity of this database can be greatly increased by including data from different institutions. This work presents the results of incorporating cross-country, multi-institutional data into our decision support system for evaluation and testing.

  5. Clinical Decision Support using a Terminology Server to improve Patient Safety.

    PubMed

    Garcia-Jimenez, Alba; Moreno-Conde, Alberto; Martínez-García, Alicia; Marín-León, Ignacio; Medrano-Ortega, Francisco Javier; Parra-Calderón, Carlos L

    2015-01-01

    Clinical Decision Support Systems (CDSS) are software applications that support clinicians in making healthcare decisions providing relevant information for individual patients about their specific conditions. The lack of integration between CDSS and Electronic Health Record (EHR) has been identified as a significant barrier to CDSS development and adoption. Andalusia Healthcare Public System (AHPS) provides an interoperable health information infrastructure based on a Service Oriented Architecture (SOA) that eases CDSS implementation. This paper details the deployment of a CDSS jointly with the deployment of a Terminology Server (TS) within the AHPS infrastructure. It also explains a case study about the application of decision support to thromboembolism patients and its potential impact on improving patient safety. We will apply the inSPECt tool proposal to evaluate the appropriateness of alerts in this scenario.

  6. External factors affecting decision-making and use of evidence in an Australian public health policy environment.

    PubMed

    Zardo, Pauline; Collie, Alex; Livingstone, Charles

    2014-05-01

    This study examined external factors affecting policy and program decision-making in a specific public health policy context: injury prevention and rehabilitation compensation in the Australian state of Victoria. The aim was twofold: identify external factors that affect policy and program decision-making in this specific context; use this evidence to inform targeting of interventions aimed at increasing research use in this context. Qualitative interviews were undertaken from June 2011 to January 2012 with 33 employees from two state government agencies. Key factors identified were stakeholder feedback and action, government and ministerial input, legal feedback and action, injured persons and the media. The identified external factors were able to significantly influence policy and program decision-making processes: acting as both barriers and facilitators, depending on the particular issue at hand. The factors with the most influence were the Minister and government, lawyers, and agency stakeholders, particularly health providers, trade unions and employer groups. This research revealed that interventions aimed at increasing use of research in this context must target and harness the influence of these groups. This research provides critical insights for researchers seeking to design interventions to increase use of research in policy environments and influence decision-making in Victorian injury prevention and rehabilitation compensation.

  7. Designing a Clinical Framework to Guide Gross Motor Intervention Decisions for Infants and Young Children with Hypotonia

    ERIC Educational Resources Information Center

    Darrah, Johanna; O'Donnell, Maureen; Lam, Joyce; Story, Maureen; Wickenheiser, Diane; Xu, Kaishou; Jin, Xiaokun

    2013-01-01

    Clinical practice frameworks are a valuable component of clinical education, promoting informed clinical decision making based on the best available evidence and/or clinical experience. They encourage standardized intervention approaches and evaluation of practice. Based on an international project to support the development of an enhanced service…

  8. Affective decision making under uncertainty during a plausible aviation task: an fMRI study.

    PubMed

    Causse, Mickaël; Péran, Patrice; Dehais, Frédéric; Caravasso, Chiara Falletta; Zeffiro, Thomas; Sabatini, Umberto; Pastor, Josette

    2013-05-01

    In aeronautics, plan continuation error (PCE) represents failure to revise a flight plan despite emerging evidence suggesting that it is no longer safe. Assuming that PCE may be associated with a shift from cold to hot reasoning, we hypothesized that this transition may result from a large range of strong negative emotional influences linked with the decision to abort a landing and circle for a repeat attempt, referred to as a "go-around". We investigated this hypothesis by combining functional neuroimaging with an ecologically valid aviation task performed under contextual variation in incentive and situational uncertainty. Our goal was to identify regional brain activity related to the sorts of conservative or liberal decision-making strategies engaged when participants were both exposed to a financial payoff matrix constructed to bias responses in favor of landing acceptance, while they were simultaneously experiencing maximum levels of uncertainty related to high levels of stimulus ambiguity. Combined with the observed behavioral outcomes, our neuroimaging results revealed a shift from cold to hot decision making in response to high uncertainty when participants were exposed to the financial incentive. Most notably, while we observed activity increases in response to uncertainty in many frontal regions such as dorsolateral prefrontal cortex (DLPFC) and anterior cingulate cortex (ACC), less overall activity was observed when the reward was combined with uncertainty. Moreover, participants with poor decision making, quantified as a lower discriminability index d', exhibited riskier behavior coupled with lower activity in the right DLPFC. These outcomes suggest a disruptive effect of biased financial incentive and high uncertainty on the rational decision-making neural network, and consequently, on decision relevance.

  9. Factors Affecting the Corporate Decision-Making Process of Air Transport Manufacturers

    NASA Technical Reports Server (NTRS)

    Ollila, R. G.; Hill, J. D.; Noton, B. R.; Duffy, M. A.; Epstein, M. M.

    1976-01-01

    Fuel economy is a pivotal question influencing the future sale and utilization of commercial aircraft. The NASA Aircraft Energy Efficiency (ACEE) Program Office has a program intended to accelerate the readiness of advanced technologies for energy efficient aircraft. Because the decision to develop a new airframe or engine is a major financial hazard for manufacturers, it is important to know what factors influence the decision making process. A method is described for identifying and ranking individuals and organizations involved at each stage of commercial air transport development, and the barriers that must be overcome in adopting new technologies.

  10. Lung Cancer Assistant: a hybrid clinical decision support application for lung cancer care

    PubMed Central

    Sesen, M. Berkan; Peake, Michael D.; Banares-Alcantara, Rene; Tse, Donald; Kadir, Timor; Stanley, Roz; Gleeson, Fergus; Brady, Michael

    2014-01-01

    Multidisciplinary team (MDT) meetings are becoming the model of care for cancer patients worldwide. While MDTs have improved the quality of cancer care, the meetings impose substantial time pressure on the members, who generally attend several such MDTs. We describe Lung Cancer Assistant (LCA), a clinical decision support (CDS) prototype designed to assist the experts in the treatment selection decisions in the lung cancer MDTs. A novel feature of LCA is its ability to provide rule-based and probabilistic decision support within a single platform. The guideline-based CDS is based on clinical guideline rules, while the probabilistic CDS is based on a Bayesian network trained on the English Lung Cancer Audit Database (LUCADA). We assess rule-based and probabilistic recommendations based on their concordances with the treatments recorded in LUCADA. Our results reveal that the guideline rule-based recommendations perform well in simulating the recorded treatments with exact and partial concordance rates of 0.57 and 0.79, respectively. On the other hand, the exact and partial concordance rates achieved with probabilistic results are relatively poorer with 0.27 and 0.76. However, probabilistic decision support fulfils a complementary role in providing accurate survival estimations. Compared to recorded treatments, both CDS approaches promote higher resection rates and multimodality treatments. PMID:24990290

  11. The anatomy of clinical decision-making in multidisciplinary cancer meetings

    PubMed Central

    Soukup, Tayana; Petrides, Konstantinos V.; Lamb, Benjamin W.; Sarkar, Somita; Arora, Sonal; Shah, Sujay; Darzi, Ara; Green, James S. A.; Sevdalis, Nick

    2016-01-01

    Abstract In the UK, treatment recommendations for patients with cancer are routinely made by multidisciplinary teams in weekly meetings. However, their performance is variable. The aim of this study was to explore the underlying structure of multidisciplinary decision-making process, and examine how it relates to team ability to reach a decision. This is a cross-sectional observational study consisting of 1045 patient reviews across 4 multidisciplinary cancer teams from teaching and community hospitals in London, UK, from 2010 to 2014. Meetings were chaired by surgeons. We used a validated observational instrument (Metric for the Observation of Decision-making in Cancer Multidisciplinary Meetings) consisting of 13 items to assess the decision-making process of each patient discussion. Rated on a 5-point scale, the items measured quality of presented patient information, and contributions to review by individual disciplines. A dichotomous outcome (yes/no) measured team ability to reach a decision. Ratings were submitted to Exploratory Factor Analysis and regression analysis. The exploratory factor analysis produced 4 factors, labeled “Holistic and Clinical inputs” (patient views, psychosocial aspects, patient history, comorbidities, oncologists’, nurses’, and surgeons’ inputs), “Radiology” (radiology results, radiologists’ inputs), “Pathology” (pathology results, pathologists’ inputs), and “Meeting Management” (meeting chairs’ and coordinators’ inputs). A negative cross-loading was observed from surgeons’ input on the fourth factor with a follow-up analysis showing negative correlation (r = −0.19, P < 0.001). In logistic regression, all 4 factors predicted team ability to reach a decision (P < 0.001). Hawthorne effect is the main limitation of the study. The decision-making process in cancer meetings is driven by 4 underlying factors representing the complete patient profile and contributions to case review by all core

  12. Replacing the mercury manometer with an oscillometric device in a hypertension clinic: implications for clinical decision making.

    PubMed

    Stergiou, G S; Lourida, P; Tzamouranis, D

    2011-11-01

    Oscillometric devices are being widely used for ambulatory, home and office blood pressure (BP) measurement, and several of them have been validated using established protocols. This cross-sectional study assessed the impact on antihypertensive treatment decisions of replacing the mercury sphygmomanometer by a validated oscillometric device. Consecutive subjects attending a hypertension clinic had triplicate simultaneous same-arm BP measurements using a mercury sphygmomanometer and a validated professional oscillometric device. For each device, uncontrolled hypertension was defined as average BP ≥140/90 mm Hg (systolic/diastolic). A total of 5108 simultaneous BP measurements were obtained from 763 subjects in 1717 clinic visits. In 24% of all visits, the mercury and the oscillometric BP measurements led to different conclusion regarding the diagnosis of uncontrolled hypertension. In 4.9% of the visits, the diagnostic disagreement was considered as 'clinically important' (BP exceeding the diagnostic threshold by >5 mm Hg). These data suggest that the replacement of the mercury sphygmomanometer by a validated professional oscillometric device will result into different treatment decisions in about 5% of the cases. Therefore, and because of the known problems when using mercury devices and the auscultatory technique in clinical practise, the oscillometric devices are regarded as reliable alternatives to the mercury sphygmomanometer for office use.

  13. Clinical judgment and decision making in wound assessment and management: is experience enough?

    PubMed

    Logan, Gemma

    2015-03-01

    The assessment and management of wounds forms a large proportion of community nurses' workload, often requiring judgment and decision-making in complex, challenging and uncertain circumstances. The processes through which nurses form judgments and make decisions within this context are reviewed in this article against existing theories on these on these subjects. There is variability in wound assessment and management practice which may be attributed to uncertainties within the context, a lack of knowledge in appropriate treatment choices and the inability to correctly value the importance of the clinical information presented. Nurses may be required to draw on intuition to guide their judgments and decision-making by association with experience and expertise. In addition, a step-by-step analytical approach underpinned by an evidence base may be required to ensure accuracy in practice. Developing an understanding of the different theories of judgment and decision-making may facilitate nurses' abilities to reflect on their own decision tasks, thereby enhancing the care provided.

  14. Conflicts of interest in research: is clinical decision-making compromised? An opinion paper.

    PubMed

    Adibi, Shawn; Abidi, Shawn; Bebermeyer, Richard D

    2010-08-01

    Lack of transparency in funded research can compromise clinical decision-making in an evidence-based practice. Transparency can be defined as full disclosure of all financial assistance and support to authors and investigators. There is a perception that ethical principles are eroding and that research data can be biased due to conflicts of interest. These research outcomes biased or not, are used for clinical decision-making in the evidence-based practice. One suggested solution to this common ethical dilemma is to continue the dialogue on transparency in research and to create oversight bodies which include representatives from business and industry, private practice, academia, and research. There is increasing evidence of the need for more ethics education at all levels.

  15. WHAT ARE 'BEST INTERESTS'? A CRITICAL EVALUATION OF 'BEST INTERESTS' DECISION-MAKING IN CLINICAL PRACTICE.

    PubMed

    Taylor, Helen J

    2016-01-01

    Obtaining the patient's consent is usually a prerequisite of any clinical intervention. However, some cognitively impaired patients may not be able to give valid consent. Following years of consultation and legislative review, the Mental Capacity Act 2005 (MCA) provides a statutory framework of 'best interests' decision-making on behalf of incapacitated individuals. However, confusion over the meaning and application of the 'best interests' standard persists. This paper explores the variation in judicial interpretation of the standard and the complexities of best interests decision-making in clinical practice. Prevailing confusion and risk-aversive practices mean that the rights and interests of cognitively impaired individuals continue to be compromised, with evidence to suggest that 'best interests' may be conflated with the clinician's evaluation of 'best medical interests'.

  16. The perils of meta-regression to identify clinical decision support system success factors.

    PubMed

    Fillmore, Christopher L; Rommel, Casey A; Welch, Brandon M; Zhang, Mingyuan; Kawamoto, Kensaku

    2015-08-01

    Clinical decision support interventions are typically heterogeneous in nature, making it difficult to identify why some interventions succeed while others do not. One approach to identify factors important to the success of health information systems is the use of meta-regression techniques, in which potential explanatory factors are correlated with the outcome of interest. This approach, however, can result in misleading conclusions due to several issues. In this manuscript, we present a cautionary case study in the context of clinical decision support systems to illustrate the limitations of this type of analysis. We then discuss implications and recommendations for future work aimed at identifying success factors of medical informatics interventions. In particular, we identify the need for head-to-head trials in which the importance of system features is directly evaluated in a prospective manner.

  17. What We Can Learn from Amazon for Clinical Decision Support Systems.

    PubMed

    Abid, Sidra; Keshavjee, Karim; Karim, Arsalan; Guergachi, Aziz

    2017-01-01

    Health care continue to lag behind other industries, such as retail and financial services, in the use of decision-support-like tools. Amazon is particularly prolific in the use of advanced predictive and prescriptive analytics to assist its customers to purchase more, while increasing satisfaction, retention, repeat-purchases and loyalty. How can we do the same in health care? In this paper, we explore various elements of the Amazon website and Amazon's data science and big data practices to gather inspiration for re-designing clinical decision support in the health care sector. For each Amazon element we identified, we present one or more clinical applications to help us better understand where Amazon's.

  18. To Push or Not to Push? Affective Influences on Moral Judgment Depend on Decision Frame

    ERIC Educational Resources Information Center

    Pastotter, Bernhard; Gleixner, Sabine; Neuhauser, Theresa; Bauml, Karl-Heinz T.

    2013-01-01

    People's moods can influence moral judgment. Such influences may arise because moods affect moral emotion, or because moods affect moral thought. The present study provides evidence that, at least in the footbridge dilemma, moods affect moral thought. The results of two experiments are reported in which, after induction of positive, negative, or…

  19. Access to augmentative and alternative communication: new technologies and clinical decision-making.

    PubMed

    Fager, Susan; Bardach, Lisa; Russell, Susanne; Higginbotham, Jeff

    2012-01-01

    Children with severe physical impairments require a variety of access options to augmentative and alternative communication (AAC) and computer technology. Access technologies have continued to develop, allowing children with severe motor control impairments greater independence and access to communication. This article will highlight new advances in access technology, including eye and head tracking, scanning, and access to mainstream technology, as well as discuss future advances. Considerations for clinical decision-making and implementation of these technologies will be presented along with case illustrations.

  20. A Serious Game for Teaching Nursing Students Clinical Reasoning and Decision-Making Skills.

    PubMed

    Johnsen, Hege Mari; Fossum, Mariann; Vivekananda-Schmidt, Pirashanthie; Fruhling, Ann; Slettebø, Åshild

    2016-01-01

    The aim of this study was to design and pilot-test a serious game for teaching nursing students clinical reasoning and decision-making skills in caring for patients with chronic obstructive pulmonary disease. A video-based serious game prototype was developed. A purposeful sample of six participants tested and evaluated the prototype. Usability issues were identified regarding functionality and user-computer interface. However, overall the serious game was perceived to be useful, usable and likable to use.

  1. Implementing Genomic Clinical Decision Support for Drug‐Based Precision Medicine

    PubMed Central

    Formea, CM; Hoffman, JM; Matey, E; Peterson, JF; Boyce, RD

    2017-01-01

    The explosive growth of patient‐specific genomic information relevant to drug therapy will continue to be a defining characteristic of biomedical research. To implement drug‐based personalized medicine (PM) for patients, clinicians need actionable information incorporated into electronic health records (EHRs). New clinical decision support (CDS) methods and informatics infrastructure are required in order to comprehensively integrate, interpret, deliver, and apply the full range of genomic data for each patient.1 PMID:28109071

  2. Factors affecting the decision of nursing students in Taiwan to be vaccinated against hepatitis B infection.

    PubMed

    Lin, W C; Ball, C

    1997-04-01

    Compliance with Hepatitis B vaccination for nurses has been reported to be low in Taiwan. Therefore, a study of nursing students' view was conducted in Taiwan to discover possible reasons. As complex decision-making was involved in taking the vaccine, a four-level utility decision model underpinned by the Multi-Attribute Utility theory was proposed to ascertain the relative contribution of the specific components of attitude and beliefs to the final decision and experience of being vaccinated against Hepatitis B infection. Results indicated that the 'personal value of Hepatitis B vaccination', in particular for 'concern about the efficacy of the Hepatitis B vaccine', 'fear of pain from repeated injections', 'time' and 'money', were the main determinants in relation to the uptake of the Hepatitis B vaccination. Such results were consistent with earlier findings based on the Health Belief Model. It appears that the greater the experience gained in nursing care the lower the rate of vaccination; the important items under the concept of 'Personal value of Hepatitis B vaccination' varied by 'experience in nursing care'. The overall predictive validity was 67%, based on the utility decision model. When stratified by 'experience in nursing care', the prediction improved, ranging from 89% to 100%. Based on these findings, a specific intervention programme should be provided to change behaviour and improve the vaccination rate.

  3. Inferential Judgments Affecting the Decision-Making Process in the Attorney General's Commission on Pornography.

    ERIC Educational Resources Information Center

    Gouran, Dennis S.

    Although the Attorney General's Commission on Pornography, also known as the Meese Commission, has been criticized excessively at times for threatening freedom of speech and press and individual rights to privacy, an analysis of its "Final Report" reveals numerous deficiencies in the Commission's decision-making process. These…

  4. Relative Saliency in Change Signals Affects Perceptual Comparison and Decision Processes in Change Detection

    ERIC Educational Resources Information Center

    Yang, Cheng-Ta

    2011-01-01

    Change detection requires perceptual comparison and decision processes on different features of multiattribute objects. How relative salience between two feature-changes influences the processes has not been addressed. This study used the systems factorial technology to investigate the processes when detecting changes in a Gabor patch with visual…

  5. Does the Availability of Parental Health Insurance Affect the College Enrollment Decision of Young Americans?

    ERIC Educational Resources Information Center

    Jung, Juergen; Hall, Diane M. Harnek; Rhoads, Thomas

    2013-01-01

    The present study examines whether the college enrollment decision of young individuals (student full-time, student part-time, and non-student) depends on health insurance coverage via a parent's family health plan. Our findings indicate that the availability of parental health insurance can have significant effects on the probability that a young…

  6. Spiking Phineas Gage: A Neurocomputational Theory of Cognitive-Affective Integration in Decision Making

    ERIC Educational Resources Information Center

    Wagar, Brandon M.; Thagard, Paul

    2004-01-01

    The authors present a neurological theory of how cognitive information and emotional information are integrated in the nucleus accumbens during effective decision making. They describe how the nucleus accumbens acts as a gateway to integrate cognitive information from the ventromedial prefrontal cortex and the hippocampus with emotional…

  7. IMPACT: How ORE Findings Have Affected Decisions in Austin and Beyond.

    ERIC Educational Resources Information Center

    Wilkinson, David, Ed.; Ligon, Glynn, Ed.

    Over the years, findings of the Office of Research and Evaluation (ORE) of the Austin (Texas) Independent School District (AISD) have had a significant impact on decisions made in the district and sometimes beyond it. The ORE's impact in the AISD is reviewed in 16 areas. Some of the major findings are summarized: (1) ORE studies of retention in…

  8. Does resuscitation status affect decision making in a deteriorating patient? Results from a randomised vignette study

    PubMed Central

    Skinner, Jane; Fritz, Zoë

    2016-01-01

    Abstract Aims and objectives The aim of this paper is to determine the influence of do not attempt cardiopulmonary resuscitation (DNACPR) orders and the Universal Form of Treatment Options (‘UFTO’: an alternative approach that contextualizes the resuscitation decision within an overall treatment plan) on nurses' decision making about a deteriorating patient. Methods An online survey with a developing case scenario across three timeframes was used on 231 nurses from 10 National Health Service Trusts. Nurses were randomised into three groups: DNACPR, the UFTO and no‐form. Statements were pooled into four subcategories: Increasing Monitoring, Escalating Concern, Initiating Treatments and Comfort Measures. Results Reported decisions were different across the three groups. Nurses in the DNACPR group agreed or strongly agreed to initiate fewer intense nursing interventions than the UFTO and no‐form groups (P < 0.001) overall and across subcategories of Increase Monitoring, Escalate Concern and Initiate Treatments (all P < 0.001). There was no difference between the UFTO and no‐form groups overall (P = 0.795) or in the subcategories. No difference in Comfort Measures were observed (P = 0.201) between the three groups. Conclusion The presence of a DNACPR order appears to influence nurse decision making in a deteriorating patient vignette. Differences were not observed in the UFTO and no‐form group. The UFTO may improve the way nurses modulate their behaviours towards critically ill patients with DNACPR status. More hospitals should consider adopting an approach where the resuscitation decisions are contextualised within overall goals of care. PMID:27237130

  9. Development and validation of a tool to measure self-confidence and anxiety in nursing students during clinical decision making.

    PubMed

    White, Krista A

    2014-01-01

    Clinical decision making (CDM) is a cornerstone skill for nurses. Self-confidence and anxiety affect the learning and adeptness of CDM. This study aimed to develop and test a quantitative tool to assess undergraduate nursing students' self-confidence and anxiety during CDM. The 27-item Nursing Anxiety and Self-Confidence with Clinical Decision Making (NASC-CDM) scale is a 6-point, Likert-type tool with two subscales. Two samples of prelicensure associate and baccalaureate nursing students participated in the pilot (n = 303) and main testing (n = 242) phases of the study. Construct validity assessment, using exploratory factor analysis, produced a stable three-dimensional scale. Convergent validity assessment produced positive, moderate, and statistically significant correlations of the tool sub-scales with two existing instruments. Internal consistency reliability was assessed for each subscale (self-confidence, α = .97; anxiety, α = .96). The NASC-CDM scale may be a useful assessment tool for nurse educators to help novice clinicians improve CDM skills.

  10. A collaborative teaching strategy for enhancing learning of evidence-based clinical decision-making.

    PubMed

    Scott, P J; Altenburger, P A; Kean, J

    2011-01-01

    The educational literature cites a lack of student motivation to learn how to use research evidence in clinical decision-making because the students do not observe clinicians using evidence. This lack of motivation presents a challenge to educators as they seek to instill the value of evidence-based clinical decision-making (EBCD) in students. One problem is that students in entry-level programs do not have the experience needed to know what to look for, and secondly, clinical decision-making is contextually based in a patient problem. Our approach offers one solution to bridging the gap between classroom teaching and real-world implementation of EBCD through a three-phase collaborative approach. Occupational and physical therapy students are partnered with clinicians to find and appraise evidence to answer the real-world questions posed by these therapists. This paper describes the implementation of the partnership, teaching/learning outcomes, logistics, and implications for clinicians. We found this approach increased student motivation and greatly enhanced the learning experience. Future directions include implementing a framework which allows for the assessment of the strategy on the facility and creates opportunities to integrate the use of EBCD in all aspects of facility practice.

  11. Can a patient smart card improve decision making in a clinical setting?.

    PubMed

    Bérubé, J; Papillon, M J; Lavoie, G; Durant, P; Fortin, J P

    1995-01-01

    In the health field, clinical information is the raw material for the clinician delivering health services. Therefore, the clinical information available to the physician is often incomplete or even non¿existent upon consultation. Furthermore, the reconstruction of the medical history, which is the most important source of data for the clinician to establish a diagnosis and initiate a treatment, suffers from many constraints. The smart card, like the one used in Quebec's project, could ease the physician's decision-making by allowing fast access to accurate and pertinent data. The smart card is a major asset in the present health system.

  12. A programmable rules engine to provide clinical decision support using HTML forms.

    PubMed

    Heusinkveld, J; Geissbuhler, A; Sheshelidze, D; Miller, R

    1999-01-01

    The authors have developed a simple method for specifying rules to be applied to information on HTML forms. This approach allows clinical experts, who lack the programming expertise needed to write CGI scripts, to construct and maintain domain-specific knowledge and ordering capabilities within WizOrder, the order-entry and decision support system used at Vanderbilt Hospital. The clinical knowledge base maintainers use HTML editors to create forms and spreadsheet programs for rule entry. A test environment has been developed which uses Netscape to display forms; the production environment displays forms using an embedded browser.

  13. Governance for clinical decision support: case studies and recommended practices from leading institutions

    PubMed Central

    Sittig, Dean F; Ash, Joan S; Bates, David W; Feblowitz, Joshua; Fraser, Greg; Maviglia, Saverio M; McMullen, Carmit; Nichol, W Paul; Pang, Justine E; Starmer, Jack; Middleton, Blackford

    2011-01-01

    Objective Clinical decision support (CDS) is a powerful tool for improving healthcare quality and ensuring patient safety; however, effective implementation of CDS requires effective clinical and technical governance structures. The authors sought to determine the range and variety of these governance structures and identify a set of recommended practices through observational study. Design Three site visits were conducted at institutions across the USA to learn about CDS capabilities and processes from clinical, technical, and organizational perspectives. Based on the results of these visits, written questionnaires were sent to the three institutions visited and two additional sites. Together, these five organizations encompass a variety of academic and community hospitals as well as small and large ambulatory practices. These organizations use both commercially available and internally developed clinical information systems. Measurements Characteristics of clinical information systems and CDS systems used at each site as well as governance structures and content management approaches were identified through extensive field interviews and follow-up surveys. Results Six recommended practices were identified in the area of governance, and four were identified in the area of content management. Key similarities and differences between the organizations studied were also highlighted. Conclusion Each of the five sites studied contributed to the recommended practices presented in this paper for CDS governance. Since these strategies appear to be useful at a diverse range of institutions, they should be considered by any future implementers of decision support. PMID:21252052

  14. Organisational factors affecting the quality of hospital clinical coding.

    PubMed

    Santos, Suong; Murphy, Gregory; Baxter, Kathryn; Robinson, Kerin M

    2008-01-01

    The influence of organisational factors on the quality of hospital coding using the International Statistical Classification of Diseases and Health Related Problems, 10th Revision, Australian Modification (ICD-10-AM) was investigated using a mixed quantitative-qualitative approach. The organisational variables studied were: hospital specialty; geographical locality; structural characteristics of the coding unit; education, training and resource supports for Clinical Coders; and quality control mechanisms. Baseline data on the hospitals' coding quality, measured by the Performance Indicators for Coding Quality tool, were used as an independent index measure. No differences were found in error rates between rural and metropolitan hospitals, or general and specialist hospitals. Clinical Coder allocation to "general" rather than "specialist" unit coding resulted in fewer errors. Coding Managers reported that coding quality can be improved by: Coders engaging in a variety of role behaviours; improved Coder career opportunities; higher staffing levels; reduced throughput; fewer time constraints on coding outputs and associated work; and increased Coder interactions with medical staff.

  15. Curvature affects Doppler investigation of vessels: implications for clinical practice.

    PubMed

    Balbis, S; Roatta, S; Guiot, C

    2005-01-01

    In clinical practice, blood velocity estimations from Doppler examination of curved vascular segments are normally different from those of nearby straight segments. The observed "accelerations," sometimes considered as a sort of stochastic disturbances, can actually be related to very specific physical effects due to vessel curvature (i.e., the development of nonaxial velocity [NAV] components) and the spreading of the axial velocity direction in the Doppler sample volume with respect to the insonation axis. The relevant phenomena and their dependence on the radius of curvature of the vessels and on the insonation angle are investigated with a beam-vessel geometry as close as possible to clinical setting, with the simplifying assumptions of steady flow, mild vessel curvature, uniform ultrasonic beam and complete vessel insonation. The insonation angles that minimize the errors are provided on the basis of the study results.

  16. Usability evaluation of a clinical decision support tool for osteoporosis disease management

    PubMed Central

    2010-01-01

    Background Osteoporosis affects over 200 million people worldwide at a high cost to healthcare systems. Although guidelines are available, patients are not receiving appropriate diagnostic testing or treatment. Findings from a systematic review of osteoporosis interventions and a series of focus groups were used to develop a functional multifaceted tool that can support clinical decision-making in osteoporosis disease management at the point of care. The objective of our study was to assess how well the prototype met functional goals and usability needs. Methods We conducted a usability study for each component of the tool--the Best Practice Recommendation Prompt (BestPROMPT), the Risk Assessment Questionnaire (RAQ), and the Customised Osteoporosis Education (COPE) sheet--using the framework described by Kushniruk and Patel. All studies consisted of one-on-one sessions with a moderator using a standardised worksheet. Sessions were audio- and video-taped and transcribed verbatim. Data analysis consisted of a combination of qualitative and quantitative analyses. Results In study 1, physicians liked that the BestPROMPT can provide customised recommendations based on risk factors identified from the RAQ. Barriers included lack of time to use the tool, the need to alter clinic workflow to enable point-of-care use, and that the tool may disrupt the real reason for the visit. In study 2, patients completed the RAQ in a mean of 6 minutes, 35 seconds. Of the 42 critical incidents, 60% were navigational and most occurred when the first nine participants were using the stylus pen; no critical incidents were observed with the last six participants that used the touch screen. Patients thought that the RAQ questions were easy to read and understand, but they found it difficult to initiate the questionnaire. Suggestions for improvement included improving aspects of the interface and navigation. The results of study 3 showed that most patients were able to understand and describe

  17. Advances In Infection Surveillance and Clinical Decision Support With Fuzzy Sets and Fuzzy Logic.

    PubMed

    Koller, Walter; de Bruin, Jeroen S; Rappelsberger, Andrea; Adlassnig, Klaus-Peter

    2015-01-01

    By the use of extended intelligent information technology tools for fully automated healthcare-associated infection (HAI) surveillance, clinicians can be informed and alerted about the emergence of infection-related conditions in their patients. Moni--a system for monitoring nosocomial infections in intensive care units for adult and neonatal patients--employs knowledge bases that were written with extensive use of fuzzy sets and fuzzy logic, allowing the inherent un-sharpness of clinical terms and the inherent uncertainty of clinical conclusions to be a part of Moni's output. Thus, linguistic as well as propositional uncertainty became a part of Moni, which can now report retrospectively on HAIs according to traditional crisp HAI surveillance definitions, as well as support clinical bedside work by more complex crisp and fuzzy alerts and reminders. This improved approach can bridge the gap between classical retrospective surveillance of HAIs and ongoing prospective clinical-decision-oriented HAI support.

  18. A First Step towards a Clinical Decision Support System for Post-traumatic Stress Disorders

    PubMed Central

    Ma, Sisi; Galatzer-Levy, Isaac R; Wang, Xuya; Fenyö, David; Shalev, Arieh Y

    2016-01-01

    PTSD is distressful and debilitating, following a non-remitting course in about 10% to 20% of trauma survivors. Numerous risk indicators of PTSD have been identified, but individual level prediction remains elusive. As an effort to bridge the gap between scientific discovery and practical application, we designed and implemented a clinical decision support pipeline to provide clinically relevant recommendation for trauma survivors. To meet the specific challenge of early prediction, this work uses data obtained within ten days of a traumatic event. The pipeline creates personalized predictive model for each individual, and computes quality metrics for each predictive model. Clinical recommendations are made based on both the prediction of the model and its quality, thus avoiding making potentially detrimental recommendations based on insufficient information or suboptimal model. The current pipeline outperforms the acute stress disorder, a commonly used clinical risk factor for PTSD development, both in terms of sensitivity and specificity. PMID:28269880

  19. Engineering of a clinical decision support framework for the point of care use.

    PubMed

    Wilk, Szymon; Michalowski, Wojtek; O'Sullivan, Dympna; Farion, Ken; Matwin, Stan

    2008-11-06

    Computerized decision support for use at the point of care has to be comprehensive. It means that clinical information stored in electronic health records needs to be integrated with various forms of clinical knowledge (elicited from experts, discovered from data or summarized in systematic reviews of clinical trials). In order to provide such comprehensive support we created the MET-A3Support framework for constructing clinical applications aimed at various medical conditions. We employed the multiagent system paradigm and the O-MaSE methodology to define an engineering process involving three main activities: requirements engineering, analysis and design. Then we applied the process to build MET-A3Support. The paper describes the engineering process and its results, including models representing selected elements of our framework.

  20. Physician Attitudes toward Adopting Genome-Guided Prescribing through Clinical Decision Support.

    PubMed

    Overby, Casey Lynnette; Erwin, Angelika Ludtke; Abul-Husn, Noura S; Ellis, Stephen B; Scott, Stuart A; Obeng, Aniwaa Owusu; Kannry, Joseph L; Hripcsak, George; Bottinger, Erwin P; Gottesman, Omri

    2014-02-27

    This study assessed physician attitudes toward adopting genome-guided prescribing through clinical decision support (CDS), prior to enlisting in the Clinical Implementation of Personalized Medicine through Electronic Health Records and Genomics pilot pharmacogenomics project (CLIPMERGE PGx). We developed a survey instrument that includes the Evidence Based Practice Attitude Scale, adapted to measure attitudes toward adopting genome-informed interventions (EBPAS-GII). The survey also includes items to measure physicians' characteristics (awareness, experience, and perceived usefulness), attitudes about personal genome testing (PGT) services, and comfort using technology. We surveyed 101 General Internal Medicine physicians from the Icahn School of Medicine at Mount Sinai (ISMMS). The majority were residency program trainees (~88%). Prior to enlisting into CLIPMERGE PGx, most physicians were aware of and had used decision support aids. Few physicians, however, were aware of and had used genome-guided prescribing. The majority of physicians viewed decision support aids and genotype data as being useful for making prescribing decisions. Most physicians had not heard of, but were willing to use, PGT services and felt comfortable interpreting PGT results. Most physicians were comfortable with technology. Physicians who perceived genotype data to be useful in making prescribing decisions, had more positive attitudes toward adopting genome-guided prescribing through CDS. Our findings suggest that internal medicine physicians have a deficit in their familiarity and comfort interpreting and using genomic information. This has reinforced the importance of gathering feedback and guidance from our enrolled physicians when designing genome-guided CDS and the importance of prioritizing genomic medicine education at our institutions.

  1. Reproductive Ethics in Commercial Surrogacy: Decision-Making in IVF Clinics in New Delhi, India.

    PubMed

    Tanderup, Malene; Reddy, Sunita; Patel, Tulsi; Nielsen, Birgitte Bruun

    2015-09-01

    As a neo-liberal economy, India has become one of the new health tourism destinations, with commercial gestational surrogacy as an expanding market. Yet the Indian Assisted Reproductive Technology (ART) Bill has been pending for five years, and the guidelines issued by the Indian Council of Medical Research are somewhat vague and contradictory, resulting in self-regulated practices of fertility clinics. This paper broadly looks at clinical ethics in reproduction in the practice of surrogacy and decision-making in various procedures. Through empirical research in New Delhi, the capital of India, from December 2011 to November 2012, issues of decision-making on embryo transfer, fetal reduction, and mode of delivery were identified. Interviews were carried out with doctors in eighteen ART clinics, agents from four agencies, and fourteen surrogates. In aiming to fulfil the commissioning parents' demands, doctors were willing to go to the greatest extent possible in their medical practice. Autonomy and decision-making regarding choice of the number of embryos to transfer and the mode of delivery lay neither with commissioning parents nor surrogate mothers but mostly with doctors. In order to ensure higher success rates, surrogates faced the risk of multiple pregnancy and fetal reduction with little information regarding the risks involved. In the globalized market of commercial surrogacy in India, and with clinics compromising on ethics, there is an urgent need for formulation of regulative law for the clinical practice and maintenance of principles of reproductive ethics in order to ensure that the interests of surrogate mothers are safeguarded.

  2. [Visual presentation of psychiatric clinical decision-making by "graphic assessment sheet for diagnoses and treatments"].

    PubMed

    Ota, Toshio; Yoshida, Sumiko; Tsunashima, Sousuke; Totsuka, Takao; Watanabe, Takafumi; Toyoshima, Ryoichi

    2011-01-01

    Psychiatrists often have to treat patients even when the clinical information is insufficient to make a definite diagnosis. This is the case especially when we are treating first-visit outpatients or inpatients who have just been admitted. One of the causes of information insufficiency is a delay in obtaining clinical information on the patient, and another is a lack of characteristic manifestations of the disease because of an immature developmental stage. Even in such situations, however, clinicians have to make reasonable judgements using the information that is available at that time. The framework for making judgements on such occasions, or "the framework of decision-making under imperfect-information conditions", is becoming more and more important in psychiatric clinical practice in Japan for the following reasons. First, team members in charge of a patient became very heterogeneous in terms of their career and motivation after the start of the new post-graduate clinical training system in Japan several years ago, resulting in a higher risk of miscommunication. Secondly, the need for precise explanation to patients and their families has become crucial in recent years as the result of various social changes. Ota T, one of the authors, once put forward the framework of decision-making under imperfect-information conditions on the basis of Bayesian statistics. In the present paper, in consideration of the above background, we devised a sheet for visualizing the above framework so that relevant staff could share the clinical decision-making process. Specifically, we visually arranged on a sheet of paper the components and variables of the framework, so that the staff could communicate with each other explicitly and precisely about the estimated probability of each possible disease, merits and demerits of each treatment option, etc. We employed the sheet on treating patients in our acute psychiatric ward, 2 of whom are presented in the paper. Discussions were

  3. Enabling health care decisionmaking through clinical decision support and knowledge management.

    PubMed Central

    Lobach, David; Sanders, Gillian D; Bright, Tiffani J; Wong, Anthony; Dhurjati, Ravi; Bristow, Erin; Bastian, Lori; Coeytaux, Remy; Samsa, Gregory; Hasselblad, Vic; Williams, John W; Wing, Liz; Musty, Michael; Kendrick, Amy S

    2012-01-01

    OBJECTIVES To catalogue study designs used to assess the clinical effectiveness of CDSSs and KMSs, to identify features that impact the success of CDSSs/KMSs, to document the impact of CDSSs/KMSs on outcomes, and to identify knowledge types that can be integrated into CDSSs/KMSs. DATA SOURCES MEDLINE(®), CINAHL(®), PsycINFO(®), and Web of Science(®). REVIEW METHODS We included studies published in English from January 1976 through December 2010. After screening titles and abstracts, full-text versions of articles were reviewed by two independent reviewers. Included articles were abstracted to evidence tables by two reviewers. Meta-analyses were performed for seven domains in which sufficient studies with common outcomes were included. RESULTS We identified 15,176 articles, from which 323 articles describing 311 unique studies including 160 reports on 148 randomized control trials (RCTs) were selected for inclusion. RCTs comprised 47.5 percent of the comparative studies on CDSSs/KMSs. Both commercially and locally developed CDSSs effectively improved health care process measures related to performing preventive services (n = 25; OR 1.42, 95% confidence interval [CI] 1.27 to 1.58), ordering clinical studies (n = 20; OR 1.72, 95% CI 1.47 to 2.00), and prescribing therapies (n = 46; OR 1.57, 95% CI 1.35 to 1.82). Fourteen CDSS/KMS features were assessed for correlation with success of CDSSs/KMSs across all endpoints. Meta-analyses identified six new success features: Integration with charting or order entry system. Promotion of action rather than inaction. No need for additional clinician data entry. Justification of decision support via research evidence. Local user involvement. Provision of decision support results to patients as well as providers. Three previously identified success features were confirmed: Automatic provision of decision support as part of clinician workflow. Provision of decision support at time and location of decisionmaking. Provision of a

  4. Analysis on factors affecting household customers decision in using electricity at peak time and its correlation towards saving electricity

    NASA Astrophysics Data System (ADS)

    Pasasa, Linus; Marbun, Parlin; Mariza, Ita

    2015-09-01

    The purpose of this paper is to study and analyse the factors affecting customer decisions in using electricity at peak-load hours (between 17.00 to 22.00 WIB) and their behaviors towards electricity conservation in Indonesian household. The underlying rationale is to influence a reduction in energy consumption by stimulating energy saving behaviors, thereby reducing the impact of energy use on the environment. How is the correlation between the decisions in using electricity during peak load hours with the household customer's behavior towards saving electricity? The primary data is obtained by distributing questionnaires to customers of PT. PLN Jakarta Raya and Tangerang Distribution from Household segment. The data is analysed using the Structural Equation Model (SEM) and AMOS Software. The research is finding that all factors (Personal, Social, PLN Services, Psychological, and Cultural) are positively influence customer decision in using electricity at peak load hours. There is a correlation between the decisions in using electricity during peak load hours with the household customer's behavior towards saving electricity.

  5. How mechanisms of perceptual decision-making affect the psychometric function.

    PubMed

    Gold, Joshua I; Ding, Long

    2013-04-01

    Psychometric functions are often interpreted in the context of Signal Detection Theory, which emphasizes a distinction between sensory processing and non-sensory decision rules in the brain. This framework has helped to relate perceptual sensitivity to the "neurometric" sensitivity of sensory-driven neural activity. However, perceptual sensitivity, as interpreted via Signal Detection Theory, is based on not just how the brain represents relevant sensory information, but also how that information is read out to form the decision variable to which the decision rule is applied. Here we discuss recent advances in our understanding of this readout process and describe its effects on the psychometric function. In particular, we show that particular aspects of the readout process can have specific, identifiable effects on the threshold, slope, upper asymptote, time dependence, and choice dependence of psychometric functions. To illustrate these points, we emphasize studies of perceptual learning that have identified changes in the readout process that can lead to changes in these aspects of the psychometric function. We also discuss methods that have been used to distinguish contributions of the sensory representation versus its readout to psychophysical performance.

  6. Feminization of pheromone-sensing neurons affects mating decisions in Drosophila males.

    PubMed

    Lu, Beika; Zelle, Kathleen M; Seltzer, Raya; Hefetz, Abraham; Ben-Shahar, Yehuda

    2014-02-15

    The response of individual animals to mating signals depends on the sexual identity of the individual and the genetics of the mating targets, which represent the mating social context (social environment). However, how social signals are sensed and integrated during mating decisions remains a mystery. One of the models for understanding mating behaviors in molecular and cellular terms is the male courtship ritual in the fruit fly (Drosophila melanogaster). We have recently shown that a subset of gustatory receptor neurons (GRNs) that are enriched in the male appendages and express the ion channel ppk23 play a major role in the initiation and maintenance of male courtship via the perception of cuticular contact pheromones, and are likely to represent the main chemosensory pathway that influences mating decisions by males. Here we show that genetic feminization of ppk23-expressing GRNs in male flies resulted in a significant increase in male-male sexual attraction without an apparent impact on sexual attraction to females. Furthermore, we show that this increase in male-male sexual attraction is sensory specific, which can be modulated by variable social contexts. Finally, we show that feminization of ppk23-expressing sensory neurons lead to major transcriptional shifts, which may explain the altered interpretation of the social environment by feminized males. Together, these data indicate that the sexual cellular identity of pheromone sensing GRNs plays a major role in how individual flies interpret their social environment in the context of mating decisions.

  7. Development of EBM-CDSS (Evidence-Based Clinical Decision Support System) to AIG Prognostication in Terminally Ill Patients

    DTIC Science & Technology

    2016-03-01

    1 Award Number: W81-XWH-09-2-0175 TITLE: Development of EBM-CDSS (Evidence-Based Clinical Decision Support System) to AIG Prognostication in...From - To) 25Sep2009 - 31Dec2015 4. TITLE AND SUBTITLE Development of EBM-CDSS (Evidence-Based Clinical Decision Support System) to AIG Prognostication...health.usf.edu 4 14. ABSTRACT Goal of the project is to develop an Evidence-based Clinical Decision Support (CDSS-EBM) system and make it available at the point

  8. Clinical Decision Velocity is Increased when Meta-search Filters Enhance an Evidence Retrieval System

    PubMed Central

    Coiera, Enrico; Westbrook, Johanna I.; Rogers, Kris

    2008-01-01

    Objective To test whether the use of an evidence retrieval system that uses clinically targeted meta-search filters can enhance the rate at which clinicians make correct decisions, reduce the effort involved in locating evidence, and provide an intuitive match between clinical tasks and search filters. Design A laboratory experiment under controlled conditions asked 75 clinicians to answer eight randomly sequenced clinical questions, using one of two randomly assigned search engines. The first search engine Quick Clinical (QC) was equipped with meta-search filters (the combined use of meta-search and search filters) designed to answer typical clinical questions e.g., treatment, diagnosis, and the second ‘library model’ system (LM) offered free access to an identical evidence set with no filter support. Measurements Changes in clinical decision making were measured by the proportion of correct post-search answers provided to questions, the time taken to answer questions, and the number of searches and links to documents followed in a search session. The intuitive match between meta-search filters and clinical tasks was measured by the proportion and distribution of filters selected for individual clinical questions. Results Clinicians in the two groups performed equally well pre-search. Post search answers improved overall by 21%, with 52.2% of answers correct with QC and 54.7% with LM (χ2 = 0.33, df = 1, p > 0.05). Users of QC obtained a significantly greater percentage of their correct answers within the first two minutes of searching compared to LM users (QC 58.2%; LM 32.9%; χ2 = 19.203, df = 1, p < 0.001). There was a statistical difference for QC and LM survival curves, which plotted overall time to answer questions, irrespective of answer (Wilcoxon, p = 0.019) and for the average time to provide a correct answer (Wilcoxon, p = 0.006). The QC system users conducted significantly fewer searches per scenario (m = 3.0 SD = 1.15 versus m = 5.5 SD1.97, t = 6

  9. Interoperability of clinical decision-support systems and electronic health records using archetypes: a case study in clinical trial eligibility.

    PubMed

    Marcos, Mar; Maldonado, Jose A; Martínez-Salvador, Begoña; Boscá, Diego; Robles, Montserrat

    2013-08-01

    Clinical decision-support systems (CDSSs) comprise systems as diverse as sophisticated platforms to store and manage clinical data, tools to alert clinicians of problematic situations, or decision-making tools to assist clinicians. Irrespective of the kind of decision-support task CDSSs should be smoothly integrated within the clinical information system, interacting with other components, in particular with the electronic health record (EHR). However, despite decades of developments, most CDSSs lack interoperability features. We deal with the interoperability problem of CDSSs and EHRs by exploiting the dual-model methodology. This methodology distinguishes a reference model and archetypes. A reference model is represented by a stable and small object-oriented model that describes the generic properties of health record information. For their part, archetypes are reusable and domain-specific definitions of clinical concepts in the form of structured and constrained combinations of the entities of the reference model. We rely on archetypes to make the CDSS compatible with EHRs from different institutions. Concretely, we use archetypes for modelling the clinical concepts that the CDSS requires, in conjunction with a series of knowledge-intensive mappings relating the archetypes to the data sources (EHR and/or other archetypes) they depend on. We introduce a comprehensive approach, including a set of tools as well as methodological guidelines, to deal with the interoperability of CDSSs and EHRs based on archetypes. Archetypes are used to build a conceptual layer of the kind of a virtual health record (VHR) over the EHR whose contents need to be integrated and used in the CDSS, associating them with structural and terminology-based semantics. Subsequently, the archetypes are mapped to the EHR by means of an expressive mapping language and specific-purpose tools. We also describe a case study where the tools and methodology have been employed in a CDSS to support

  10. A survey of the perceptions and behaviors of chiropractic interns pertaining to evidence-based principles in clinical decision making

    PubMed Central

    Dane, Dawn E.; Dane, Andrew B.; Crowther, Edward R.

    2016-01-01

    Objective: This study explored how chiropractic interns applied evidenced-based concepts, the sources of evidence they used, and how useful they perceived these sources to be in clinical decision making. Methods: A questionnaire containing 13 items in a Likert 5-point scale was administered to 28 chiropractic interns to gather information on the evidence types they commonly accessed and their perceived usefulness of these sources in clinical decision making. The interns were in the 8th semester of the training program. Results: There was a 93% (n = 26) response rate. Clinical guidelines were rated as the most helpful resource in clinical decision making (81%), followed by lecture materials (77%), journals (54%), databases (50%), and textbooks (35%). Students recognized scientific evidence as the most important aspect in clinical decision making. They found their personal experience and the views of their clinician to be equally important and patient preference the least. Conclusion: Interns routinely employed high-quality levels of evidence in clinical decision making. They also considered their early, limited clinical experience as important as that of their clinical supervisor in decision making. This finding should be investigated further. PMID:27389528

  11. Is there a "magic" hemoglobin number? Clinical decision support promoting restrictive blood transfusion practices.

    PubMed

    Goodnough, Lawrence Tim; Shah, Neil

    2015-10-01

    Blood transfusion has been identified as one of the most frequently performed therapeutic procedures, with a significant percentage of transfusions identified to be inappropriate. Recent key clinical trials in adults have provided Level 1 evidence to support restrictive red blood cell (RBC) transfusion practices. However, some advocates have attempted to identify a "correct" Hb threshold for RBC transfusion; whereas others assert that management of anemia, including transfusion decisions, must take into account clinical patient variables, rather than simply one diagnostic laboratory test. The heterogeneity of guidelines for blood transfusion by a number of medical societies reflects this controversy. Clinical decision support (CDS) uses a Hb threshold number in a smart Best Practices Alert (BPA) upon physician order, to trigger a concurrent utilization self-review for whether blood transfusion therapy is appropriate. This review summarizes Level 1 evidence in seven key clinical trials in adults that support restrictive transfusion practices, along strategies made possible by CDS that have demonstrated value in improving blood utilization by promoting restrictive transfusion practices.

  12. Trail Blazing or Jam Session? Towards a New Concept of Clinical Decision-making.

    PubMed

    Risør, Torsten

    2016-11-17

    Clinical decision-making (CDM) is key in learning to be a doctor as the defining activity in their clinical work. CDM is often portrayed in the literature as similar to 'trail blazing'; the doctor as the core agent, clearing away obstacles on the path towards diagnosis and treatment. However, in a fieldwork of young doctors in Denmark, it was difficult connect their practice to this image. This paper presents the exploration of this discrepancy in the heart of medical practice and how an alternative image emerged; that of a 'jam session'. The exploration is represented as a case-based hypothesis-testing: first, a theoretically and empirically informed hypothesis (H0) of how doctors perform CDM is developed. In H0, CDM is a stepwise process of reasoning about clinical data, often influenced by outside contextual factors. Then, H0 is tested against a case from ethnographic fieldwork with doctors going through internship. Although the case is chosen for characteristics that make it 'most likely' to verify the hypothesis, verification proves difficult. The case challenges preconceptions in CDM literature about chronology, context, objectivity, cognition, agency, and practice. The young doctor is found not to make decisions, but rather to participate in CDM; an activity akin to the dynamics found in a jam session. Their participation circles in and through four concurrent interrelated constructions that suggest a new conceptualization of CDM; a starting point for a deeper understanding of actual practice in a changing clinical environment.

  13. The integration of surface electromyography in the clinical decision making process: a case report

    PubMed Central

    Nicholson, W Reg

    1998-01-01

    Objective: To demonstrate how the findings of surface electromyography (S.E.M.G.) were integrated into the clinical decision-making process. Clinical Features: This is a retrospective review of the file of a 27-year-old male suffering from mechanical low back pain. He was evaluated on 3 separate occasions over a 3 year period. History, radiography, functional outcome studies, visual-numerical pain score, pain drawing, physical examination and surface electromyography were utilized in evaluating this patient. Intervention and Outcome: The two clinical interventions of spinal manipulative therapy (S.M.T.) had positive results in that the patient achieved an asymptomatic state and returned to his position of employment. The S.E.M.G. data collected during the industrial assessment, did not provide the outcome that the patient had anticipated. Conclusion: Surface electromyography is a useful clinical tool in the author’s decision-making process for the treatment of mechanical lower back pain. Therapeutic intervention by S.M.T., therapeutic exercises and rating risk factors were influenced by the S.E.M.G. findings.

  14. The role of analogy-guided learning experiences in enhancing students' clinical decision-making skills.

    PubMed

    Edelen, Bonnie Gilbert; Bell, Alexandra Alice

    2011-08-01

    The purpose of this study was to address the need for effective educational interventions to promote students' clinical decision making (CDM) within clinical practice environments. Researchers used a quasi-experimental, non-equivalent groups, posttest-only design to assess differences in CDM ability between intervention group students who participated in analogy-guided learning activities and control group students who participated in traditional activities. For the intervention, analogy-guided learning activities were incorporated into weekly group discussions, reflective journal writing, and questioning with clinical faculty. The researcher-designed Assessment of Clinical Decision Making Rubric was used to assess indicators of CDM ability in all students' reflective journal entries. Results indicated that the intervention group demonstrated significantly higher levels of CDM ability in their journals compared with the control group (ES(sm) = 0.52). Recommendations provide nurse educators with strategies to maximize students' development of CDM ability, better preparing students for the demands they face when they enter the profession.

  15. Clinical assessment of decision-making capacity in acquired brain injury with personality change

    PubMed Central

    Owen, Gareth S.; Freyenhagen, Fabian; Martin, Wayne; David, Anthony S.

    2017-01-01

    Assessment of decision-making capacity (DMC) can be difficult in acquired brain injury (ABI) particularly with the syndrome of organic personality disorder (OPD) (the “frontal lobe syndrome”). Clinical neuroscience may help but there are challenges translating its constructs to the decision-making abilities considered relevant by law and ethics. An in-depth interview study of DMC in OPD was undertaken. Six patients were purposefully sampled and rich interview data were acquired for scrutiny using interpretative phenomenological analysis. Interview data revealed that awareness of deficit and thinking about psychological states can be present. However, the awareness of deficit may not be “online” and effectively integrated into decision-making. Without this online awareness of deficit the ability to appreciate or use and weigh information in the process of deciding some matters appeared absent. We argue that the decision-making abilities discussed are: (1) necessary for DMC, (2) threatened by ABI , and (3) assessable at interview. Some advice for practically incorporating these abilities within assessments of DMC in patients with OPD is outlined. PMID:26088818

  16. [Human body meridian spatial decision support system for clinical treatment and teaching of acupuncture and moxibustion].

    PubMed

    Wu, Dehua

    2016-01-01

    The spatial position and distribution of human body meridian are expressed limitedly in the decision support system (DSS) of acupuncture and moxibustion at present, which leads to the failure to give the effective quantitative analysis on the spatial range and the difficulty for the decision-maker to provide a realistic spatial decision environment. Focusing on the limit spatial expression in DSS of acupuncture and moxibustion, it was proposed that on the basis of the geographic information system, in association of DSS technology, the design idea was developed on the human body meridian spatial DSS. With the 4-layer service-oriented architecture adopted, the data center integrated development platform was taken as the system development environment. The hierarchical organization was done for the spatial data of human body meridian via the directory tree. The structured query language (SQL) server was used to achieve the unified management of spatial data and attribute data. The technologies of architecture, configuration and plug-in development model were integrated to achieve the data inquiry, buffer analysis and program evaluation of the human body meridian spatial DSS. The research results show that the human body meridian spatial DSS could reflect realistically the spatial characteristics of the spatial position and distribution of human body meridian and met the constantly changeable demand of users. It has the powerful spatial analysis function and assists with the scientific decision in clinical treatment and teaching of acupuncture and moxibustion. It is the new attempt to the informatization research of human body meridian.

  17. Does Coxiella burnetii affect reproduction in cattle? A clinical update.

    PubMed

    Garcia-Ispierto, I; Tutusaus, J; López-Gatius, F

    2014-08-01

    Q fever is a zoonosis produced by Coxiella burnetii, a bacterium that is widely distributed worldwide. Domestic ruminants are the most important source of C. burnetii for human infection. In sheep and goats, abortion is the main clinical consequence of infection, yet the symptoms described in cattle have so far been inconsistent. Q fever has been also scarcely reported in cattle, most likely because of its difficult diagnosis at the farm level and because of the many existing responsible C. burnetii strains. In this report, the effects of C. burnetii infection or Q fever disease on the reproductive behaviour of dairy cattle are reviewed, with special emphasis placed on the scarcity of data available and possible control actions discussed.

  18. [Seasonal affective syndrome and phototherapy: theoretical concepts and clinical applications].

    PubMed

    Sartori, S; Poirrier, R

    1996-01-01

    Since 1984, there has been a great interest in the phenomenon of a particular seasonally recurrent mood disorder called seasonal affective disorder (SAD) or winter depression and its treatment: the phototherapy. Seasonal affective disorder is a syndrome described by Rosenthal in 1984. This mood disorder is characterized by depression with onset recurrent in autumn or winter and spontaneous spring or summer remission. It is associated with hypersomnia, anergia, increased appetite, weight gain and carbohydrate craving. The population prevalence in the north of the USA is estimated between 3 and 5%, but it changes with sex, age and also latitude. A long time ago, we know that animals are photoperiod sensitive and that the melatonin secretion in mammals is suppressed by the light. In 1980, Czeiler reported for the first time that human melatonin secretion can be suppressed by high light exposure (+/- 1500 lux). In 1982, Rosenthal, Lewy and al. reported an antidepressant effect of light exposure of a manic-depressive patient. The phototherapy was born. To treat the SAD, the most common procedure of phototherapy is to expose the subject during 2 hours early in the morning, between 06:00 and 09:00 AM. The subject is sitting before a light screen, he can work and has to fix the screen one time every minute. The most common side effects are headache, eyestrain, muscle pain. The ocular phototoxicity is controversed and it seems to be potentially dangerous if phototherapy is associated with tricyclic antidepressants, neuroleptics and other medication containing a tricyclic, heterocyclic or porphyrin ring system. Since this finding, many questions are asked about photoperiod and its effects in the human being. Lewy proposes for the winter depression the hypothesis of a phase delayed circadian rhythm, that can be treated by a morning light exposure. At the present time, many trials are going on to study the effects of phototherapy in other problems like insomnia, maladaptation

  19. The effects of specific educational preparation on emergency nurses' clinical decisions regarding supplemental oxygen administration.

    PubMed

    Considine, Julie; Botti, Mari; Thomas, Shane

    2006-06-01

    The use of supplemental oxygen by emergency nurses has important implications for patient outcomes, yet there is significant variability in oxygen administration practises. Specific education related to oxygen administration increases factual knowledge in this domain; however, the impact of knowledge acquisition on nurses' clinical decisions is poorly understood. This study aimed to examine the effect of educational preparation on 20 emergency nurses' decisions regarding the assessment of oxygenation and the use of supplemental oxygen. A pre-test/post-test, quasi-experimental design was used. The intervention was a written, self-directed learning package. The major effects of the completion of the learning package included no change in the number or types of parameters used by nurses to assess oxygenation, a significant decrease in the selection of simple masks, a significant increase in the selection of air entrainment masks, fewer hypothetical outcomes of unresolved respiratory distress and more hypothetical outcomes of decreased respiratory distress. As many nursing education programs are aimed at increasing factual knowledge, while experience remains relatively constant, a greater understanding of the relationship between factual knowledge and clinical decisions is needed if educational interventions are to improve patient outcomes.

  20. Clinical Decisions: Determining When to Save or Remove an Ailing Implant.

    PubMed

    Tarnow, Dennis P; Chu, Stephen J; Fletcher, Paul D

    2016-04-01

    The basis for the decision to either save or remove an ailing implant is multifactorial, and, as such, it has become one of the more controversial topics in the field of dental implantology. While bone lost to peri-implant disease can now be augmented with increasing predictability, the degree of success still varies depending on the size and configuration of the osseous defect. Concurrently, with the development of improved high-reverse torque instrumentation, minimally invasive techniques can be used to easily remove an implant that is malpositioned, causing an esthetic problem, or showing advanced bone loss. Any eventual decision regarding the retention or removal of an ailing implant must also be balanced with the desires of the patient, who typically will have already invested significant time and money to have the implant initially placed and restored. This article will present the variables involved in the decision-making process for when to save or remove an ailing implant. Clinical examples illustrating the management for these factors will be offered, providing clinicians a variety of alternatives available for managing different clinical circumstances that may be encountered.

  1. Implementation of a clinical decision support system using a service model: results of a feasibility study.

    PubMed

    Borbolla, Damian; Otero, Carlos; Lobach, David F; Kawamoto, Kensaku; Gomez Saldaño, Ana M; Staccia, Gustavo; Lopez, Gastón; Figar, Silvana; Luna, Daniel; Bernaldo de Quiros, Fernan Gonzalez

    2010-01-01

    Numerous studies have shown that the quality of health care is inadequate, and healthcare organizations are increasingly turning to clinical decision support systems (CDSS) to address this problem. In implementing CDSS, a highly promising architectural approach is the use of decision support services. However, there are few reported examples of successful implementations of operational CDSS using this approach. Here, we describe how Hospital Italiano de Buenos Aires evaluated the feasibility of using the SEBASTIAN clinical decision support Web service to implement a CDSS integrated with its electronic medical record system. The feasibility study consisted of three stages: first, end-user acceptability testing of the proposed CDSS through focus groups; second, the design and implementation of the system through integration of SEBASTIAN and the authoring of new rules; and finally, validation of system performance and accuracy. Through this study, we found that it is feasible to implement CDSS using a service-based approach. The CDSS is now under evaluation in a randomized controlled trial. The processes and lessons learned from this initiative are discussed.

  2. Client Preferences Affect Treatment Satisfaction, Completion, and Clinical Outcome: A Meta-Analysis

    PubMed Central

    Lindhiem, Oliver; Bennett, Charles B.; Trentacosta, Christopher J.; McLear, Caitlin

    2014-01-01

    We conducted a meta-analysis on the effects of client preferences on treatment satisfaction, completion, and clinical outcome. Our search of the literature resulted in 34 empirical articles describing 32 unique clinical trials that either randomized some clients to an active choice condition (shared decision making condition or choice of treatment) or assessed client preferences. Clients who were involved in shared decision making, chose a treatment condition, or otherwise received their preferred treatment evidenced higher treatment satisfaction (ESd = .34; p < .001), increased completion rates (ESOR = 1.37; ESd = .17; p < .001), and superior clinical outcome (ESd = .15; p < .0001), compared to clients who were not involved in shared decision making, did not choose a treatment condition, or otherwise did not receive their preferred treatment. Although the effect sizes are modest in magnitude, they were generally consistent across several potential moderating variables including study design (preference versus active choice), psychoeducation (informed versus uninformed), setting (inpatient versus outpatient), client diagnosis (mental health versus other), and unit of randomization (client versus provider). Our findings highlight the clinical benefit of assessing client preferences, providing treatment choices when two or more efficacious options are available, and involving clients in treatment-related decisions when treatment options are not available. PMID:25189522

  3. The Utilization of a Clinical Decision Support System to Manage Adult Type 2 Diabetes: A Correlational Study

    ERIC Educational Resources Information Center

    Faught, I. Charie

    2012-01-01

    While the Institute of Medicine (2001) has promoted health information technology to improve the process of care such as compliance with clinical practice guidelines and quicker access to clinical information, diagnostic tests, and treatment results, very little was known about how a clinical decision support system can contribute to diabetes…

  4. Clinical Instructors' Perceptions of the Importance of Affective Behaviors in Undergraduate Athletic Training Clinical Education

    ERIC Educational Resources Information Center

    Mokris, Rebecca L.

    2012-01-01

    The affective domain represents a set of learning objectives that are difficult to assess and instruct. Affective behaviors consist of different attributes such as interpersonal relationships, professionalism, trust, empathy, and integrity to name a few. This study surveyed athletic training clinical instructors' perception of the importance…

  5. Stroke navigator--a clinical decision support system for acute stroke.

    PubMed

    van Zon, Kees; Lord, William P; Lagor, Charles; Theiss, Stephan; Brosig, Torge; Siebler, Mario

    2008-11-06

    The Stroke Navigator is a clinical decision support system aimed at improving the diagnosis and treatment of acute stroke. It combines an audit trail, a differential diagnosis window, an interactive stroke protocol map, and a list of recommendations for hospital staff. It provides a patient-specific overview of the workflow status and of the available clinical findings, with the goal of improving the continuity of care. For this purpose, it uses a workflow engine that was specifically designed to meet the demands of clinical practice. The Stroke Navigator furthermore calculates and displays the probabilities of various stroke differential diagnoses. The demonstration will introduce these and other features by means of a hypothetical patient case. It will also summarize the status of alpha-testing the first prototype.

  6. A Bridging Opportunities Work-frame to develop mobile applications for clinical decision making

    PubMed Central

    van Rooij, Tibor; Rix, Serena; Moore, James B; Marsh, Sharon

    2015-01-01

    Background: Mobile applications (apps) providing clinical decision support (CDS) may show the greatest promise when created by and for frontline clinicians. Our aim was to create a generic model enabling healthcare providers to direct the development of CDS apps. Methods: We combined Change Management with a three-tier information technology architecture to stimulate CDS app development. Results: A Bridging Opportunities Work-frame model was developed. A test case was used to successfully develop an app. Conclusion: Healthcare providers can re-use this globally applicable model to actively create and manage regional decision support applications to translate evidence-based medicine in the use of emerging medication or novel treatment regimens. PMID:28031883

  7. Test Case Selection in Pre-Deployment Testing of Complex Clinical Decision Support Systems

    PubMed Central

    Tso, Geoffrey J.; Yuen, Kaeli; Martins, Susana; Tu, Samson W.; Ashcraft, Michael; Heidenreich, Paul; Hoffman, Brian B.; Goldstein, Mary K.

    2016-01-01

    Clinical decision support (CDS) systems with complex logic are being developed. Ensuring the quality of CDS is imperative, but there is no consensus on testing standards. We tested ATHENA-HTN CDS after encoding updated hypertension guidelines into the system. A logic flow and a complexity analysis of the encoding were performed to guide testing. 100 test cases were selected to test the major pathways in the CDS logic flow, and the effectiveness of the testing was analyzed. The encoding contained 26 decision points and 3120 possible output combinations. The 100 cases selected tested all of the major pathways in the logic, but only 1% of the possible output combinations. Test case selection is one of the most challenging aspects in CDS testing and has a major impact on testing coverage. A test selection strategy should take into account the complexity of the system, identification of major logic pathways, and available resources. PMID:27570678

  8. Defining reactivity: how several methodological decisions can affect conclusions about emotional reactivity in psychopathology.

    PubMed

    Nelson, Brady D; Shankman, Stewart A; Olino, Thomas M; Klein, Daniel N

    2011-12-01

    There are many important methodological decisions that need to be made when examining emotional reactivity in psychopathology. In the present study, we examined the effects of two such decisions in an investigation of emotional reactivity in depression: (1) which (if any) comparison condition to employ; and (2) how to define change. Depressed (N = 69) and control (N = 37) participants viewed emotion-inducing film clips while subjective and facial responses were measured. Emotional reactivity was defined using no comparison condition (i.e., raw scores), baseline comparison condition (i.e., no stimulus presented), and neutral comparison condition (i.e., neutral stimulus presented). Change in emotional reactivity was assessed using four analytic approaches: difference scores, percentage change, residualised change, and ANCOVA. Results differed among the three comparison conditions and among several of the analytic approaches. Overall, our investigation suggests that choosing a comparison condition and the definition of change can significantly influence the presence of group differences in emotional reactivity. Recommendations for studies of emotional reactivity in psychopathology are discussed.

  9. Design of a nursing clinical decision support system applying nursing diagnosis and nursing evaluation model based data mining.

    PubMed

    Kim, Hyungyung; Kim, Insook; Chae, Yougmoon

    2006-01-01

    This study a methodological study; to acquire knowledge on the nursing process by steps of knowledge definition, collection, and representation; then, to design a data warehouse and nursing process clinical decision support system.

  10. The need for clinical decision support integrated with the electronic health record for the clinical application of whole genome sequencing information.

    PubMed

    Welch, Brandon M; Kawamoto, Kensaku

    2013-12-18

    Whole genome sequencing (WGS) is rapidly approaching widespread clinical application. Technology advancements over the past decade, since the first human genome was decoded, have made it feasible to use WGS for clinical care. Future advancements will likely drive down the price to the point wherein WGS is routinely available for care. However, were this to happen today, most of the genetic information available to guide clinical care would go unused due to the complexity of genetics, limited physician proficiency in genetics, and lack of genetics professionals in the clinical workforce. Furthermore, these limitations are unlikely to change in the future. As such, the use of clinical decision support (CDS) to guide genome-guided clinical decision-making is imperative. In this manuscript, we describe the barriers to widespread clinical application of WGS information, describe how CDS can be an important tool for overcoming these barriers, and provide clinical examples of how genome-enabled CDS can be used in the clinical setting.

  11. Emotion, rationality, and decision-making: how to link affective and social neuroscience with social theory.

    PubMed

    Verweij, Marco; Senior, Timothy J; Domínguez D, Juan F; Turner, Robert

    2015-01-01

    In this paper, we argue for a stronger engagement between concepts in affective and social neuroscience on the one hand, and theories from the fields of anthropology, economics, political science, and sociology on the other. Affective and social neuroscience could provide an additional assessment of social theories. We argue that some of the most influential social theories of the last four decades-rational choice theory, behavioral economics, and post-structuralism-contain assumptions that are inconsistent with key findings in affective and social neuroscience. We also show that another approach from the social sciences-plural rationality theory-shows greater compatibility with these findings. We further claim that, in their turn, social theories can strengthen affective and social neuroscience. The former can provide more precise formulations of the social phenomena that neuroscientific models have targeted, can help neuroscientists who build these models become more aware of their social and cultural biases, and can even improve the models themselves. To illustrate, we show how plural rationality theory can be used to further specify and test the somatic marker hypothesis. Thus, we aim to accelerate the much-needed merger of social theories with affective and social neuroscience.

  12. Emotion, rationality, and decision-making: how to link affective and social neuroscience with social theory

    PubMed Central

    Verweij, Marco; Senior, Timothy J.; Domínguez D., Juan F.; Turner, Robert

    2015-01-01

    In this paper, we argue for a stronger engagement between concepts in affective and social neuroscience on the one hand, and theories from the fields of anthropology, economics, political science, and sociology on the other. Affective and social neuroscience could provide an additional assessment of social theories. We argue that some of the most influential social theories of the last four decades—rational choice theory, behavioral economics, and post-structuralism—contain assumptions that are inconsistent with key findings in affective and social neuroscience. We also show that another approach from the social sciences—plural rationality theory—shows greater compatibility with these findings. We further claim that, in their turn, social theories can strengthen affective and social neuroscience. The former can provide more precise formulations of the social phenomena that neuroscientific models have targeted, can help neuroscientists who build these models become more aware of their social and cultural biases, and can even improve the models themselves. To illustrate, we show how plural rationality theory can be used to further specify and test the somatic marker hypothesis. Thus, we aim to accelerate the much-needed merger of social theories with affective and social neuroscience. PMID:26441506

  13. Development and impact of computerised decision support systems for clinical management of depression: A systematic review.

    PubMed

    Triñanes, Yolanda; Atienza, Gerardo; Louro-González, Arturo; de-las-Heras-Liñero, Elena; Alvarez-Ariza, María; Palao, Diego J

    2015-01-01

    One of the proposals for improving clinical practice is to introduce computerised decision support systems (CDSS) and integrate these with electronic medical records. Accordingly, this study sought to systematically review evidence on the effectiveness of CDSS in the management of depression. A search was performed in Medline, EMBASE and PsycInfo, in order to do this. The quality of quantitative studies was assessed using the SIGN method, and qualitative studies using the CASPe checklist. Seven studies were identified (3 randomised clinical trials, 3 non-randomised trials, and one qualitative study). The CDSS assessed incorporated content drawn from guidelines and other evidence-based products. In general, the CDSS had a positive impact on different aspects, such as the screening and diagnosis, treatment, improvement in depressive symptoms and quality of life, and referral of patients. The use of CDSS could thus serve to optimise care of depression in various scenarios by providing recommendations based on the best evidence available and facilitating decision-making in clinical practice.

  14. A study of diverse clinical decision support rule authoring environments and requirements for integration

    PubMed Central

    2012-01-01

    Background Efficient rule authoring tools are critical to allow clinical Knowledge Engineers (KEs), Software Engineers (SEs), and Subject Matter Experts (SMEs) to convert medical knowledge into machine executable clinical decision support rules. The goal of this analysis was to identify the critical success factors and challenges of a fully functioning Rule Authoring Environment (RAE) in order to define requirements for a scalable, comprehensive tool to manage enterprise level rules. Methods The authors evaluated RAEs in active use across Partners Healthcare, including enterprise wide, ambulatory only, and system specific tools, with a focus on rule editors for reminder and medication rules. We conducted meetings with users of these RAEs to discuss their general experience and perceived advantages and limitations of these tools. Results While the overall rule authoring process is similar across the 10 separate RAEs, the system capabilities and architecture vary widely. Most current RAEs limit the ability of the clinical decision support (CDS) interventions to be standardized, sharable, interoperable, and extensible. No existing system meets all requirements defined by knowledge management users. Conclusions A successful, scalable, integrated rule authoring environment will need to support a number of key requirements and functions in the areas of knowledge representation, metadata, terminology, authoring collaboration, user interface, integration with electronic health record (EHR) systems, testing, and reporting. PMID:23145874

  15. Teaching clinical decision-making to pediatric residents in an era of managed care.

    PubMed

    Chessare, J B

    1998-04-01

    The growth of managed care has brought a new focus on physician competency in the appropriate use of resources to help patients. The community of pediatric educators must improve residency curricula and teaching methodologies to ensure that graduates of their programs can effectively and efficiently meet the needs of children and their families. The educational approach in many pediatric residency programs is an implicit apprenticeship model, with which the residents follow the actions of attending physicians with little attention to scrutiny of the clinical evidence for and against diagnostic and treatment strategies. Evidence-based medicine stresses to the trainee the importance of the evaluation of evidence from clinical research and cautions against the use of intuition, unsystematic clinical experience, and untested pathophysiologic reasoning as sufficient for medical decision-making. Managed care also has helped to create a heightened awareness of the need to educate residents to incorporate the preferences of patients and families into diagnostic and treatment decisions. Trainees must know how to balance their duty to maximize the health of populations at the lowest resource use with their duty to each individual patient and family. Changes in the residency curriculum will bring change in educational settings and the structure of rotations. Potential barriers to implementation will include the need for faculty development and financial resources for information technology.

  16. Data Mining for Understanding and Improving Decision-making Affecting Ground Delay Programs

    NASA Technical Reports Server (NTRS)

    Kulkarni, Deepak; Wang, Yao; Sridhar, Banavar

    2013-01-01

    The continuous growth in the demand for air transportation results in an imbalance between airspace capacity and traffic demand. The airspace capacity of a region depends on the ability of the system to maintain safe separation between aircraft in the region. In addition to growing demand, the airspace capacity is severely limited by convective weather. During such conditions, traffic managers at the FAA's Air Traffic Control System Command Center (ATCSCC) and dispatchers at various Airlines' Operations Center (AOC) collaborate to mitigate the demand-capacity imbalance caused by weather. The end result is the implementation of a set of Traffic Flow Management (TFM) initiatives such as ground delay programs, reroute advisories, flow metering, and ground stops. Data Mining is the automated process of analyzing large sets of data and then extracting patterns in the data. Data mining tools are capable of predicting behaviors and future trends, allowing an organization to benefit from past experience in making knowledge-driven decisions.

  17. Comparing social factors affecting recommender decisions in online and educational social network

    NASA Astrophysics Data System (ADS)

    MartÍn, Estefanía; Hernán-Losada, Isidoro; Haya, Pablo A.

    2016-01-01

    In the educational context, there is an increasing interest in learning networks. Recommender systems (RSs) can play an important role in achieving educational objectives. Although we can find many papers focused on recommendation techniques and algorithms, in general, less attention has been dedicated to social factors that influence the recommendation process. This process could be improved if we had a deeper understanding of the social factors that influence the quality or validity of a suggestion made by the RS. This work elucidates and analyses the social factors that influence the design and decision-making process of RSs. We conducted a survey in which 126 undergraduate students were asked to extract which are the main factors for improving suggestions when they are interacting with an Online Social Network (OSN) or in an Educational Social Network (ESN). The results show that different factors have to be considered depending on the type of network.

  18. Data Mining for Understanding and Impriving Decision-Making Affecting Ground Delay Programs

    NASA Technical Reports Server (NTRS)

    Kulkarni, Deepak; Wang, Yao Xun; Sridhar, Banavar

    2013-01-01

    The continuous growth in the demand for air transportation results in an imbalance between airspace capacity and traffic demand. The airspace capacity of a region depends on the ability of the system to maintain safe separation between aircraft in the region. In addition to growing demand, the airspace capacity is severely limited by convective weather. During such conditions, traffic managers at the FAA's Air Traffic Control System Command Center (ATCSCC) and dispatchers at various Airlines' Operations Center (AOC) collaborate to mitigate the demand-capacity imbalance caused by weather. The end result is the implementation of a set of Traffic Flow Management (TFM) initiatives such as ground delay programs, reroute advisories, flow metering, and ground stops. Data Mining is the automated process of analyzing large sets of data and then extracting patterns in the data. Data mining tools are capable of predicting behaviors and future trends, allowing an organization to benefit from past experience in making knowledge-driven decisions. The work reported in this paper is focused on ground delay programs. Data mining algorithms have the potential to develop associations between weather patterns and the corresponding ground delay program responses. If successful, they can be used to improve and standardize TFM decision resulting in better predictability of traffic flows on days with reliable weather forecasts. The approach here seeks to develop a set of data mining and machine learning models and apply them to historical archives of weather observations and forecasts and TFM initiatives to determine the extent to which the theory can predict and explain the observed traffic flow behaviors.

  19. A Study of the Patients Admitted to the Clinical Decision Unit over One Year.

    PubMed

    O'Shea, E; Cusack, S; O'Sullivan, I

    2016-06-10

    Clinical decision units (CDUs) are areas within an emergency department (ED) providing care for the patient who may benefit from an extended observation period, usually for a maximum of twenty-four hours. A retrospective patient record audit was performed to determine the characteristics of patients admitted to the Cork University Hospital (CUH) CDU over 12 months. The average length of stay of a patient in the CDU was 29 hours. The most common diagnoses admitted to the CDU were chest pain (9.5%) and headache (7.2%). The research implies that the CDU provided a means for CUH to save approximately €2 million annually.

  20. Laboratory Medicine in the Clinical Decision Support for Treatment of Hypercholesterolemia: Pharmacogenetics of Statins.

    PubMed

    Ruaño, Gualberto; Seip, Richard; Windemuth, Andreas; Wu, Alan H B; Thompson, Paul D

    2016-09-01

    Statin responsiveness is an area of great research interest given the success of the drug class in the treatment of hypercholesterolemia and in primary and secondary prevention of cardiovascular disease. Interrogation of the patient's genome for gene variants will eventually guide anti-hyperlipidemic intervention. In this review, we discuss methodological approaches to discover genetic markers predictive of class-wide and drug-specific statin efficacy and safety. Notable pharmacogenetic findings are summarized from hypothesis-free genome wide and hypothesis-led candidate gene association studies. Physiogenomic models and clinical decision support systems will be required for DNA-guided statin therapy to reach practical use in medicine.

  1. Integrating complex business processes for knowledge-driven clinical decision support systems.

    PubMed

    Kamaleswaran, Rishikesan; McGregor, Carolyn

    2012-01-01

    This paper presents in detail the component of the Complex Business Process for Stream Processing framework that is responsible for integrating complex business processes to enable knowledge-driven Clinical Decision Support System (CDSS) recommendations. CDSSs aid the clinician in supporting the care of patients by providing accurate data analysis and evidence-based recommendations. However, the incorporation of a dynamic knowledge-management system that supports the definition and enactment of complex business processes and real-time data streams has not been researched. In this paper we discuss the process web service as an innovative method of providing contextual information to a real-time data stream processing CDSS.

  2. Magnetic resonance imaging of the vagina: an overview for radiologists with emphasis on clinical decision making*

    PubMed Central

    Ferreira, Daian Miranda; Bezerra, Régis Otaviano França; Ortega, Cinthia Denise; Blasbalg, Roberto; Viana, Públio César Cavalcante; de Menezes, Marcos Roberto; Rocha, Manoel de Souza

    2015-01-01

    Magnetic resonance imaging is a method with high contrast resolution widely used in the assessment of pelvic gynecological diseases. However, the potential of such method to diagnose vaginal lesions is still underestimated, probably due to the scarce literature approaching the theme, the poor familiarity of radiologists with vaginal diseases, some of them relatively rare, and to the many peculiarities involved in the assessment of the vagina. Thus, the authors illustrate the role of magnetic resonance imaging in the evaluation of vaginal diseases and the main relevant findings to be considered in the clinical decision making process. PMID:26379324

  3. Performance of online drug information databases as clinical decision support tools in infectious disease medication management.

    PubMed

    Polen, Hyla H; Zapantis, Antonia; Clauson, Kevin A; Clauson, Kevin Alan; Jebrock, Jennifer; Paris, Mark

    2008-11-06

    Infectious disease (ID) medication management is complex and clinical decision support tools (CDSTs) can provide valuable assistance. This study evaluated scope and completeness of ID drug information found in online databases by evaluating their ability to answer 147 question/answer pairs. Scope scores produced highest rankings (%) for: Micromedex (82.3), Lexi-Comp/American Hospital Formulary Service (81.0), and Medscape Drug Reference (81.0); lowest includes: Epocrates Online Premium (47.0), Johns Hopkins ABX Guide (45.6), and PEPID PDC (40.8).

  4. 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

  5. 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.

  6. Affective Priming in a Lexical Decision Task: Is There an Effect of Words' Concreteness?

    ERIC Educational Resources Information Center

    Ferré, Pilar; Sánchez-Casas, Rosa

    2014-01-01

    Affective priming occurs when responses to a target are facilitated when it is preceded by a prime congruent in valence. We conducted two experiments in order to test whether this is a genuine emotional effect or rather it can be accounted for by semantic relatedness between primes and targets. With this aim, semantic relatedness and emotional…

  7. 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…

  8. From the shadows into the light: How pretrial publicity and deliberation affect mock jurors' decisions, impressions, and memory.

    PubMed

    Ruva, Christine L; Guenther, Christina C

    2015-06-01

    This 2-part study explored how exposure to negative pretrial publicity (Neg-PTP) influences the jury process, as well as possible mechanisms responsible for its biasing effects on decisions. Study Part A explored how PTP and jury deliberations affect juror/jury verdicts, memory, and impressions of the defendant and attorneys. One week before viewing a criminal trial mock-jurors (N = 320 university students) were exposed to Neg-PTP or unrelated crime stories (No-PTP). Two days later deliberating jurors came to a group decision, whereas nondeliberating jurors completed an unrelated task before making an individual decision. Neg-PTP jurors were more likely to vote guilty, make memory errors, and rate the defendant lower in credibility. Deliberation reduced Neg-PTP jurors' memory accuracy and No-PTP jurors' guilty verdicts (leniency bias). Jurors' memory and ratings of the defendant and prosecuting attorney significantly mediated the effect of PTP on guilt ratings. Study Part B content analyzed 30 mock-jury deliberations and explored how PTP influenced deliberations and ultimately jury decisions. Neg-PTP juries were more likely than No-PTP juries to discuss ambiguous trial evidence in a proprosecution manner and less likely to discuss judicial instructions and lack of evidence. All Neg-PTP juries mentioned PTP, after instructed otherwise, and rarely corrected jury members who mentioned PTP. Discussion of ambiguous trial evidence in a proprosecution manner and lack of evidence significantly mediated the effect of PTP on jury-level guilt ratings. Together the findings suggest that judicial admonishments and deliberations may not be sufficient to reduce PTP bias, because of memory errors, biased impressions, and predecisional distortion.

  9. Clinical Decision-Making in the Treatment of Schizophrenia: Focus on Long-Acting Injectable Antipsychotics

    PubMed Central

    Samalin, Ludovic; Garnier, Marion; Auclair, Candy; Llorca, Pierre-Michel

    2016-01-01

    The purpose of this study was to identify clinician characteristics associated with higher prescription rates of long-acting injectable (LAI) antipsychotics, as well as the sources that influence medical decision-making regarding the treatment of schizophrenia. We surveyed 202 psychiatrists during six regional French conferences (Bordeaux, Lyon, Marseille, Nice, Paris, and Strasbourg). Data on the characteristics of practice, prescription rates of antipsychotic, and information sources about their clinical decisions were collected. Most psychiatrists used second-generation antipsychotics (SGAs), and preferentially an oral formulation, in the treatment of schizophrenia. LAI SGAs were prescribed to 30.4% of schizophrenic patients. The duration and type of practice did not influence the class or formulation of antipsychotics used. The clinicians following the higher percentage of schizophrenic patients were associated with a higher use of LAI antipsychotics and a lower use of oral SGAs. Personal experience, government regulatory approval, and guidelines for the treatment of schizophrenia were the three main contributing factors guiding clinicians’ decision-making regarding the treatment of schizophrenia. The more clinicians follow schizophrenic patients, the more they use LAI antipsychotics. The development of specialized programs with top specialists should lead to better use of LAI antipsychotics in the treatment of schizophrenia. PMID:27869767

  10. Clinical Decision-Making in the Treatment of Schizophrenia: Focus on Long-Acting Injectable Antipsychotics.

    PubMed

    Samalin, Ludovic; Garnier, Marion; Auclair, Candy; Llorca, Pierre-Michel

    2016-11-19

    The purpose of this study was to identify clinician characteristics associated with higher prescription rates of long-acting injectable (LAI) antipsychotics, as well as the sources that influence medical decision-making regarding the treatment of schizophrenia. We surveyed 202 psychiatrists during six regional French conferences (Bordeaux, Lyon, Marseille, Nice, Paris, and Strasbourg). Data on the characteristics of practice, prescription rates of antipsychotic, and information sources about their clinical decisions were collected. Most psychiatrists used second-generation antipsychotics (SGAs), and preferentially an oral formulation, in the treatment of schizophrenia. LAI SGAs were prescribed to 30.4% of schizophrenic patients. The duration and type of practice did not influence the class or formulation of antipsychotics used. The clinicians following the higher percentage of schizophrenic patients were associated with a higher use of LAI antipsychotics and a lower use of oral SGAs. Personal experience, government regulatory approval, and guidelines for the treatment of schizophrenia were the three main contributing factors guiding clinicians' decision-making regarding the treatment of schizophrenia. The more clinicians follow schizophrenic patients, the more they use LAI antipsychotics. The development of specialized programs with top specialists should lead to better use of LAI antipsychotics in the treatment of schizophrenia.

  11. Protein source and choice of anticoagulant decisively affect nanoparticle protein corona and cellular uptake

    NASA Astrophysics Data System (ADS)

    Schöttler, S.; Klein, Katja; Landfester, K.; Mailänder, V.

    2016-03-01

    Protein adsorption on nanoparticles has been a focus of the field of nanocarrier research in the past few years and more and more papers are dealing with increasingly detailed lists of proteins adsorbed to a plethora of nanocarriers. While there is an urgent need to understand the influence of this protein corona on nanocarriers' interactions with cells the strong impact of the protein source on corona formation and the consequence for interaction with different cell types are factors that are regularly neglected, but should be taken into account for a meaningful analysis. In this study, the importance of the choice of protein source used for in vitro protein corona analysis is concisely investigated. Major and decisive differences in cellular uptake of a polystyrene nanoparticle incubated in fetal bovine serum, human serum, human citrate and heparin plasma are reported. Furthermore, the protein compositions are determined for coronas formed in the respective incubation media. A strong influence of heparin, which is used as an anticoagulant for plasma generation, on cell interaction is demonstrated. While heparin enhances the uptake into macrophages, it prevents internalization into HeLa cells. Taken together we can give the recommendation that human plasma anticoagulated with citrate seems to give the most relevant results for in vitro studies of nanoparticle uptake.Protein adsorption on nanoparticles has been a focus of the field of nanocarrier research in the past few years and more and more papers are dealing with increasingly detailed lists of proteins adsorbed to a plethora of nanocarriers. While there is an urgent need to understand the influence of this protein corona on nanocarriers' interactions with cells the strong impact of the protein source on corona formation and the consequence for interaction with different cell types are factors that are regularly neglected, but should be taken into account for a meaningful analysis. In this study, the importance

  12. ZNF804A variants confer risk for heroin addiction and affect decision making and gray matter volume in heroin abusers.

    PubMed

    Sun, Yan; Zhao, Li-Yan; Wang, Gui-Bin; Yue, Wei-Hua; He, Yong; Shu, Ni; Lin, Qi-Xiang; Wang, Fan; Li, Jia-Li; Chen, Na; Wang, Hui-Min; Kosten, Thomas R; Feng, Jia-Jia; Wang, Jun; Tang, Yu-De; Liu, Shu-Xue; Deng, Gui-Fa; Diao, Gan-Huan; Tan, Yun-Long; Han, Hong-Bin; Lin, Lu; Shi, Jie

    2016-05-01

    Drug addiction shares common neurobiological pathways and risk genes with other psychiatric diseases, including psychosis. One of the commonly identified risk genes associated with broad psychosis has been ZNF804A. We sought to test whether psychosis risk variants in ZNF804A increase the risk of heroin addiction by modulating neurocognitive performance and gray matter volume (GMV) in heroin addiction. Using case-control genetic analysis, we compared the distribution of ZNF804A variants (genotype and haplotype) in 1035 heroin abusers and 2887 healthy subjects. We also compared neurocognitive performance (impulsivity, global cognitive ability and decision-making ability) in 224 subjects and GMV in 154 subjects based on the ZNF804A variants. We found significant differences in the distribution of ZNF804A intronic variants (rs1344706 and rs7597593) allele and haplotype frequencies between the heroin and control groups. Decision-making impairment was worse in heroin abusers who carried the ZNF804A risk allele and haplotype. Subjects who carried more risk alleles and haplotypes of ZNF804A had greater GMV in the bilateral insular cortex, right temporal cortex and superior parietal cortex. The interaction between heroin addiction and ZNF804A variants affected GMV in the left sensorimotor cortex. Our findings revealed several ZNF804A variants that were significantly associated with the risk of heroin addiction, and these variants affected decision making and GMV in heroin abusers compared with controls. The precise neural mechanisms that underlie these associations are unknown, which requires future investigations of the effects of ZNF804A on both dopamine neurotransmission and the relative increases in the volume of various brain areas.

  13. To certify or not to certify: clinical social work decisions and involuntary hospitalization.

    PubMed

    Dworkin, J

    1988-01-01

    This research compares, on a variety of clinical and contextual factors, case episodes in which Clinical Social Workers decided to certify patients for involuntary hospitalization with those episodes where they decided not to certify them. A cross-sectional exploratory design was developed, and descriptive data was collected using a modified critical incident technique and a structured interview schedule. Among certified cases, the dangerousness of the patient was the major reason for certification, especially dangerousness to others. Lack of dangerousness to others and use of alternatives to involuntary hospitalization were major factors in the decision not to certify. Schizophrenic disorders were most frequently identified in certified patients; depressive and neurotic conditions in non-certified cases.

  14. Development of a decision support model for scheduling clinical studies and assigning medical personnel.

    PubMed

    Grunow, Martin; Günther, Hans-Otto; Yang, Gang

    2004-11-01

    Clinical studies for the development of new drugs in the pharmaceutical industry consist of a number of individual tasks which have to be carried out in a pre-defined chronological order. Each task requires certain types of medical personnel. This paper investigates the scheduling of clinical studies to be performed during a short-term planning horizon, the allocation of workforce between the studies, and the assignment of individual employees to tasks. Instead of developing a complex monolithic decision model, a hierarchical modelling approach is suggested. In the first stage, a compact integer optimization model is solved in order to determine the start-off times of the studies and the required staffing while taking the limited availability of personnel into account. The objective is to minimize total staffing costs. The assignment of individual employees to tasks is then made in the second stage of the procedure using a binary optimization model.

  15. Multidisciplinary Modelling of Symptoms and Signs with Archetypes and SNOMED-CT for Clinical Decision Support.

    PubMed

    Marco-Ruiz, Luis; Maldonado, J Alberto; Karlsen, Randi; Bellika, Johan G

    2015-01-01

    Clinical Decision Support Systems (CDSS) help to improve health care and reduce costs. However, the lack of knowledge management and modelling hampers their maintenance and reuse. Current EHR standards and terminologies can allow the semantic representation of the data and knowledge of CDSS systems boosting their interoperability, reuse and maintenance. This paper presents the modelling process of respiratory conditions' symptoms and signs by a multidisciplinary team of clinicians and information architects with the help of openEHR, SNOMED and clinical information modelling tools for a CDSS. The information model of the CDSS was defined by means of an archetype and the knowledge model was implemented by means of an SNOMED-CT based ontology.

  16. Modeling the costs of clinical decision support for genomic precision medicine

    PubMed Central

    Mathias, Patrick C.; Tarczy-Hornoch, Peter; Shirts, Brian H.

    2016-01-01

    Clinical decision support (CDS) within the electronic health record represents a promising mechanism to provide important genomic findings within clinical workflows. To better understand the current and possible future costs of genomic CDS, we leveraged our local CDS experience to assemble a simple model with inputs such as initial cost and numbers of patients, rules, and institutions. Our model assumed efficiencies of scale and allowed us to perform a one-way sensitivity analysis of the impact of each model input. The number of patients with genomic results per institution was the only single variable that could decrease the cost of CDS per useful alert below projected genomic sequencing costs. Because of the prohibitive upfront cost of sequencing large numbers of individuals, increasing the number of institutions using genomic CDS and improving the efficiency of sharing CDS infrastructure represent the most promising paths to making genomic CDS cost-effective. PMID:27570652

  17. Modeling access, cost, and perceived quality: computer simulation benefits orthodontic clinic staffing decisions.

    PubMed

    Montgomery, J B; LaFrancois, G G; Perry, M J

    2000-02-01

    Given limited financial resources, simulation permits a financial analysis of the optimum staffing levels for orthodontists and dental assistants in an orthodontic clinic. A computer simulation provides the information for managerial review. This study, by building a computer simulation of an orthodontic service, set out to determine the most efficient mix between providers and support staff to maximize access, maximize perceived quality, and minimize expenditures. Six combinations of providers and support staff were compared during an animated, computer-generated what-if analysis. Based on the clinic workload and size, on the cost per patient, and on the cost per quality point, the research team recommended a staffing mix of one orthodontist and three assistants. This study shows that computer simulation is an enormous asset as a decision support tool for management.

  18. The cognitive processes underlying affective decision-making predicting adolescent smoking behaviors in a longitudinal study

    PubMed Central

    Xiao, Lin; Koritzky, Gilly; Johnson, C. Anderson; Bechara, Antoine

    2013-01-01

    This study investigates the relationship between three different cognitive processes underlying the Iowa Gambling Task (IGT) and adolescent smoking behaviors in a longitudinal study. We conducted a longitudinal study of 181 Chinese adolescents in Chengdu City, China. The participants were followed from 10th to 11th grade. When they were in the 10th grade (Time 1), we tested these adolescents' decision-making using the IGT and working memory capacity using the Self-ordered Pointing Test (SOPT). Self-report questionnaires were used to assess school academic performance and smoking behaviors. The same questionnaires were completed again at the 1-year follow-up (Time 2). The Expectancy-Valence (EV) Model was applied to distill the IGT performance into three different underlying psychological components: (i) a motivational component which indicates the subjective weight the adolescents assign to gains vs. losses; (ii) a learning-rate component which indicates the sensitivity to recent outcomes vs. past experiences; and (iii) a response component which indicates how consistent the adolescents are between learning and responding. The subjective weight to gains vs. losses at Time 1 significantly predicted current smokers and current smoking levels at Time 2, controlling for demographic variables and baseline smoking behaviors. Therefore, by decomposing the IGT into three different psychological components, we found that the motivational process of weight gain vs. losses may serve as a neuropsychological marker to predict adolescent smoking behaviors in a general youth population. PMID:24101911

  19. A Diffusion Model Analysis of Decision Biases Affecting Delayed Recognition of Emotional Stimuli

    PubMed Central

    Bowen, Holly J.; Spaniol, Julia; Patel, Ronak; Voss, Andreas

    2016-01-01

    Previous empirical work suggests that emotion can influence accuracy and cognitive biases underlying recognition memory, depending on the experimental conditions. The current study examines the effects of arousal and valence on delayed recognition memory using the diffusion model, which allows the separation of two decision biases thought to underlie memory: response bias and memory bias. Memory bias has not been given much attention in the literature but can provide insight into the retrieval dynamics of emotion modulated memory. Participants viewed emotional pictorial stimuli; half were given a recognition test 1-day later and the other half 7-days later. Analyses revealed that emotional valence generally evokes liberal responding, whereas high arousal evokes liberal responding only at a short retention interval. The memory bias analyses indicated that participants experienced greater familiarity with high-arousal compared to low-arousal items and this pattern became more pronounced as study-test lag increased; positive items evoke greater familiarity compared to negative and this pattern remained stable across retention interval. The findings provide insight into the separate contributions of valence and arousal to the cognitive mechanisms underlying delayed emotion modulated memory. PMID:26784108

  20. Involvement in shared decision-making for patients in public specialist outpatient clinics in Hong Kong

    PubMed Central

    Xu, Richard H; Wong, Eliza LY

    2017-01-01

    Objective This study is a preliminary exploration of the association between patient involvement in decision-making and patient socioeconomic characteristics and experience in specialist outpatient clinics (SOPCs) in Hong Kong. Methods Cross-sectional telephone interviews were conducted using the Specialist Outpatient Experience Questionnaire (SOPEQ) in 26 Hospital Authority public SOPCs in Hong Kong. The SOPEQ was designed by The School of Public Health and Primary Care at The Chinese University of Hong Kong, fully taking into account both literature review and the local context of the public specialist outpatient system in Hong Kong. A total of 22,525 eligible participants were recruited for the study. Results There were 13,966 valid responses. The results indicated that the patients who had more involvement in decision-making were younger (odds ratio [OR] =2.10; 95% CI 1.75, 2.53), more highly educated (OR =1.67; 95% CI 1.45, 1.93), less likely to be receiving a government allowance (OR =0.61; 95% CI 0.57, 0.65), and less likely to be in the new case group (OR =0.84; 95% CI 0.78, 0.92). Participants living with their families (OR =3.38; 95% CI 2.03, 5.63) or who were unemployed (OR =1.10; 95% CI 1.01, 1.21) had a more decisive role in the decision- making process. Those participants who had been more involved in decision-making and wanted to continue being more involved had greater levels of satisfaction (mean =7.94; P<0.001) and a better health status (OR =0.49; 95% CI 0.41, 0.58). Conclusion Engaging patients in their health care management remains a challenge in improving patient-centered care. Our results suggest that patient engagement is associated with perceived health status and the experience of using a health service. Understanding patients’ characteristics and roles facilitates the development of preferred styles in the decision-making model. PMID:28331297

  1. Patient factors that influence clinicians’ decision making in self-management support: A clinical vignette study

    PubMed Central

    Bos-Touwen, Irene D.; Trappenburg, Jaap C. A.; van der Wulp, Ineke; Schuurmans, Marieke J.; de Wit, Niek J.

    2017-01-01

    Background and aim Self-management support is an integral part of current chronic care guidelines. The success of self-management interventions varies between individual patients, suggesting a need for tailored self-management support. Understanding the role of patient factors in the current decision making of health professionals can support future tailoring of self-management interventions. The aim of this study is to identify the relative importance of patient factors in health professionals’ decision making regarding self-management support. Method A factorial survey was presented to primary care physicians and nurses. The survey consisted of clinical vignettes (case descriptions), in which 11 patient factors were systematically varied. Each care provider received a set of 12 vignettes. For each vignette, they decided whether they would give this patient self-management support and whether they expected this support to be successful. The associations between respondent decisions and patient factors were explored using ordered logit regression. Results The survey was completed by 60 general practitioners and 80 nurses. Self-management support was unlikely to be provided in a third of the vignettes. The most important patient factor in the decision to provide self-management support as well as in the expectation that self-management support would be successful was motivation, followed by patient-provider relationship and illness perception. Other factors, such as depression or anxiety, education level, self-efficacy and social support, had a small impact on decisions. Disease, disease severity, knowledge of disease, and age were relatively unimportant factors. Conclusion This is the first study to explore the relative importance of patient factors in decision making and the expectations regarding the provision of self-management support to chronic disease patients. By far, the most important factor considered was patient’s motivation; unmotivated patients

  2. A Mathematical Model for Interpretable Clinical Decision Support with Applications in Gynecology

    PubMed Central

    Van Belle, Vanya M. C. A.; Van Calster, Ben; Timmerman, Dirk; Bourne, Tom; Bottomley, Cecilia; Valentin, Lil; Neven, Patrick; Van Huffel, Sabine; Suykens, Johan A. K.; Boyd, Stephen

    2012-01-01

    Background Over time, methods for the development of clinical decision support (CDS) systems have evolved from interpretable and easy-to-use scoring systems to very complex and non-interpretable mathematical models. In order to accomplish effective decision support, CDS systems should provide information on how the model arrives at a certain decision. To address the issue of incompatibility between performance, interpretability and applicability of CDS systems, this paper proposes an innovative model structure, automatically leading to interpretable and easily applicable models. The resulting models can be used to guide clinicians when deciding upon the appropriate treatment, estimating patient-specific risks and to improve communication with patients. Methods and Findings We propose the interval coded scoring (ICS) system, which imposes that the effect of each variable on the estimated risk is constant within consecutive intervals. The number and position of the intervals are automatically obtained by solving an optimization problem, which additionally performs variable selection. The resulting model can be visualised by means of appealing scoring tables and color bars. ICS models can be used within software packages, in smartphone applications, or on paper, which is particularly useful for bedside medicine and home-monitoring. The ICS approach is illustrated on two gynecological problems: diagnosis of malignancy of ovarian tumors using a dataset containing 3,511 patients, and prediction of first trimester viability of pregnancies using a dataset of 1,435 women. Comparison of the performance of the ICS approach with a range of prediction models proposed in the literature illustrates the ability of ICS to combine optimal performance with the interpretability of simple scoring systems. Conclusions The ICS approach can improve patient-clinician communication and will provide additional insights in the importance and influence of available variables. Future challenges

  3. Paying for treatments? Influences on negotiating clinical need and decision-making for dental implant treatment

    PubMed Central

    Exley, Catherine E; Rousseau, Nikki S; Steele, Jimmy; Finch, Tracy; Field, James; Donaldson, Cam; Thomason, J Mark; May, Carl R; Ellis, Janice S

    2009-01-01

    Background The aim of this study is to examine how clinicians and patients negotiate clinical need and treatment decisions within a context of finite resources. Dental implant treatment is an effective treatment for missing teeth, but is only available via the NHS in some specific clinical circumstances. The majority of people who receive this treatment therefore pay privately, often at substantial cost to themselves. People are used to paying towards dental treatment costs. However, dental implant treatment is much more expensive than existing treatments – such as removable dentures. We know very little about how dentists make decisions about whether to offer such treatments, or what patients consider when deciding whether or not to pay for them. Methods/Design Mixed methods will be employed to provide insight and understanding into how clinical need is determined, and what influences people's decision making processes when deciding whether or not to pursue a dental implant treatment. Phase 1 will use a structured scoping questionnaire with all the General dental practitioners (GDPs) in three Primary Care Trust areas (n = 300) to provide base-line data about existing practice in relation to dental implant treatment, and to provide data to develop a systematic sampling procedure for Phase 2. Phases 2 (GDPs) and 3 (patients) use qualitative focused one to one interviews with a sample of these practitioners (up to 30) and their patients (up to 60) to examine their views and experiences of decision making in relation to dental implant treatment. Purposive sampling for phases 2 and 3 will be carried out to ensure participants represent a range of socio-economic circumstances, and choices made. Discussion Most dental implant treatment is conducted in primary care. Very little information was available prior to this study about the quantity and type of treatment carried out privately. It became apparent during phase 2 that ISOD treatment was an unusual treatment in

  4. A Mobile Clinical Decision Support Tool for Pediatric Cardiovascular Risk-Reduction Clinical Practice Guidelines: Development and Description

    PubMed Central

    2017-01-01

    Background Widespread application of research findings to improve patient outcomes remains inadequate, and failure to routinely translate research findings into daily clinical practice is a major barrier for the implementation of any evidence-based guideline. Strategies to increase guideline uptake in primary care pediatric practices and to facilitate adherence to recommendations are required. Objective Our objective was to operationalize the US National Heart, Lung, and Blood Institute’s Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents into a mobile clinical decision support (CDS) system for healthcare providers, and to describe the process development and outcomes. Methods To overcome the difficulty of translating clinical practice guidelines into a computable form that can be used by a CDS system, we used a multilayer framework to convert the evidence synthesis into executable knowledge. We used an iterative process of design, testing, and revision through each step in the translation of the guidelines for use in a CDS tool to support the development of 4 validated modules: an integrated risk assessment; a blood pressure calculator; a body mass index calculator; and a lipid management instrument. Results The iterative revision process identified several opportunities to improve the CDS tool. Operationalizing the integrated guideline identified numerous areas in which the guideline was vague or incorrect and required more explicit operationalization. Iterative revisions led to workable solutions to problems and understanding of the limitations of the tool. Conclusions The process and experiences described provide a model for other mobile CDS systems that translate written clinical practice guidelines into actionable, real-time clinical recommendations. PMID:28270384

  5. Anticoagulation manager: development of a clinical decision support mobile application for management of anticoagulants.

    PubMed

    Chih-Wen Cheng; Hang Wu; Thompson, Pamela J; Taylor, Julie R; Zehnbauer, Barbara A; Wilson, Karlyn K; Wang, May D

    2016-08-01

    Patients with certain clotting disorders or conditions have a greater risk of developing arterial or venous clots and downstream embolisms, strokes, and arterial insufficiency. These patients need prescription anticoagulant drugs to reduce the possibility of clot formation. However, historically, the clinical decision making workflow in determining the correct type and dosage of anticoagulant(s) is part science and part art. To address this problem, we developed Anticoagulation Manager, an intelligent clinical decision workflow management system on iOS-based mobile devices to help clinicians effectively choose the most appropriate and helpful follow-up clotting tests for patients with a common clotting profile. The app can provide physicians guidance to prescribe the most appropriate medication for patients in need of anticoagulant drugs. This intelligent app was jointly designed and developed by medical professionals in CDC and engineers at Georgia Tech, and will be evaluated by physicians for ease-of-use, robustness, flexibility, and scalability. Eventually, it will be deployed and shared in both physician community and developer community.

  6. Valuing structured professional judgment: predictive validity, decision-making, and the clinical-actuarial conflict.

    PubMed

    Falzer, Paul R

    2013-01-01

    Structured professional judgment (SPJ) has received considerable attention as an alternative to unstructured clinical judgment and actuarial assessment, and as a means of resolving their ongoing conflict. However, predictive validity studies have typically relied on receiver operating characteristic (ROC) analysis, the same technique commonly used to validate actuarial assessment tools. This paper presents SPJ as distinct from both unstructured clinical judgment and actuarial assessment. A key distinguishing feature of SPJ is the contribution of modifiable factors, either dynamic or protective, to summary risk ratings. With modifiable factors, the summary rating scheme serves as a prognostic model rather than a classification procedure. However, prognostic models require more extensive and thorough predictive validity testing than can be provided by ROC analysis. It is proposed that validation should include calibration and reclassification techniques, as well as additional measures of discrimination. Several techniques and measures are described and illustrated. The paper concludes by tracing the limitations of ROC analysis to its philosophical foundation and its origin as a statistical theory of decision-making. This foundation inhibits the performance of crucial tasks, such as determining the sufficiency of a risk assessment and examining the evidentiary value of statistical findings. The paper closes by noting a current effort to establish a viable and complementary relationship between SPJ and decision-making theory.

  7. Using statistical process control to make data-based clinical decisions.

    PubMed Central

    Pfadt, A; Wheeler, D J

    1995-01-01

    Applied behavior analysis is based on an investigation of variability due to interrelationships among antecedents, behavior, and consequences. This permits testable hypotheses about the causes of behavior as well as for the course of treatment to be evaluated empirically. Such information provides corrective feedback for making data-based clinical decisions. This paper considers how a different approach to the analysis of variability based on the writings of Walter Shewart and W. Edwards Deming in the area of industrial quality control helps to achieve similar objectives. Statistical process control (SPC) was developed to implement a process of continual product improvement while achieving compliance with production standards and other requirements for promoting customer satisfaction. SPC involves the use of simple statistical tools, such as histograms and control charts, as well as problem-solving techniques, such as flow charts, cause-and-effect diagrams, and Pareto charts, to implement Deming's management philosophy. These data-analytic procedures can be incorporated into a human service organization to help to achieve its stated objectives in a manner that leads to continuous improvement in the functioning of the clients who are its customers. Examples are provided to illustrate how SPC procedures can be used to analyze behavioral data. Issues related to the application of these tools for making data-based clinical decisions and for creating an organizational climate that promotes their routine use in applied settings are also considered. PMID:7592154

  8. Clinical decision making in a patient with secondary hip-spine syndrome.

    PubMed

    Burns, Scott A; Mintken, Paul E; Austin, Gary P

    2011-07-01

    The prevalence of lumbar and hip pathology is on the rise; however, treatment outcomes have not improved, highlighting the difficulty in identifying and treating the correct impairments. The purpose of this case report is to describe the clinical decision making in the examination and treatment of an individual with secondary hip-spine syndrome. Our case study was a 62-year-old male with low back pain with concomitant right hip pain. His Oswestry Disability Index (ODI) was 18%, back numeric pain rating scale (NPRS) was 4/10, fear avoidance beliefs questionnaire (FABQ) work subscale was 0, FABQ physical activity subscale was 18, and patient specific functional scale (PSFS) was 7.33. Physical examination revealed findings consistent with secondary hip-spine syndrome. He was treated for four visits with joint mobilization/manipulation and strengthening exercises directed at the hip. At discharge, all standardized outcome measures achieved full resolution. Clinical decision making in the presence of lumbopelvic-hip pain is often difficult. Previous literature has shown that some patients with lumbopelvic-hip pain respond favorably to manual therapy and exercise targeting regions adjacent to the lumbar spine. The findings of this case report suggest that individuals with a primary complaint of LBP with hip impairments may benefit from interventions to reduce hip impairments.

  9. Improving completeness of electronic problem lists through clinical decision support: a randomized, controlled trial

    PubMed Central

    Pang, Justine; Feblowitz, Joshua C; Maloney, Francine L; Wilcox, Allison R; McLoughlin, Karen Sax; Ramelson, Harley; Schneider, Louise; Bates, David W

    2012-01-01

    Background Accurate clinical problem lists are critical for patient care, clinical decision support, population reporting, quality improvement, and research. However, problem lists are often incomplete or out of date. Objective To determine whether a clinical alerting system, which uses inference rules to notify providers of undocumented problems, improves problem list documentation. Study Design and Methods Inference rules for 17 conditions were constructed and an electronic health record-based intervention was evaluated to improve problem documentation. A cluster randomized trial was conducted of 11 participating clinics affiliated with a large academic medical center, totaling 28 primary care clinical areas, with 14 receiving the intervention and 14 as controls. The intervention was a clinical alert directed to the provider that suggested adding a problem to the electronic problem list based on inference rules. The primary outcome measure was acceptance of the alert. The number of study problems added in each arm as a pre-specified secondary outcome was also assessed. Data were collected during 6-month pre-intervention (11/2009–5/2010) and intervention (5/2010–11/2010) periods. Results 17 043 alerts were presented, of which 41.1% were accepted. In the intervention arm, providers documented significantly more study problems (adjusted OR=3.4, p<0.001), with an absolute difference of 6277 additional problems. In the intervention group, 70.4% of all study problems were added via the problem list alerts. Significant increases in problem notation were observed for 13 of 17 conditions. Conclusion Problem inference alerts significantly increase notation of important patient problems in primary care, which in turn has the potential to facilitate quality improvement. Trial Registration ClinicalTrials.gov: NCT01105923. PMID:22215056

  10. Increasing Complexity in Rule-Based Clinical Decision Support: The Symptom Assessment and Management Intervention

    PubMed Central

    Johns, Ellis B; Halpenny, Barbara; Saunders, Toni-Ann; Brzozowski, Jane; Del Fiol, Guilherme; Berry, Donna L; Braun, Ilana M; Finn, Kathleen; Wolfe, Joanne; Abrahm, Janet L; Cooley, Mary E

    2016-01-01

    Background Management of uncontrolled symptoms is an important component of quality cancer care. Clinical guidelines are available for optimal symptom management, but are not often integrated into the front lines of care. The use of clinical decision support (CDS) at the point-of-care is an innovative way to incorporate guideline-based symptom management into routine cancer care. Objective The objective of this study was to develop and evaluate a rule-based CDS system to enable management of multiple symptoms in lung cancer patients at the point-of-care. Methods This study was conducted in three phases involving a formative evaluation, a system evaluation, and a contextual evaluation of clinical use. In Phase 1, we conducted iterative usability testing of user interface prototypes with patients and health care providers (HCPs) in two thoracic oncology clinics. In Phase 2, we programmed complex algorithms derived from clinical practice guidelines into a rules engine that used Web services to communicate with the end-user application. Unit testing of algorithms was conducted using a stack-traversal tree-spanning methodology to identify all possible permutations of pathways through each algorithm, to validate accuracy. In Phase 3, we evaluated clinical use of the system among patients and HCPs in the two clinics via observations, structured interviews, and questionnaires. Results In Phase 1, 13 patients and 5 HCPs engaged in two rounds of formative testing, and suggested improvements leading to revisions until overall usability scores met a priori benchmarks. In Phase 2, symptom management algorithms contained between 29 and 1425 decision nodes, resulting in 19 to 3194 unique pathways per algorithm. Unit testing required 240 person-hours, and integration testing required 40 person-hours. In Phase 3, both patients and HCPs found the system usable and acceptable, and offered suggestions for improvements. Conclusions A rule-based CDS system for complex symptom management

  11. Factors affecting decisions to seek treatment for sick children in Kerala, India.

    PubMed

    Pillai, Rajamohanan K; Williams, Sankey V; Glick, Henry A; Polsky, Daniel; Berlin, Jesse A; Lowe, Robert A

    2003-09-01

    The purpose of this study was to measure the effects of social and economic variables, disease-related variables, and child gender on the decisions of parents in Kerala, India, to seek care for their children and on their choice of providers in the allopathic vs. the alternative system. A case-control analysis was done using data from the Kerala section of the 1996 Indian National Family Health Survey, a cross-sectional survey of a probability sample of households conducted by trained interviewers with a close-ended questionnaire. Of the 469 children who were eligible for this study because they had at least one common symptom suggestive of acute respiratory illness or diarrhea during the 2 weeks before the interview, 78 (17%) did not receive medical care, while the remaining 391 (83%) received medical care. Of the 391 children who received medical care, 342 (88%) received allopathic medical care, and 48 (12%) received alternative medical care. In multivariable analyses, parents chose not to seek medical care for their children significantly more often when the illness was mild, the child had a specific diagnosis, the mother had previously made fewer antenatal visits, and the family had a higher economic status. When parents sought medical care for their children, care was sought significantly more often in the alternative provider system when the child was a boy, the family lived in a rural area, and the family had a lower social class. We conclude that, in Kerala, disease severity and economic status predict whether children with acute respiratory infection or diarrhea are taken to medical providers. In contrast, most studies of this issue carried out in other populations have identified economic status as the primary predictor of medical system utilization. Also in Kerala, the gender of the child did not influence whether or not the child was taken for treatment but did influence whether care was sought in the alternative or the allopathic system.

  12. Does host plant quality affect the oviposition decisions of an omnivore?

    PubMed

    Vankosky, Meghan A; VanLaerhoven, Sherah L

    2016-01-22

    Optimal oviposition theory predicts a positive relationship between female preference for oviposition hosts and offspring performance. Interspecies effects on oviposition preference have been widely investigated, especially for herbivores. However, intraspecies variation, such as nitrogen content, might also influence female preference for oviposition hosts and subsequent offspring performance. To evaluate this possibility, we investigated the oviposition preference of a zoophytophagous omnivore and the development and survival of its nymphs on a single species of host plant that varied in nitrogen content. In choice and no-choice experiments without prey, female omnivores were allowed to oviposit on plants that had been fertilized using four rates of nitrogen fertilizer (39, 78, 156 and 311 mg/L nitrogen) for 72 h. After 72 h, the most females were found on tomato plants receiving high concentrations of nitrogen fertilizer and more eggs were laid on those plants. First instar nymphs developed more rapidly on high nitrogen plants and third instar nymphs developed faster on low nitrogen plans. Plant nitrogen did not affect nymph survival to the adult stage, or the probability of survival over time. Although female omnivores did discriminate between potential oviposition hosts based on plant nitrogen, their choices did not significantly impact nymph development or survival. This is the first study to show that intraspecies variation in nitrogen content between plants affects the oviposition preference of female omnivores, but not offspring performance. This article is protected by copyright. All rights reserved.

  13. A clinical decision support system with an integrated EMR for diagnosis of peripheral neuropathy.

    PubMed

    Kunhimangalam, Reeda; Ovallath, Sujith; Joseph, Paul K

    2014-04-01

    The prevalence of peripheral neuropathy in general population is ever increasing. The diagnosis and classification of peripheral neuropathies is often difficult as it involves careful clinical and electro-diagnostic examination by an expert neurologist. In developing countries a large percentage of the disease remains undiagnosed due to lack of adequate number of experts. In this study a novel clinical decision support system has been developed using a fuzzy expert system. The study was done to provide a solution to the demand of systems that can improve health care by accurate diagnosis in limited time, in the absence of specialists. It employs a graphical user interface and a fuzzy logic controller with rule viewer for identification of the type of peripheral neuropathy. An integrated medical records database is also developed for the storage and retrieval of the data. The system consists of 24 input fields, which includes the clinical values of the diagnostic test and the clinical symptoms. The output field is the disease diagnosis, whether it is Motor (Demyelinating/Axonopathy) neuropathy, sensory (Demyelinating/Axonopathy) neuropathy, mixed type or a normal case. The results obtained were compared with the expert's opinion and the system showed 93.27 % accuracy. The study aims at showing that Fuzzy Expert Systems may prove useful in providing diagnostic and predictive medical opinions. It enables the clinicians to arrive at a better diagnosis as it keeps the expert knowledge in an intelligent system to be used efficiently and effectively.

  14. Lung cancer patients' decisions about clinical trials and the theory of planned behavior.

    PubMed

    Quinn, Gwendolyn P; Pratt, Christie L; Bryant-George, Kathy; Caraway, Vicki D; Paternoster, Bonnie; Roldan, Tere; Shaffer, Andrea; Shimizu, Cynthia O; Vaughn, Elizabeth J; Williams, Charles; Bepler, Gerold

    2011-12-01

    The theory of planned behavior explores the relationship between behavior, beliefs, attitudes, and intentions presupposing that behavioral intention is influenced by a person's attitude about the behavior and beliefs about whether individuals, who are important to them, approve or disapprove of the behavior (subjective norm). An added dimension to the theory is the idea of perceived behavioral control, or the belief that one has control over performing the behavior. The theory of planned behavior suggests that people may make greater efforts to perform a behavior if they feel they have a high level of control over it. In this examination of data, we explored the application of the theory of planned behavior to patient's decisions about participating in a clinic trial. Twelve respondents in this study had previously participated in a clinical trial for lung cancer and nine respondents had declined a clinical trial for lung cancer. The data were analyzed with regard to the four constructs associated with the theory of planned behavior: behavioral intention, attitude, subjective norm, and perceived behavioral control. Results indicate that the theory of planned behavior may be a useful tool to examine psychosocial needs in relation to behavioral intention of clinical trial participation.

  15. Recommended practices for computerized clinical decision support and knowledge management in community settings: a qualitative study

    PubMed Central

    2012-01-01

    Background The purpose of this study was to identify recommended practices for computerized clinical decision support (CDS) development and implementation and for knowledge management (KM) processes in ambulatory clinics and community hospitals using commercial or locally developed systems in the U.S. Methods Guided by the Multiple Perspectives Framework, the authors conducted ethnographic field studies at two community hospitals and five ambulatory clinic organizations across the U.S. Using a Rapid Assessment Process, a multidisciplinary research team: gathered preliminary assessment data; conducted on-site interviews, observations, and field surveys; analyzed data using both template and grounded methods; and developed universal themes. A panel of experts produced recommended practices. Results The team identified ten themes related to CDS and KM. These include: 1) workflow; 2) knowledge management; 3) data as a foundation for CDS; 4) user computer interaction; 5) measurement and metrics; 6) governance; 7) translation for collaboration; 8) the meaning of CDS; 9) roles of special, essential people; and 10) communication, training, and support. Experts developed recommendations about each theme. The original Multiple Perspectives framework was modified to make explicit a new theoretical construct, that of Translational Interaction. Conclusions These ten themes represent areas that need attention if a clinic or community hospital plans to implement and successfully utilize CDS. In addition, they have implications for workforce education, research, and national-level policy development. The Translational Interaction construct could guide future applied informatics research endeavors. PMID:22333210

  16. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours

    PubMed Central

    2011-01-01

    Esophageal perforation is a rare and potentially life-threatening condition. Early clinical suspicion and imaging is important for case management to achieve a good outcome. However, recent studies continue to report high morbidity and mortality greater than 20% from esophageal perforation. At least half of the perforations are iatrogenic, mostly related to endoscopic instrumentation used in the upper gastrointestinal tract, while about a third are spontaneous perforations. Surgical treatment remains an important option for many patients, but a non-operative approach, with or without use of an endoscopic stent or placement of internal or external drains, should be considered when the clinical situation allows for a less invasive approach. The rarity of this emergency makes it difficult for a physician to obtain extensive individual clinical experience; it is also challenging to obtain firm scientific evidence that informs patient management and clinical decision-making. Improved attention to non-specific symptoms and signs and early diagnosis based on imaging may translate into better outcomes for this group of patients, many of whom are elderly with significant comorbidity. PMID:22035338

  17. Usability Testing and Adaptation of the Pediatric Cardiovascular Risk Reduction Clinical Decision Support Tool

    PubMed Central

    Furberg, Robert D; Bagwell, Jacqueline E; LaBresh, Kenneth A

    2016-01-01

    Background Cardiovascular disease (CVD) is 1 of the leading causes of death, years of life lost, and disability-adjusted years of life lost worldwide. CVD prevention for children and teens is needed, as CVD risk factors and behaviors beginning in youth contribute to CVD development. In 2012, the National Heart, Lung, and Blood Institute released their “Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents” for clinicians, describing CVD risk factors they should address with patients at primary care preventative visits. However, uptake of new guidelines is slow. Clinical decision support (CDS) tools can improve guideline uptake. In this paper, we describe our process of testing and adapting a CDS tool to help clinicians evaluate patient risk, recommend behaviors to prevent development of risk, and complete complex calculations to determine appropriate interventions as recommended by the guidelines, using a user-centered design approach. Objective The objective of the study was to assess the usability of a pediatric CVD risk factor tool by clinicians. Methods The tool was tested using one-on-one in-person testing and a “think aloud” approach with 5 clinicians and by using the tool in clinical practice along with formal usability metrics with 14 pediatricians. Thematic analysis of the data from the in-person testing and clinical practice testing identified suggestions for change in 3 major areas: user experience, content refinement, and technical deployment. Descriptive statistical techniques were employed to summarize users’ overall experience with the tool. Results Data from testers showed that general reactions toward the CDS tool were positive. Clinical practice testers suggested revisions to make the application more user-friendly, especially for clinicians using the application on the iPhone, and called for refining recommendations to be more succinct and better tailored to the patient. Tester feedback was

  18. The NIAID Division of AIDS enterprise information system: integrated decision support for global clinical research programs.

    PubMed

    Kagan, Jonathan M; Gupta, Nitin; Varghese, Suresh; Virkar, Hemant

    2011-12-01

    The National Institute of Allergy and Infectious Diseases (NIAID) Division of AIDS (DAIDS) Enterprise Information System (DAIDS-ES) is a web-based system that supports NIAID in the scientific, strategic, and tactical management of its global clinical research programs for HIV/AIDS vaccines, prevention, and therapeutics. Different from most commercial clinical trials information systems, which are typically protocol-driven, the DAIDS-ES was built to exchange information with those types of systems and integrate it in ways that help scientific program directors lead the research effort and keep pace with the complex and ever-changing global HIV/AIDS pandemic. Whereas commercially available clinical trials support systems are not usually disease-focused, DAIDS-ES was specifically designed to capture and incorporate unique scientific, demographic, and logistical aspects of HIV/AIDS treatment, prevention, and vaccine research in order to provide a rich source of information to guide informed decision-making. Sharing data across its internal components and with external systems, using defined vocabularies, open standards and flexible interfaces, the DAIDS-ES enables NIAID, its global collaborators and stakeholders, access to timely, quality information about NIAID-supported clinical trials which is utilized to: (1) analyze the research portfolio, assess capacity, identify opportunities, and avoid redundancies; (2) help support study safety, quality, ethics, and regulatory compliance; (3) conduct evidence-based policy analysis and business process re-engineering for improved efficiency. This report summarizes how the DAIDS-ES was conceptualized, how it differs from typical clinical trial support systems, the rationale for key design choices, and examples of how it is being used to advance the efficiency and effectiveness of NIAID's HIV/AIDS clinical research programs.

  19. Predictive Modeling of Physician-Patient Dynamics That Influence Sleep Medication Prescriptions and Clinical Decision-Making

    PubMed Central

    Beam, Andrew L.; Kartoun, Uri; Pai, Jennifer K.; Chatterjee, Arnaub K.; Fitzgerald, Timothy P.; Shaw, Stanley Y.; Kohane, Isaac S.

    2017-01-01

    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. PMID:28181568

  20. 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.

  1. Referring periodontal patients: clinical decision making by dental and dental hygiene students.

    PubMed

    Williams, Karen B; Burgardt, Grayson J; Rapley, John W; Bray, Kimberly K; Cobb, Charles M

    2014-03-01

    Referral of periodontal patients requires development of a complex set of decision making skills. This study was conducted to determine criteria used by dental and dental hygiene students regarding the referral of periodontal patients for specialty care. Using mixed methods, a thirteen-item survey was developed to elicit the students' perceptions of their knowledge, confidence regarding managing patients, and clinical reasoning related to periodontal patients. The instrument was administered during the summer prior to (T1) and at the end of the students' final year (T2) of training. Seventy-nine dental students (81 percent of total class) and thirty dental hygiene students (83 percent of total class) completed T1. At T2, forty-two dental (44 percent of total class) and twenty-six dental hygiene students (87 percent of total class) completed the questionnaire. While 90 percent of dental and 96 percent of dental hygiene respondents reported a willingness to refer patients with active disease to specialists, only 40 percent of dental and 36 percent of dental hygiene respondents reported confidence in diagnosing, treating, and appropriately referring such patients. The students' ability to recognize critical disease and risk factors influencing referral was good; however, clinical application of that knowledge indicated a gap between knowledge and applied reasoning. The students' attitudes about the importance of periodontal disease and their perceived competence to identify critical disease risk factors were not significantly related (p>0.05) to correct clinical decisions in the case scenarios. The study concludes that dental and dental hygiene curricula should emphasize both the acquisition and application of knowledge regarding criteria for referral of periodontal patients.

  2. Improving the care of children with urinary tract infection: use of a clinical decision proforma.

    PubMed

    Leach, Daniel

    2015-01-01

    Urinary tract infection (UTI) is a common and important clinical problem in children. Follow up imaging is indicated in some cases to reduce the risk of long-term harm from UTI and sometimes to help guide acute management. Overuse of imaging may be harmful due to radiation exposure, as well as increasing demand on services and budgets. On the other hand under-use of imaging may leave children vulnerable to renal damage and long-term morbidity. Accepted standards propose an imaging strategy specific to age and type of UTI. The complexity of the guideline makes compliance with the standards challenging. The aim of this project was to assess current practice for imaging of children with UTI managed at The Royal Oldham Hospital and to improve compliance with accepted standards through the use of a proforma to aid clinical decision making, supported by an education programme. A retrospective audit was performed over a 6 month period both prior to and after the intervention. The baseline audit found 57.7% of children treated for UTI (n=26) had imaging compliant with the accepted standards, which improved to 75.9% (n=29) on post-measurement. The percentage of inappropriate investigations reduced from 52.4% to 10.5%. The percentage of missed investigations reduced from 35.0% to 32.0%. The proforma was used and filed in 40% of cases where practice was in line with accepted standards. It was not used in any of the cases where practice deviated. In conclusion, a clear clinical decision aid, supported by an education programme, can significantly improve compliance with accepted standards for imaging of children with UTI. This may also be transferable to other scenarios where guidelines exist but have reduced efficacy due to complexity and/or lack of understanding.

  3. Cognitive and affective components of mental workload: Understanding the effects of each on human decision making behavior

    NASA Technical Reports Server (NTRS)

    Nygren, Thomas E.

    1992-01-01

    Human factors and ergonomics researchers have recognized for some time the increasing importance of understanding the role of the construct of mental workload in flight research. Current models of mental workload suggest that it is a multidimensional and complex construct, but one that has proved difficult to measure. Because of this difficulty, emphasis has usually been placed on using direct reports through subjective measures such as rating scales to assess levels of mental workload. The NASA Task Load Index (NASA/TLX, Hart and Staveland) has been shown to be a highly reliable and sensitive measure of perceived mental workload. But a problem with measures like TLX is that there is still considerable disagreement as to what it is about mental workload that these subjective measures are actually measuring. The empirical use of subjective workload measures has largely been to provide estimates of the cognitive components of the actual mental workload required for a task. However, my research suggests that these measures may, in fact have greater potential in accurately assessing the affective components of workload. That is, for example, TLX may be more likely to assess the positive and negative feelings associated with varying workload levels, which in turn may potentially influence the decision making behavior that directly bears on performance and safety issues. Pilots, for example, are often called upon to complete many complex tasks that are high in mental workload, stress, and frustration, and that have significant dynamic decision making components -- often ones that involve risk as well.

  4. Effects of time-pressure on decision-making under uncertainty: changes in affective state and information processing strategy.

    PubMed

    Maule, A J; Hockey, G R; Bdzola, L

    2000-06-01

    An experiment is reported that investigated the extent to which affective state, information processing strategy and task structure determine the effects of time-pressure on decision-making. Research participants were presented with risk scenarios involving a choice between safe and risky actions. The scenarios were systematically varied in terms of outcome valence (positive or negative) and effort associated with taking the safe action (high or low). Half the participants were given unlimited time to make their decision, the other half were required to choose within a deadline. The findings showed that time-pressured participants were more anxious and energetic and used a number of different strategies to cope with the deadline. These effects, as well as changes in risk-taking, were shown to vary systematically with task structure, particularly the effort manipulation. The findings are discussed in terms of how they contribute to theories of time-pressure and the methodological implications they have for future research in this area.

  5. Target templates: the precision of mental representations affects attentional guidance and decision-making in visual search

    PubMed Central

    Hout, Michael C.; Goldinger, Stephen D.

    2014-01-01

    When people look for things in the environment, they use target templates—mental representations of the objects they are attempting to locate—to guide attention and to assess incoming visual input as potential targets. However, unlike laboratory participants, searchers in the real world rarely have perfect knowledge regarding the potential appearance of targets. In seven experiments, we examined how the precision of target templates affects the ability to conduct visual search. Specifically, we degraded template precision in two ways: 1) by contaminating searchers’ templates with inaccurate features, and 2) by introducing extraneous features to the template that were unhelpful. We recorded eye movements to allow inferences regarding the relative extents to which attentional guidance and decision-making are hindered by template imprecision. Our findings support a dual-function theory of the target template and highlight the importance of examining template precision in visual search. PMID:25214306

  6. Autonomy, religion and clinical decisions: findings from a national physician survey

    PubMed Central

    Lawrence, R E; Curlin, F A

    2010-01-01

    Background Patient autonomy has been promoted as the most important principle to guide difficult clinical decisions. To examine whether practising physicians indeed value patient autonomy above other considerations, physicians were asked to weight patient autonomy against three other criteria that often influence doctors’ decisions. Associations between physicians’ religious characteristics and their weighting of the criteria were also examined. Methods Mailed survey in 2007 of a stratified random sample of 1000 US primary care physicians, selected from the American Medical Association masterfile. Physicians were asked how much weight should be given to the following: (1) the patient’s expressed wishes and values, (2) the physician’s own judgment about what is in the patient’s best interest, (3) standards and recommendations from professional medical bodies and (4) moral guidelines from religious traditions. Results Response rate 51% (446/879). Half of physicians (55%) gave the patient’s expressed wishes and values “the highest possible weight”. In comparative analysis, 40% gave patient wishes more weight than the other three factors, and 13% ranked patient wishes behind some other factor. Religious doctors tended to give less weight to the patient’s expressed wishes. For example, 47% of doctors with high intrinsic religious motivation gave patient wishes the “highest possible weight”, versus 67% of those with low (OR 0.5; 95% CI 0.3 to 0.8). Conclusions Doctors believe patient wishes and values are important, but other considerations are often equally or more important. This suggests that patient autonomy does not guide physicians’ decisions as much as is often recommended in the ethics literature. PMID:19332575

  7. Clinical experience with a decision support computer program using Bayes' theorem to diagnose chest pain patients.

    PubMed

    Aase, O

    1999-01-01

    A decision support computer program (DSP) was used by the emergency room physician as a diagnostic tool on patients admitted with acute chest pain to guide the referral of these patients either to the Coronary Care Unit (CCU) or general ward. The DSP used Bayes' theorem on 38 anamnestic and clinical variables to classify patients into one of nine diagnoses. During a six months trial period 32 physicians used the DSP to diagnose 493 patients admitted with acute chest pain. The physicians referred the patients to CCU or general ward based on their clinical judgements, the ECG findings and the diagnostic estimates given by the DSP. The program correctly diagnosed 150 (84%) of 178 patients with acute myocardial infarction and 63 of 112 patients with unstable angina. However, acute ischemic heart disease (acute myocardial infarction or unstable angina) was correctly classified by the DSP for 259 (89%) of 290 patients. By using the DSP, the number of patients unnecessarily referred to CCU was reduced from 35% to 19% and the number of patients in need of CCU observation misallocated to general ward was reduced from 13% to 10%. Thus, use of the DSP in the emergency room on easily available anamnestic and clinical variables may improve referrals to the CCU, optimize therapy and resource use.

  8. Longitudinal feasibility of MINDSET: a clinic decision aid for epilepsy self-management.

    PubMed

    Begley, Charles; Shegog, Ross; Harding, Angelique; Goldsmith, Corey; Hope, Omotola; Newmark, Michael

    2015-03-01

    The purpose of this paper is to report on the development and feasibility of the longitudinal version of MINDSET, a clinical tool to assist patients and health-care providers in epilepsy self-management. A previous study described the feasibility of using MINDSET to identify and prioritize self-management issues during a clinic visit. This paper describes the development of the longitudinal version of MINDSET and feasibility test over multiple visits with a printed action plan for goal setting and the capacity for monitoring changes in self-management. Feasibility was assessed based on 1) postvisit patient and provider interviews addressing ease of use and usefulness, patient/provider communication, and shared decision-making and 2) the capacity of the tool to monitor epilepsy characteristics and self-management over time. Results indicate MINDSET feasibility for 1) identifying and facilitating discussion of self-management issues during clinic visits, 2) providing a printable list of prioritized issues and tailored self-management goals, and 3) tracking changes in epilepsy characteristics and self-management over time.

  9. icuARM-An ICU Clinical Decision Support System Using Association Rule Mining

    PubMed Central

    Chanani, Nikhil; Venugopalan, Janani; Maher, Kevin; Wang, May Dongmei

    2013-01-01

    The rapid development of biomedical monitoring technologies has enabled modern intensive care units (ICUs) to gather vast amounts of multimodal measurement data about their patients. However, processing large volumes of complex data in real-time has become a big challenge. Together with ICU physicians, we have designed and developed an ICU clinical decision support system icuARM based on associate rule mining (ARM), and a publicly available research database MIMIC-II (Multi-parameter Intelligent Monitoring in Intensive Care II) that contains more than 40,000 ICU records for 30,000+patients. icuARM is constructed with multiple association rules and an easy-to-use graphical user interface (GUI) for care providers to perform real-time data and information mining in the ICU setting. To validate icuARM, we have investigated the associations between patients' conditions such as comorbidities, demographics, and medications and their ICU outcomes such as ICU length of stay. Coagulopathy surfaced as the most dangerous co-morbidity that leads to the highest possibility (54.1%) of prolonged ICU stay. In addition, women who are older than 50 years have the highest possibility (38.8%) of prolonged ICU stay. For clinical conditions treatable with multiple drugs, icuARM suggests that medication choice can be optimized based on patient-specific characteristics. Overall, icuARM can provide valuable insights for ICU physicians to tailor a patient's treatment based on his or her clinical status in real time. PMID:27170860

  10. The Arden Syntax standard for clinical decision support: experiences and directions.

    PubMed

    Samwald, Matthias; Fehre, Karsten; de Bruin, Jeroen; Adlassnig, Klaus-Peter

    2012-08-01

    Arden Syntax is a widely recognized standard for representing clinical and scientific knowledge in an executable format. It has a history that reaches back until 1989 and is currently maintained by the Health Level 7 (HL7) organization. We created a production-ready development environment, compiler, rule engine and application server for Arden Syntax. Over the course of several years, we have applied this Arden - Syntax - based CDS system in a wide variety of clinical problem domains, such as hepatitis serology interpretation, monitoring of nosocomial infections or the prediction of metastatic events in melanoma patients. We found the Arden Syntax standard to be very suitable for the practical implementation of CDS systems. Among the advantages of Arden Syntax are its status as an actively developed HL7 standard, the readability of the syntax, and various syntactic features such as flexible list handling. A major challenge we encountered was the technical integration of our CDS systems in existing, heterogeneous health information systems. To address this issue, we are currently working on incorporating the HL7 standard GELLO, which provides a standardized interface and query language for accessing data in health information systems. We hope that these planned extensions of the Arden Syntax might eventually help in realizing the vision of a global, interoperable and shared library of clinical decision support knowledge.

  11. [The added value of information summaries supporting clinical decisions at the point-of-care.

    PubMed

    Banzi, Rita; González-Lorenzo, Marien; Kwag, Koren Hyogene; Bonovas, Stefanos; Moja, Lorenzo

    2016-11-01

    Evidence-based healthcare requires the integration of the best research evidence with clinical expertise and patients' values. International publishers are developing evidence-based information services and resources designed to overcome the difficulties in retrieving, assessing and updating medical information as well as to facilitate a rapid access to valid clinical knowledge. Point-of-care information summaries are defined as web-based medical compendia that are specifically designed to deliver pre-digested, rapidly accessible, comprehensive, and periodically updated information to health care providers. Their validity must be assessed against marketing claims that they are evidence-based. We periodically evaluate the content development processes of several international point-of-care information summaries. The number of these products has increased along with their quality. The last analysis done in 2014 identified 26 products and found that three of them (Best Practice, Dynamed e Uptodate) scored the highest across all evaluated dimensions (volume, quality of the editorial process and evidence-based methodology). Point-of-care information summaries as stand-alone products or integrated with other systems, are gaining ground to support clinical decisions. The choice of one product over another depends both on the properties of the service and the preference of users. However, even the most innovative information system must rely on transparent and valid contents. Individuals and institutions should regularly assess the value of point-of-care summaries as their quality changes rapidly over time.

  12. 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.

  13. [From library to clinical decision support systems: access of general practitioner to quality information].

    PubMed

    Fauquert, B

    2012-09-01

    Since 2003, the following tools have been implemented in Belgium for improving the access of general practioners to the EBM literature: the Digital Library for Health and the evidence-linker of the CEBAM, the portal EBMPracticeNet.be and the multidimensional electronic clinical decision support EBMeDS. The aim of this article is to show the progress achieved in the information dissemination toward the belgian general practioners, particularly the access from the electronic health record. From the literature published these last years, the opportunities cited by the users are for using EBM and the strong willingness for using these literature access in the future; the limits are the medical data coding, the irrelevance of the search results, the alerts fatigue induced by EBMeDS. The achievements done and planned for the new EBMPracticeNet guidelines portal and the EBMeDS system are explained in the aim of informing belgian healthcare professionals. These projects are claiming for lauching a participatory process in the production and dissemination of EBM information. The discussion is focused on the belgian healthcare system advantages, the solutions for a reasonable implementation of these projects and for increasing the place of an evidence-based information in the healthcare decision process. Finally the input of these projects to the continuing medical education and to the healthcare quality are discussed, in a context of multifactorial interaction healthcare design (complexity design).

  14. An image feature-based approach to automatically find images for application to clinical decision support.

    PubMed

    Stanley, R Joe; De, Soumya; Demner-Fushman, Dina; Antani, Sameer; Thoma, George R

    2011-07-01

    The illustrations in biomedical publications often provide useful information in aiding clinicians' decisions when full text searching is performed to find evidence in support of a clinical decision. In this research, image analysis and classification techniques are explored to automatically extract information for differentiating specific modalities to characterize illustrations in biomedical publications, which may assist in the evidence finding process. Global, histogram-based, and texture image illustration features were compared to basis function luminance histogram correlation features for modality-based discrimination over a set of 742 manually annotated images by modality (radiological, photo, etc.) selected from the 2004-2005 issues of the British Journal of Oral and Maxillofacial Surgery. Using a mean shifting supervised clustering technique, automatic modality-based discrimination results as high as 95.57% were obtained using the basis function features. These results compared favorably to other feature categories examined. The experimental results show that image-based features, particularly correlation-based features, can provide useful modality discrimination information.

  15. Using brain-based cognitive measures to support clinical decisions in ADHD.

    PubMed

    Williams, Leanne M; Hermens, Daniel F; Thein, Thida; Clark, C Richard; Cooper, Nicholas J; Clarke, Simon D; Lamb, Chris; Gordon, Evian; Kohn, Michael R

    2010-02-01

    Measures of cognition support diagnostic and treatment decisions in attention deficit hyperactivity disorder. We used an integrative neuroscience framework to assess cognition and associated brain-function correlates in large attention deficit hyperactivity disorder and healthy groups. Matched groups of 175 attention deficit hyperactivity disorder children/adolescents and 175 healthy control subjects were assessed clinically, with the touch screen-based cognitive assessment battery "IntegNeuro" (Brain Resource Ltd., Sydney, Australia) and the "LabNeuro" (Brain Resource Ltd., Sydney, Australia) platform for psychophysiologic recordings of brain function and body arousal. IntegNeuro continuous performance task measures of sustained attention classified 68% of attention deficit hyperactivity disorder patients with 76% specificity, consistent with previous reports. Our additional cognitive measures of impulsivity, intrusive errors, inhibition, and response variability improved sensitivity to 88%, and specificity to 91%. Positive predictive power was 96%, and negative predictive power, 88%. These metrics were stable across attention deficit hyperactivity disorder subtypes and age. Consistent with their brain-based validity, cognitive measures were correlated with corresponding brain-function and body-arousal measures. We propose a combination of candidate cognitive "markers" that define a signature for attention deficit hyperactivity disorder: "sustained attention," "impulsivity," "inhibition," "intrusions," and "response variability." These markers offer a frame of reference to support diagnostic and treatment decisions, and an objective benchmark for monitoring outcomes of interventions.

  16. Can Psychological, Social and Demographical Factors Predict Clinical Characteristics Symptomatology of Bipolar Affective Disorder and Schizophrenia?

    PubMed

    Maciukiewicz, Malgorzata; Pawlak, Joanna; Kapelski, Pawel; Łabędzka, Magdalena; Skibinska, Maria; Zaremba, Dorota; Leszczynska-Rodziewicz, Anna; Dmitrzak-Weglarz, Monika; Hauser, Joanna

    2016-09-01

    Schizophrenia (SCH) is a complex, psychiatric disorder affecting 1 % of population. Its clinical phenotype is heterogeneous with delusions, hallucinations, depression, disorganized behaviour and negative symptoms. Bipolar affective disorder (BD) refers to periodic changes in mood and activity from depression to mania. It affects 0.5-1.5 % of population. Two types of disorder (type I and type II) are distinguished by severity of mania episodes. In our analysis, we aimed to check if clinical and demographical characteristics of the sample are predictors of symptom dimensions occurrence in BD and SCH cases. We included total sample of 443 bipolar and 439 schizophrenia patients. Diagnosis was based on DSM-IV criteria using Structured Clinical Interview for DSM-IV. We applied regression models to analyse associations between clinical and demographical traits from OPCRIT and symptom dimensions. We used previously computed dimensions of schizophrenia and bipolar affective disorder as quantitative traits for regression models. Male gender seemed protective factor for depression dimension in schizophrenia and bipolar disorder sample. Presence of definite psychosocial stressor prior disease seemed risk factor for depressive and suicidal domain in BD and SCH. OPCRIT items describing premorbid functioning seemed related with depression, positive and disorganised dimensions in schizophrenia and psychotic in BD. We proved clinical and demographical characteristics of the sample are predictors of symptom dimensions of schizophrenia and bipolar disorder. We also saw relation between clinical dimensions and course of disorder and impairment during disorder.

  17. Service oriented architecture for clinical decision support: a systematic review and future directions.

    PubMed

    Loya, Salvador Rodriguez; Kawamoto, Kensaku; Chatwin, Chris; Huser, Vojtech

    2014-12-01

    The use of a service-oriented architecture (SOA) has been identified as a promising approach for improving health care by facilitating reliable clinical decision support (CDS). A review of the literature through October 2013 identified 44 articles on this topic. The review suggests that SOA related technologies such as Business Process Model and Notation (BPMN) and Service Component Architecture (SCA) have not been generally adopted to impact health IT systems' performance for better care solutions. Additionally, technologies such as Enterprise Service Bus (ESB) and architectural approaches like Service Choreography have not been generally exploited among researchers and developers. Based on the experience of other industries and our observation of the evolution of SOA, we found that the greater use of these approaches have the potential to significantly impact SOA implementations for CDS.

  18. Colon trauma--clinical staging for surgical decision making. Analysis of 119 cases.

    PubMed

    Morgado, P J; Alfaro, R; Morgado, P J; León, P

    1992-10-01

    A retrospective study is presented of 119 patients admitted to the Central Hospital of the Venezuelan Institute of Social Security, in Caracas, between 1982 and 1990, with the diagnosis of colon trauma. Several parameters including age, etiology, time elapsed between the accident or assault and hospital admission, preoperative and postoperative hemoglobin and diastolic blood pressure, associated lesions, procedure practiced, complication rate, and hospital mortality are reviewed. The second and third decades of life appear most often involved. Most patients reached the hospital within the first four hours of the accident or assault. Anemia, sustained diastolic hypotension, and number of organs involved in addition to the colon were important prognostic factors for complications. Apparently the surgical procedure, with simple suture or resection, mostly without "protective" colostomy, was not very relevant. Hospital mortality was 2.4 percent. A staging system based on clinical conditions for decision making in the operating room was used in an attempt to inject some objectivity into the surgical approach.

  19. An Investigation of Factors Influencing Nurses' Clinical Decision-Making Skills.

    PubMed

    Wu, Min; Yang, Jinqiu; Liu, Lingying; Ye, Benlan

    2016-08-01

    This study aims to investigate the influencing factors on nurses' clinical decision-making (CDM) skills. A cross-sectional nonexperimental research design was conducted in the medical, surgical, and emergency departments of two university hospitals, between May and June 2014. We used a quantile regression method to identify the influencing factors across different quantiles of the CDM skills distribution and compared the results with the corresponding ordinary least squares (OLS) estimates. Our findings revealed that nurses were best at the skills of managing oneself. Educational level, experience, and the total structural empowerment had significant positive impacts on nurses' CDM skills, while the nurse-patient relationship, patient care and interaction, formal empowerment, and information empowerment were negatively correlated with nurses' CDM skills. These variables explained no more than 30% of the variance in nurses' CDM skills and mainly explained the lower quantiles of nurses' CDM skills distribution.

  20. Bayesian decision sequential analysis with survival endpoint in phase II clinical trials.

    PubMed

    Zhao, Lili; Woodworth, George

    2009-04-30

    Chen and Chaloner (Statist. Med. 2006; 25:2956-2966. DOI: 10.1002/sim.2429) present a Bayesian stopping rule for a single-arm clinical trial with a binary endpoint. In some cases, earlier stopping may be possible by basing the stopping rule on the time to a binary event. We investigate the feasibility of computing exact, Bayesian, decision-theoretic time-to-event stopping rules for a single-arm group sequential non-inferiority trial relative to an objective performance criterion. For a conjugate prior distribution, exponential failure time distribution, and linear and threshold loss structures, we obtain the optimal Bayes stopping rule by backward induction. We compute frequentist operating characteristics of including Type I error, statistical power, and expected run length. We also briefly address design issues.

  1. Recurrent neural networks in computer-based clinical decision support for laryngopathies: an experimental study.

    PubMed

    Szkoła, Jarosław; Pancerz, Krzysztof; Warchoł, Jan

    2011-01-01

    The main goal of this paper is to give the basis for creating a computer-based clinical decision support (CDS) system for laryngopathies. One of approaches which can be used in the proposed CDS is based on the speech signal analysis using recurrent neural networks (RNNs). RNNs can be used for pattern recognition in time series data due to their ability of memorizing some information from the past. The Elman networks (ENs) are a classical representative of RNNs. To improve learning ability of ENs, we may modify and combine them with another kind of RNNs, namely, with the Jordan networks. The modified Elman-Jordan networks (EJNs) manifest a faster and more exact achievement of the target pattern. Validation experiments were carried out on speech signals of patients from the control group and with two kinds of laryngopathies.

  2. Randomized Trial of Population-Based Clinical Decision Support to Facilitate Care Transitions.

    PubMed

    Eisenstein, Eric L; Willis, Janese M; Edwards, Rex; Anstrom, Kevin J; Kawamoto, Kensaku; Fiol, Guilherme Del; Johnson, Fred S; Lobach, David F

    2017-01-01

    Medicaid beneficiaries in 6 North Carolina counties were randomly assigned to 1 of 3 clinical decision support (CDS) care transition strategies: (1) usual care (Control), (2) CDS messaging to patients and their medical homes (Reports), or (3) CDS messaging to patients, their medical homes, and their care managers (Reports+). We included 7146 Medicaid patients and evaluated transitions from specialist visit, ER and hospital encounters back to the patient's medical home. Patients enrolled in Medicare and Medicaid were not eligible. The number of care manager contacts was greater for patients in the Reports+ Group than in the Control Group. However, there were no treatment-related differences in emergency department (ED) encounter rates, or in the secondary outcomes of outpatient and hospital encounter rates and medical costs. Study monitors found study intervention documentation in approximately 60% of patient charts. These results highlight the importance of effectively integrating information interventions into healthcare delivery workflow systems.

  3. Patients' Perceptions and Experiences of Shared Decision-Making in Primary HIV Care Clinics.

    PubMed

    Fuller, Shannon M; Koester, Kimberly A; Guinness, Ryan R; Steward, Wayne T

    Shared decision-making (SDM) is considered best practice in health care. Prior studies have explored attitudes and barriers/facilitators to SDM, with few specific to HIV care. We interviewed 53 patients in HIV primary care clinics in California to understand the factors and situations that may promote or hinder engagement in SDM. Studies in other populations have found that patients' knowledge about their diseases and their trust in providers facilitated SDM. We found these features to be more nuanced for HIV. Perceptions of personal agency, knowledge about one's disease, and trust in provider were factors that could work for or against SDM. Overall, we found that participants described few experiences of SDM, especially among those with no comorbidities. Opportunities for SDM in routine HIV care (e.g., determining antiretroviral therapy) may arise infrequently because of treatment advances. These findings yield considerations for adapting SDM to fit the context of HIV care.

  4. Partnering With Your Health System to Select and Implement Clinical Decision Support for Imaging.

    PubMed

    Jensen, Jeff D; Durand, Daniel J

    2017-02-01

    Recent legislation mandates the documentation of appropriateness criteria consultation when ordering advanced imaging for Medicare patients to remain eligible for reimbursement. Implementation of imaging clinical decision support (CDS) is a solution adopted by many systems to automate compliance with the new requirements. This article is intended to help radiologists who are employed by, contracted with, or otherwise affiliated with systems planning to implement CDS in the near future and ensure that they are able to understand and contribute to the process wherever possible. It includes an in-depth discussion of the legislation, evidence for and against the efficacy of imaging CDS, considerations for selecting a CDS vendor, tips for configuring CDS in a fashion consistent with departmental goals, and pointers for implementation and change management.

  5. Implementing a decision-theoretic design in clinical trials: why and how?

    PubMed

    Palmer, Christopher R; Shahumyan, Harutyun

    2007-11-30

    This paper addresses two main questions: first, why should Bayesian and other innovative, data-dependent design models be put into practice and, secondly, given the past dearth of actual applications, how might one example of such a design be implemented in a genuine example trial? Clinical trials amalgamate theory, practice and ethics, but this last point has become relegated to the background, rather than taking often a more appropriate primary role. Trial practice has evolved but has its roots in R. A. Fisher's randomized agricultural field trials of the 1920s. Reasons for, and consequences of, this are discussed from an ethical standpoint, drawing on an under-used dichotomy introduced by French authors Lellouch and Schwartz (Int. Statist. Rev. 1971; 39:27-36). Plenty of ethically motivated designs for trials, including Bayesian designs have been proposed, but have found little application thus far. One reason for this is a lack of awareness of such alternative designs among trialists, while another reason is a lack of user-friendly software to allow study simulations. To encourage implementation, a new C++ program called 'Daniel' is introduced, offering much potential to assist the design of today's randomized controlled trials. Daniel evaluates a particular decision-theoretic method suitable for coping with either two or three Bernoulli response treatments with input features allowing user-specified choices of: patient horizon (number to be treated before and after the comparative stages of the trial); an arbitrary fixed trial truncation size (to allow ready comparison with traditional designs or to cope with practical constraints); anticipated success rates and a measure of their uncertainty (a matter ignored in standard power calculations); and clinically relevant, and irrelevant, differences in treatment effect sizes. Error probabilities and expected trial durations can be thoroughly explored via simulation, it being better by far to harm 'computer patients

  6. The 2013 symposium on pathology data integration and clinical decision support and the current state of field

    PubMed Central

    Baron, Jason M.; Dighe, Anand S.; Arnaout, Ramy; Balis, Ulysses J.; Black-Schaffer, W. Stephen; Carter, Alexis B.; Henricks, Walter H.; Higgins, John M.; Jackson, Brian R.; Kim, JiYeon; Klepeis, Veronica E.; Le, Long P.; Louis, David N.; Mandelker, Diana; Mermel, Craig H.; Michaelson, James S.; Nagarajan, Rakesh; Platt, Mihae E.; Quinn, Andrew M.; Rao, Luigi; Shirts, Brian H.; Gilbertson, John R.

    2014-01-01

    Background: Pathologists and informaticians are becoming increasingly interested in electronic clinical decision support for pathology, laboratory medicine and clinical diagnosis. Improved decision support may optimize laboratory test selection, improve test result interpretation and permit the extraction of enhanced diagnostic information from existing laboratory data. Nonetheless, the field of pathology decision support is still developing. To facilitate the exchange of ideas and preliminary studies, we convened a symposium entitled: Pathology data integration and clinical decision support. Methods: The symposium was held at the Massachusetts General Hospital, on May 10, 2013. Participants were selected to represent diverse backgrounds and interests and were from nine different institutions in eight different states. Results: The day included 16 plenary talks and three panel discussions, together covering four broad areas. Summaries of each presentation are included in this manuscript. Conclusions: A number of recurrent themes emerged from the symposium. Among the most pervasive was the dichotomy between diagnostic data and diagnostic information, including the opportunities that laboratories may have to use electronic systems and algorithms to convert the data they generate into more useful information. Differences between human talents and computer abilities were described; well-designed symbioses between humans and computers may ultimately optimize diagnosis. Another key theme related to the unique needs and challenges in providing decision support for genomics and other emerging diagnostic modalities. Finally, many talks relayed how the barriers to bringing decision support toward reality are primarily personnel, political, infrastructural and administrative challenges rather than technological limitations. PMID:24672737

  7. Clinical decision making by dentists working in the NHS General Dental Services since April 2006.

    PubMed

    Davies, B J B; Macfarlane, F

    2010-11-27

    In April 2006 a new contract was introduced that governed how NHS General Dental Practitioners would be funded for the services they provide. This study looks at the impact that the contract has had in the three years since its introduction, evaluating its influence on the clinical care that patients receive and the clinical decisions that dentists are making. This qualitative service evaluation involved interviewing 12 dentists representative of a range of NHS dentists involved with the new NHS dental contract using a semi-structured approach. We found evidence that the new contract has led to dentists making different decisions in their daily practice and sometimes altering their treatment plans and referral patterns to ensure that their business is not disadvantaged. Access to care for some patients without a regular dentist can be compromised by the new contract as it can be financially challenging for a dentist to accept to care for a new patient who has an unknown and potentially large need for treatment. Cherry-picking of potentially more profitable patients may be common. The incentive is to watch borderline problems rather than to treat if a treatment band threshold has already been crossed and treatment may be delayed until a later course of treatment for the same reason. Dentists often feel that complex treatments (for example, endodontic treatments) are financially unviable. Some dentists are referring difficult cases that might previously have been treated 'in house', such as extractions, to another provider, as this enables offloading of costs while potentially retaining full fees. Younger and less experienced dentists may be further pressured.

  8. Clinical and surgical data of affected members of a classic CFEOM 1 family

    PubMed Central

    Magli, Adriano; de Berardinis, Teresa; D'Esposito, Fabiana; Gagliardi, Vincenzo

    2003-01-01

    Background Congenital fibiosis of the extraocular muscles (CFEOM1) refers to a group of congenital eye movement disorders that are characterized by non-progressive restrictive ophthalmoplegia. We present clinical and surgical data on affected members of a classic CFEOM1 family. Methods Ten members of a fifteen-member, three-generation Italian family affected by classic CFEOM participated in this study. Each affected family member underwent ophthalmologic (corrected visual acuity, pupillary function, anterior segment and fundus examination), orthoptic (cover test, cover-uncover test, prism alternate cover test), and preoperative examinations. Eight of the ten affected members had surgery and underwent postoperative examinations. Surgical procedures are listed. Results All affected members were born with varying degrees of bilateral ptosis and ophthalmoplegia with both eyes fixed in a hypotropic position (classic CFEOM). The affected members clinical data prior to surgery, surgery procedures and postoperative outcomes are presented. On 14 operated eyes to correct ptosis there was an improvement in 12 eyes. In addition, the head position improved in all patients. Conclusions Surgery is effective at improving ptosis in the majority of patients with classic CFEOM. However, the surgical approach should be individualized to each patient, as inherited CFEOM exhibits variable expressivity and the clinical features may differ markedly between affected individuals, even within the same family. PMID:12702216

  9. Comparison of Decision-Assist and Clinical Judgment of Experts for Prediction of Lifesaving Interventions.

    PubMed

    Mackenzie, Colin F; Gao, Cheng; Hu, Peter F; Anazodo, Amechi; Chen, Hegang; Dinardo, Theresa; Imle, P Cristina; Hartsky, Lauren; Stephens, Christopher; Menaker, Jay; Fouche, Yvette; Murdock, Karen; Galvagno, Samuel; Alcorta, Richard; Shackelford, Stacy

    2015-03-01

    Early recognition of hemorrhage during the initial resuscitation of injured patients is associated with improved survival in both civilian and military casualties. We tested a transfusion and lifesaving intervention (LSI) prediction algorithm in comparison with clinical judgment of expert trauma care providers. We collected 15 min of pulse oximeter photopletysmograph waveforms and extracted features to predict LSIs. We compared this with clinical judgment of LSIs by individual categories of prehospital providers, nurses, and physicians and a combined judgment of all three providers using the Area Under Receiver Operating Curve (AUROC). We obtained clinical judgment of need for LSI from 405 expert clinicians in135 trauma patients. The pulse oximeter algorithm predicted transfusion within 6 h (AUROC, 0.92; P < 0.003) more accurately than either physicians or prehospital providers and as accurately as nurses (AUROC, 0.76; P = 0.07). For prediction of surgical procedures, the algorithm was as accurate as the three categories of clinicians. For prediction of fluid bolus, the diagnostic algorithm (AUROC, 0.9) was significantly more accurate than prehospital providers (AUROC, 0.62; P = 0.02) and nurses (AUROC, 0.57; P = 0.04) and as accurate as physicians (AUROC, 0.71; P = 0.06). Prediction of intubation by the algorithm (AUROC, 0.92) was as accurate as each of the three categories of clinicians. The algorithm was more accurate (P < 0.03) for blood and fluid prediction than the combined clinical judgment of all three providers but no different from the clinicians in the prediction of surgery (P = 0.7) or intubation (P = 0.8). Automated analysis of 15 min of pulse oximeter waveforms predicts the need for LSIs during initial trauma resuscitation as accurately as judgment of expert trauma clinicians. For prediction of emergency transfusion and fluid bolus, pulse oximetry features were more accurate than these experts. Such automated decision support could assist

  10. Summary of the proceedings of the international forum 2016: "Imaging referral guidelines and clinical decision support - how can radiologists implement imaging referral guidelines in clinical routine?"

    PubMed

    2017-02-01

    The International Forum is held once a year by the ESR and its international radiological partner societies with the aim to address and discuss selected subjects of global relevance in radiology. In 2016, the issue of implementing imaging referral guidelines in clinical routine was analysed. The legal environment in the USA requires that after January 1, 2017, physicians must consult government-approved, evidence-based appropriate-use criteria through a clinical decision support system when ordering advanced diagnostic imaging exams. The ESR and the National Decision Support Company are developing "ESR iGuide", a clinical decision support system for European imaging referral guidelines using ESR imaging referral guidelines based on ACR Appropriateness Criteria. In many regions of the world, the situation is different and quite diverse, depending on the specific features of health care systems in different countries, but there are, unlike in the USA and EU, no legal obligations to implement imaging referral guidelines into the clinical practice. Imaging referral guidelines and clinical decision support implementation is a complex issue everywhere and the legal environment surrounding it even more so; how they will be implemented into the clinical practice in different areas of the world needs yet to be decided.

  11. Clinical Performance and Management Outcomes with the DecisionDx-UM Gene Expression Profile Test in a Prospective Multicenter Study.

    PubMed

    Plasseraud, Kristen Meldi; Cook, Robert W; Tsai, Tony; Shildkrot, Yevgeniy; Middlebrook, Brooke; Maetzold, Derek; Wilkinson, Jeff; Stone, John; Johnson, Clare; Oelschlager, Kristen; Aaberg, Thomas M

    2016-01-01

    Uveal melanoma management is challenging due to its metastatic propensity. DecisionDx-UM is a prospectively validated molecular test that interrogates primary tumor biology to provide objective information about metastatic potential that can be used in determining appropriate patient care. To evaluate the continued clinical validity and utility of DecisionDx-UM, beginning March 2010, 70 patients were enrolled in a prospective, multicenter, IRB-approved study to document patient management differences and clinical outcomes associated with low-risk Class 1 and high-risk Class 2 results indicated by DecisionDx-UM testing. Thirty-seven patients in the prospective study were Class 1 and 33 were Class 2. Class 1 patients had 100% 3-year metastasis-free survival compared to 63% for Class 2 (log rank test p = 0.003) with 27.3 median follow-up months in this interim analysis. Class 2 patients received significantly higher-intensity monitoring and more oncology/clinical trial referrals compared to Class 1 patients (Fisher's exact test p = 2.1 × 10(-13) and p = 0.04, resp.). The results of this study provide additional, prospective evidence in an independent cohort of patients that Class 1 and Class 2 patients are managed according to the differential metastatic risk indicated by DecisionDx-UM. The trial is registered with Clinical Application of DecisionDx-UM Gene Expression Assay Results (NCT02376920).

  12. Clinical decision-making: midwifery students' recognition of, and response to, post partum haemorrhage in the simulation environment

    PubMed Central

    2012-01-01

    Background This paper reports the findings of a study of how midwifery students responded to a simulated post partum haemorrhage (PPH). Internationally, 25% of maternal deaths are attributed to severe haemorrhage. Although this figure is far higher in developing countries, the risk to maternal wellbeing and child health problem means that all midwives need to remain vigilant and respond appropriately to early signs of maternal deterioration. Methods Simulation using a patient actress enabled the research team to investigate the way in which 35 midwifery students made decisions in a dynamic high fidelity PPH scenario. The actress wore a birthing suit that simulated blood loss and a flaccid uterus on palpation. The scenario provided low levels of uncertainty and high levels of relevant information. The student's response to the scenario was videoed. Immediately after, they were invited to review the video, reflect on their performance and give a commentary as to what affected their decisions. The data were analysed using Dimensional Analysis. Results The students' clinical management of the situation varied considerably. Students struggled to prioritise their actions where more than one response was required to a clinical cue and did not necessarily use mnemonics as heuristic devices to guide their actions. Driven by a response to single cues they also showed a reluctance to formulate a diagnosis based on inductive and deductive reasoning cycles. This meant they did not necessarily introduce new hypothetical ideas against which they might refute or confirm a diagnosis and thereby eliminate fixation error. Conclusions The students response demonstrated that a number of clinical skills require updating on a regular basis including: fundal massage technique, the use of emergency standing order drugs, communication and delegation of tasks to others in an emergency and working independently until help arrives. Heuristic devices helped the students to evaluate their

  13. [Adequacy of clinical interventions in patients with advanced and complex disease. Proposal of a decision making algorithm].

    PubMed

    Ameneiros-Lago, E; Carballada-Rico, C; Garrido-Sanjuán, J A; García Martínez, A

    2015-01-01

    Decision making in the patient with chronic advanced disease is especially complex. Health professionals are obliged to prevent avoidable suffering and not to add any more damage to that of the disease itself. The adequacy of the clinical interventions consists of only offering those diagnostic and therapeutic procedures appropriate to the clinical situation of the patient and to perform only those allowed by the patient or representative. In this article, the use of an algorithm is proposed that should serve to help health professionals in this decision making process.

  14. Cognitive elements in clinical decision-making: toward a cognitive model for medical education and understanding clinical reasoning.

    PubMed

    Dunphy, Bruce C; Cantwell, Robert; Bourke, Sid; Fleming, Mark; Smith, Bruce; Joseph, K S; Dunphy, Stacey L

    2010-05-01

    Physician cognition, metacognition and affect may have an impact upon the quality of clinical reasoning. The purpose of this study was to examine the relationship between measures of physician metacognition and affect and patient outcomes in obstetric practice. Reflective coping (RC), proactive coping, need for cognition (NFC), tolerance for ambiguity, state-trait anxiety and metacognitive awareness were assessed for obstetricians (n = 12) who provided intra-partum care to 4,149 women. Outcome measures included delivery mode and intrapartum asphyxia. Analysis was carried out using logistic regression and tree-based classification. Obstetricians with high RC scores were more likely to perform a caesarean section (OR 1.59, p < 0.0001), less likely undertake a mid-forceps or low forceps delivery (OR 0.41, p < 0.0001; OR 0.49, p < 0.0001), and more likely to supervise a spontaneous vaginal delivery (OR 1.17, p = 0.08). Obstetricians with high NFC scores were more likely to perform a caesarean section (OR 1.53, p = 0.03), more likely to undertake a vacuum delivery (OR 5.8, p = 0.001), less likely undertake a mid-forceps delivery (OR 0.45, p = 0.02) and less likely to supervise a spontaneous vaginal delivery (OR 0.47, p < 0.0001). Obstetricians high in trait anxiety were more likely to perform a mid forceps delivery (OR 2.49, p = 0.01) or a vacuum delivery (OR 5.08, p = 0.003), and less likely to supervise a spontaneous vaginal delivery (OR 0.38, p < 0.0001). NFC was negatively associated (OR 0.10, p < 0.001) and trait anxiety was positively associated with intrapartum asphyxia (p < 0.05, rho = 0.582). In summary, physician cognitive processes and affect have a significant impact on patient outcomes, particularly in situations where there is a higher level of clinical unpredictability.

  15. Using evidence-based algorithms to improve clinical decision making: the case of a first-time anterior shoulder dislocation.

    PubMed

    Federer, Andrew E; Taylor, Dean C; Mather, Richard C

    2013-09-01

    Decision making in health care has evolved substantially over the last century. Up until the late 1970s, medical decision making was predominantly intuitive and anecdotal. It was based on trial and error and involved high levels of problem solving. The 1980s gave way to empirical medicine, which was evidence based probabilistic, and involved pattern recognition and less problem solving. Although this represented a major advance in the quality of medical decision making, limitations existed. The advantages of the gold standard of the randomized controlled clinical trial (RCT) are well-known and this technique is irreplaceable in its ability to answer critical clinical questions. However, the RCT does have drawbacks. RCTs are expensive and can only capture a snapshot in time. As treatments change and new technologies emerge, new expensive clinical trials must be undertaken to reevaluate them. Furthermore, in order to best evaluate a single intervention, other factors must be controlled. In addition, the study population may not match that of another organization or provider. Although evidence-based medicine has provided powerful data for clinicians, effectively and efficiently tailoring it to the individual has not yet evolved. We are now in a period of transition from this evidence-based era to one dominated by the personalization and customization of care. It will be fueled by policy decisions to shift financial responsibility to the patient, creating a powerful and sophisticated consumer, unlike any patient we have known before. The challenge will be to apply medical evidence and personal preferences to medical decisions and deliver it efficiently in the increasingly busy clinical setting. In this article, we provide a robust review of the concepts of customized care and some of techniques to deliver it. We will illustrate this through a personalized decision model for the treatment decision after a first-time anterior shoulder dislocation.

  16. Clinical decision support for drug related events: Moving towards better prevention

    PubMed Central

    Kane-Gill, Sandra L; Achanta, Archita; Kellum, John A; Handler, Steven M

    2016-01-01

    Clinical decision support (CDS) systems with automated alerts integrated into electronic medical records demonstrate efficacy for detecting medication errors (ME) and adverse drug events (ADEs). Critically ill patients are at increased risk for ME, ADEs and serious negative outcomes related to these events. Capitalizing on CDS to detect ME and prevent adverse drug related events has the potential to improve patient outcomes. The key to an effective medication safety surveillance system incorporating CDS is advancing the signals for alerts by using trajectory analyses to predict clinical events, instead of waiting for these events to occur. Additionally, incorporating cutting-edge biomarkers into alert knowledge in an effort to identify the need to adjust medication therapy portending harm will advance the current state of CDS. CDS can be taken a step further to identify drug related physiological events, which are less commonly included in surveillance systems. Predictive models for adverse events that combine patient factors with laboratory values and biomarkers are being established and these models can be the foundation for individualized CDS alerts to prevent impending ADEs. PMID:27896144

  17. Effect of Focused Bedside Ultrasonography in Hypotensive Patients on the Clinical Decision of Emergency Physicians

    PubMed Central

    Gungor, Faruk; Guven, Ramazan; Akyol, K. Can; Kozaci, Nalan; Kesapli, Mustafa

    2017-01-01

    We assessed the effect of focused point of care ultrasound (POCUS) used for critical nontraumatic hypotensive patients presenting to the emergency department of our hospital on the clinical decisions of the physicians and whether it led to the modification of the treatment modality. This prospective clinical study was conducted at the Emergency Department of Antalya Training and Research Hospital. Nontraumatic patients aged 18 and older who presented to our emergency department and whose systolic blood pressure was <100 mmHg or shock index (heart rate/systolic blood pressure) was >1 were included in the study. While the most probable preliminary diagnosis established by the physician before POCUS was consistent with the definitive diagnosis in 60.6% (n = 109) of 180 patients included in the study, it was consistent with the definitive diagnosis in 85.0% (n = 153) of the patients after POCUS (p < 0.001). POCUS performed for critical hypotensive patients presenting to the emergency department is an appropriate diagnostic tool that can be used to enable the physicians to make the accurate preliminary diagnosis and start the appropriate treatment in a short time. PMID:28357139

  18. Clinical Decision Support Alert Appropriateness: A Review and Proposal for Improvement

    PubMed Central

    McCoy, Allison B.; Thomas, Eric J.; Krousel-Wood, Marie; Sittig, Dean F.

    2014-01-01

    Background Many healthcare providers are adopting clinical decision support (CDS) systems to improve patient safety and meet meaningful use requirements. Computerized alerts that prompt clinicians about drug-allergy, drug-drug, and drug-disease warnings or provide dosing guidance are most commonly implemented. Alert overrides, which occur when clinicians do not follow the guidance presented by the alert, can hinder improved patient outcomes. Methods We present a review of CDS alerts and describe a proposal to develop novel methods for evaluating and improving CDS alerts that builds upon traditional informatics approaches. Our proposal incorporates previously described models for predicting alert overrides that utilize retrospective chart review to determine which alerts are clinically relevant and which overrides are justifiable. Results Despite increasing implementations of CDS alerts, detailed evaluations rarely occur because of the extensive labor involved in manual chart reviews to determine alert and response appropriateness. Further, most studies have solely evaluated alert overrides that are appropriate or justifiable. Our proposal expands the use of web-based monitoring tools with an interactive dashboard for evaluating CDS alert and response appropriateness that incorporates the predictive models. The dashboard provides 2 views, an alert detail view and a patient detail view, to provide a full history of alerts and help put the patient's events in context. Conclusion The proposed research introduces several innovations to address the challenges and gaps in alert evaluations. This research can transform alert evaluation processes across healthcare settings, leading to improved CDS, reduced alert fatigue, and increased patient safety. PMID:24940129

  19. Usability of Selected Databases for Low-Resource Clinical Decision Support

    PubMed Central

    Sheets, L; Callaghan, F.; Gavino, A.; Liu, F.; Fontelo, P.

    2012-01-01

    Background Smartphones are increasingly important for clinical decision support, but smartphone and Internet use are limited by cost or coverage in many settings. txt2MEDLINE provides access to published medical evidence by text messaging. Previous studies have evaluated this approach, but we found no comparisons with other tools in this format. Objectives To compare txt2MEDLINE with other databases for answering clinical queries by text messaging in low-resource settings. Methods Using varied formats, we searched txt2MEDLINE and five other search portals (askMEDLINE, Cochrane, DynaMed, PubMed PICO, and UpToDate) to develop optimal strategies for each. We then searched each database again with five benchmark queries, using the customized search-optimization formats. We truncated the results to less than 480 characters each to simulate delivering them to a maximum of three text messages. Clinicians with practice experience in low-resource areas scored the results on a 5-point Likert scale. Results Median scores and standard deviations from 17 reviewers were: txt2M2MEDLINE, 3.2±0.82 (control); askMEDLINE, 3.2±0.90 (p = 0.918); Cochrane, 3.8±0.58 (p = 0.073); DynaMed, 3.6±0.65 (p = 0.105); PubMed PICO, 3.6±0.82 (p = 0.005); and UpToDate, 4.0±0.52 (p = 0.002). Our sample size was sufficiently powered to find differences of 1.0 point. Conclusions Comparing several possible sources for texting-based clinical-decision-support information, our results did not demonstrate one-point differences in usefulness on a scale of 1 to 5. PubMed PICO and UpToDate were significantly better than txt2MEDLINE, but with relatively small improvements in Likert score (0.4 and 0.8, respectively). In a texting-only setting, txt2MEDLINE is comparable to simulated alternatives based on established reference sources. PMID:23646080

  20. Standards for Scalable Clinical Decision Support: Need, Current and Emerging Standards, Gaps, and Proposal for Progress

    PubMed Central

    Kawamoto, Kensaku; Del Fiol, Guilherme; Lobach, David F.; Jenders, Robert A

    2010-01-01

    Despite their potential to significantly improve health care, advanced clinical decision support (CDS) capabilities are not widely available in the clinical setting. An important reason for this limited availability of CDS capabilities is the application-specific and institution-specific nature of most current CDS implementations. Thus, a critical need for enabling CDS capabilities on a much larger scale is the development and adoption of standards that enable current and emerging CDS resources to be more effectively leveraged across multiple applications and care settings. Standards required for such effective scaling of CDS include (i) standard terminologies and information models to represent and communicate about health care data; (ii) standard approaches to representing clinical knowledge in both human-readable and machine-executable formats; and (iii) standard approaches for leveraging these knowledge resources to provide CDS capabilities across various applications and care settings. A number of standards do exist or are under development to meet these needs. However, many gaps and challenges remain, including the excessive complexity of many standards; the limited availability of easily accessible knowledge resources implemented using standard approaches; and the lack of tooling and other practical resources to enable the efficient adoption of existing standards. Thus, the future development and widespread adoption of current CDS standards will depend critically on the availability of tooling, knowledge bases, and other resources that make the adoption of CDS standards not only the right approach to take, but the cost-effective path to follow given the alternative of using a traditional, ad hoc approach to implementing CDS. PMID:21603283

  1. Standards for scalable clinical decision support: need, current and emerging standards, gaps, and proposal for progress.

    PubMed

    Kawamoto, Kensaku; Del Fiol, Guilherme; Lobach, David F; Jenders, Robert A

    2010-01-01

    Despite their potential to significantly improve health care, advanced clinical decision support (CDS) capabilities are not widely available in the clinical setting. An important reason for this limited availability of CDS capabilities is the application-specific and institution-specific nature of most current CDS implementations. Thus, a critical need for enabling CDS capabilities on a much larger scale is the development and adoption of standards that enable current and emerging CDS resources to be more effectively leveraged across multiple applications and care settings. Standards required for such effective scaling of CDS include (i) standard terminologies and information models to represent and communicate about health care data; (ii) standard approaches to representing clinical knowledge in both human-readable and machine-executable formats; and (iii) standard approaches for leveraging these knowledge resources to provide CDS capabilities across various applications and care settings. A number of standards do exist or are under development to meet these needs. However, many gaps and challenges remain, including the excessive complexity of many standards; the limited availability of easily accessible knowledge resources implemented using standard approaches; and the lack of tooling and other practical resources to enable the efficient adoption of existing standards. Thus, the future development and widespread adoption of current CDS standards will depend critically on the availability of tooling, knowledge bases, and other resources that make the adoption of CDS standards not only the right approach to take, but the cost-effective path to follow given the alternative of using a traditional, ad hoc approach to implementing CDS.

  2. Clinical Decision-Making Following Disasters: Efficient Identification of PTSD Risk in Adolescents.

    PubMed

    Danielson, Carla Kmett; Cohen, Joseph R; Adams, Zachary W; Youngstrom, Eric A; Soltis, Kathryn; Amstadter, Ananda B; Ruggiero, Kenneth J

    2017-01-01

    The present study aimed to utilize a Receiver Operating Characteristic (ROC) approach in order to improve clinical decision-making for adolescents at risk for the development of psychopathology in the aftermath of a natural disaster. Specifically we assessed theoretically-driven individual, interpersonal, and event-related vulnerability factors to determine which indices were most accurate in forecasting PTSD. Furthermore, we aimed to translate these etiological findings by identifying clinical cut-off recommendations for relevant vulnerability factors. Our study consisted of structured phone-based clinical interviews with 2000 adolescent-parent dyads living within a 5-mile radius of tornados that devastated Joplin, MO, and northern Alabama in Spring 2011. Demographics, tornado incident characteristics, prior trauma, mental health, and family support and conflict were assessed. A subset of youth completed two behavioral assessment tasks online to assess distress tolerance and risk-taking behavior. ROC analyses indicated four variables that significantly improved PTSD diagnostic efficiency: Lifetime depression (AUC = .90), trauma history (AUC = .76), social support (AUC = .70), and family conflict (AUC = .72). Youth were 2-3 times more likely to have PTSD if they had elevated scores on any of these variables. Of note, event-related characteristics (e.g., property damage) were not related to PTSD diagnostic status. The present study adds to the literature by making specific recommendations for empirically-based, efficient disaster-related PTSD assessment for adolescents following a natural disaster. Implications for practice and future trauma-related developmental psychopathology research are discussed.

  3. Supporting clinical decision making during deep brain stimulation surgery by means of a stochastic dynamical model

    NASA Astrophysics Data System (ADS)

    Karamintziou, Sofia D.; Tsirogiannis, George L.; Stathis, Pantelis G.; Tagaris, George A.; Boviatsis, Efstathios J.; Sakas, Damianos E.; Nikita, Konstantina S.

    2014-10-01

    Objective. During deep brain stimulation (DBS) surgery for the treatment of advanced Parkinson's disease (PD), microelectrode recording (MER) in conjunction with functional stimulation techniques are commonly applied for accurate electrode implantation. However, the development of automatic methods for clinical decision making has to date been characterized by the absence of a robust single-biomarker approach. Moreover, it has only been restricted to the framework of MER without encompassing intraoperative macrostimulation. Here, we propose an integrated series of novel single-biomarker approaches applicable to the entire electrophysiological procedure by means of a stochastic dynamical model. Approach. The methods are applied to MER data pertinent to ten DBS procedures. Considering the presence of measurement noise, we initially employ a multivariate phase synchronization index for automatic delineation of the functional boundaries of the subthalamic nucleus (STN) and determination of the acceptable MER trajectories. By introducing the index into a nonlinear stochastic model, appropriately fitted to pre-selected MERs, we simulate the neuronal response to periodic stimuli (130 Hz), and examine the Lyapunov exponent as an indirect indicator of the clinical effectiveness yielded by stimulation at the corresponding sites. Main results. Compared with the gold-standard dataset of annotations made intraoperatively by clinical experts, the STN detection methodology demonstrates a false negative rate of 4.8% and a false positive rate of 0%, across all trajectories. Site eligibility for implantation of the DBS electrode, as implicitly determined through the Lyapunov exponent of the proposed stochastic model, displays a sensitivity of 71.43%. Significance. The suggested comprehensive method exhibits remarkable performance in automatically determining both the acceptable MER trajectories and the optimal stimulation sites, thereby having the potential to accelerate precise

  4. Formative assessment and design of a complex clinical decision support tool for pulmonary embolism.

    PubMed

    Khan, Sundas; McCullagh, Lauren; Press, Anne; Kharche, Manish; Schachter, Andy; Pardo, Salvatore; McGinn, Thomas

    2016-02-01

    Electronic health record (EHR)-based clinical decision support (CDS) tools are rolled out with the urgency to meet federal requirements without time for usability testing and refinement of the user interface. As part of a larger project to design, develop and integrate a pulmonary embolism CDS tool for emergency physicians, we conducted a formative assessment to determine providers' level of interest and input on designs and content. This was a study to conduct a formative assessment of emergency medicine (EM) physicians that included focus groups and key informant interviews. The focus of this study was twofold, to determine the general attitude towards CDS tool integration and the ideal integration point into the clinical workflow. To accomplish this, we first approached EM physicians in a focus group, then, during key informant interviews, we presented workflow designs and gave a scenario to help the providers visualise how the CDS tool works. Participants were asked questions regarding the trigger location, trigger words, integration into their workflow, perceived utility and heuristic of the tool. Results from the participants' survey responses to trigger location, perceived utility and efficiency, indicated that the providers felt the tool would be more of a hindrance than an aid. However, some providers commented that they had not had exposure to CDS tools but had used online calculators, and thought the tools would be helpful at the point-of-care if integrated into the EHR. Furthermore, there was a preference for an order entry wireframe. This study highlights several factors to consider when designing CDS tools: (1) formative assessment of EHR functionality and clinical environment workflow, (2) focus groups and key informative interviews to incorporate providers' perceptions of CDS and workflow integration and/or (3) the demonstration of proposed workflows through wireframes to help providers visualise design concepts.

  5. Development and use of active clinical decision support for preemptive pharmacogenomics

    PubMed Central

    Bell, Gillian C; Crews, Kristine R; Wilkinson, Mark R; Haidar, Cyrine E; Hicks, J Kevin; Baker, Donald K; Kornegay, Nancy M; Yang, Wenjian; Cross, Shane J; Howard, Scott C; Freimuth, Robert R; Evans, William E; Broeckel, Ulrich; Relling, Mary V; Hoffman, James M

    2014-01-01

    Background Active clinical decision support (CDS) delivered through an electronic health record (EHR) facilitates gene-based drug prescribing and other applications of genomics to patient care. Objective We describe the development, implementation, and evaluation of active CDS for multiple pharmacogenetic test results reported preemptively. Materials and methods Clinical pharmacogenetic test results accompanied by clinical interpretations are placed into the patient's EHR, typically before a relevant drug is prescribed. Problem list entries created for high-risk phenotypes provide an unambiguous trigger for delivery of post-test alerts to clinicians when high-risk drugs are prescribed. In addition, pre-test alerts are issued if a very-high risk medication is prescribed (eg, a thiopurine), prior to the appropriate pharmacogenetic test result being entered into the EHR. Our CDS can be readily modified to incorporate new genes or high-risk drugs as they emerge. Results Through November 2012, 35 customized pharmacogenetic rules have been implemented, including rules for TPMT with azathioprine, thioguanine, and mercaptopurine, and for CYP2D6 with codeine, tramadol, amitriptyline, fluoxetine, and paroxetine. Between May 2011 and November 2012, the pre-test alerts were electronically issued 1106 times (76 for thiopurines and 1030 for drugs metabolized by CYP2D6), and the post-test alerts were issued 1552 times (1521 for TPMT and 31 for CYP2D6). Analysis of alert outcomes revealed that the interruptive CDS appropriately guided prescribing in 95% of patients for whom they were issued. Conclusions Our experience illustrates the feasibility of developing computational systems that provide clinicians with actionable alerts for gene-based drug prescribing at the point of care. PMID:23978487

  6. Student specialty plans, clinical decision-making, and health care reform

    PubMed Central

    Williams, Robert L.; Romney, Crystal; Kano, Miria; Wright, Randy; Skipper, Betty; Getrich, Christina; Sussman, Andrew L.; Zyzanski, Stephen J.

    2014-01-01

    Background and objectives Health care reform aims to increase evidence based, cost-conscious, and patient-centered care. Family medicine is seen as central to these aims in part due to evidence of lower cost, comparable quality care compared with other specialties. We sought evidence that senior medical students planning family medicine residency differ from peers entering other fields in decision-making patterns relevant to these health care reform aims. Methods We conducted a national, anonymous, internet-based survey of senior medical students. Students chose one of two equivalent management options for a set of patient vignettes based on preventive care, medication selection or initial chronic disease management scenarios, representing in turn, evidence-based care, cost-conscious care, and patient-centered care. We examined differences in student recommendations, comparing those planning to enter family medicine with all others using bivariate and weighted, multilevel, multivariable analyses. Results Among 4,656 surveys received from seniors at 84 participating medical schools, students entering family medicine were significantly more likely to recommend patient management options that were more cost-conscious (p=.01) and more patient-centered (p<.001). We did not find a significant difference between the student groups in recommendations for evidence-based care vignettes. Conclusions This study provides preliminary evidence suggesting that students planning to enter family practice may already have clinical decision-making patterns that support health care reform goals to a greater extent than their peers. If confirmed by additional studies, this could have implications for medical school admission and training processes. PMID:24915476

  7. Studying Readiness for Clinical Decision Support for Worker Health Using the Rapid Assessment Process and Mixed Methods Interviews

    PubMed Central

    Ash, Joan S.; Chase, Dian; Wiesen, Jane F.; Murphy, Elizabeth V.; Marovich, Stacey

    2016-01-01

    To determine how the Rapid Assessment Process (RAP) can be adapted to evaluate the readiness of primary care clinics for acceptance and use of computerized clinical decision support (CDS) related to clinical management of working patients, we used a unique blend of ethnographic methods for gathering data. First, knowledge resources, which were prototypes of CDS content areas (diabetes, lower back pain, and asthma) containing evidence-based information, decision logic, scenarios and examples of use, were developed by subject matter experts. A team of RAP researchers then visited five clinic settings to identify barriers and facilitators to implementing CDS about the health of workers in general and the knowledge resources specifically. Methods included observations, semi-structured qualitative interviews and graphic elicitation interviews about the knowledge resources. We used both template and grounded hermeneutic approaches to data analysis. Preliminary results indicate that the methods succeeded in generating specific actionable recommendations for CDS design. PMID:28269822

  8. Studying Readiness for Clinical Decision Support for Worker Health Using the Rapid Assessment Process and Mixed Methods Interviews.

    PubMed

    Ash, Joan S; Chase, Dian; Wiesen, Jane F; Murphy, Elizabeth V; Marovich, Stacey

    2016-01-01

    To determine how the Rapid Assessment Process (RAP) can be adapted to evaluate the readiness of primary care clinics for acceptance and use of computerized clinical decision support (CDS) related to clinical management of working patients, we used a unique blend of ethnographic methods for gathering data. First, knowledge resources, which were prototypes of CDS content areas (diabetes, lower back pain, and asthma) containing evidence-based information, decision logic, scenarios and examples of use, were developed by subject matter experts. A team of RAP researchers then visited five clinic settings to identify barriers and facilitators to implementing CDS about the health of workers in general and the knowledge resources specifically. Methods included observations, semi-structured qualitative interviews and graphic elicitation interviews about the knowledge resources. We used both template and grounded hermeneutic approaches to data analysis. Preliminary results indicate that the methods succeeded in generating specific actionable recommendations for CDS design.

  9. Decision making in midwifery: rationality and intuition.

    PubMed

    Steinhauer, Suyai

    2015-04-01

    Decision making in midwifery is a complex process that shapes and underpins clinical practice and determines, to a large extent, the quality of care. Effective decision making and professional accountability are central to clinical governance, and being able.to justify all decisions is a professional and legal requirement. At the same time, there is an emphasis in midwifery on shared decision making, and keeping women at the centre of their care, and research reveals that feelings of choice, control and autonomy are central to a positive birth experience. However the extent to which decisions are really shared and care truly woman-centred is debatable and affected by environment and culture. Using a case study of a decision made in clinical practice around amniotomy, this article explores the role of the intuitive thinking system in midwifery decision making, and highlights the importance of involving women in the decision making process.

  10. Cognitive and affective components of Theory of Mind in preschoolers with oppositional defiance disorder: Clinical evidence.

    PubMed

    de la Osa, Nuria; Granero, Roser; Domenech, Josep Maria; Shamay-Tsoory, Simone; Ezpeleta, Lourdes

    2016-07-30

    The goal of the study was to examine the affective-cognitive components of Theory of Mind (ToM), in a community sample of 538 preschoolers, and more specifically in a subsample of 40 children diagnosed with ODD. The relationship between affective and cognitive ToM and some ODD clinical characteristics was examined. Children were assessed with structured diagnostic interviews and dimensional measures of psychopathology, impairment and unemotional traits. A measure based on eye-gaze was used to assess ToM. Mixed analysis of variance compared the mean cognitive versus affective scale scores and the between-subjects factor ODD. The association between ToM-scores and clinical measures was assessed through correlation models. Execution and reaction time to emotional and cognitive components of ToM tasks are different at age 5 in normally developing children. Oppositional Defiant children had slower response time when performing the affective mentalizing condition than children without the disorder. The correlation matrix between ToM-scores and clinical measures showed specific associations depending on the impaired ToM aspect and the psychological domain. Results may have clinical implications for the prevention and management of ODD.

  11. The Affective Reactivity Index: A Concise Irritability Scale for Clinical and Research Settings

    ERIC Educational Resources Information Center

    Stringaris, Argyris; Goodman, Robert; Ferdinando, Sumudu; Razdan, Varun; Muhrer, Eli; Leibenluft, Ellen; Brotman, Melissa A.

    2012-01-01

    Background: Irritable mood has recently become a matter of intense scientific interest. Here, we present data from two samples, one from the United States and the other from the United Kingdom, demonstrating the clinical and research utility of the parent- and self-report forms of the Affective Reactivity Index (ARI), a concise dimensional measure…

  12. Design, Implementation, Use, and Preliminary Evaluation of an UMLS-Enabled Terminology Web Service for Clinical Decision Support

    PubMed Central

    Kawamoto, Kensaku; Lobach, David F.

    2006-01-01

    To facilitate the provision of clinical decision support (CDS), the Unified Medical Language System (UMLS) was leveraged to implement a terminology Web service. Supported functions include inter-vocabulary translation and the identification of concepts subsumed by a parent concept. Currently, the service is being used to aid the specification of clinical concepts within CDS knowledge modules. Insights gained from this process are discussed, including the limitations of using the UMLS to fulfill CDS terminology needs. PMID:17238598

  13. BRIDGING FROM CLINICAL ENDPOINTS TO ESTIMATES OF TREATMENT VALUE FOR EXTERNAL DECISION MAKERS

    PubMed Central

    ZHU, C.W.; LEIBMAN, C.; TOWNSEND, R.; MCLAUGHLIN, T.; SCARMEAS, N.; ALBERT, M.; BRANDT, J.; BLACKER, D.; SANO, M.; STERN, Y.

    2009-01-01

    Aim While clinical endpoints provide important information on the efficacy of treatment in controlled conditions, they often are not relevant to decision makers trying to gauge the potential economic impact or value of new treatments. Therefore, it is often necessary to translate changes in cognition, function or behavior into changes in cost or other measures, which can be problematic if not conducted in a transparent manner. The Dependence Scale (DS), which measures the level of assistance a patient requires due to AD-related deficits, may provide a useful measure of the impact of AD progression in a way that is relevant to patients, providers and payers, by linking clinical endpoints to estimates of cost effectiveness or value. The aim of this analysis was to test the association of the DS to clinical endpoints and AD-related costs. Method The relationship between DS score and other endpoints was explored using the Predictors Study, a large, multi-center cohort of patients with probable AD followed annually for four years. Enrollment required a modified Mini-Mental State Examination (mMMS) score ≥30, equivalent to a score of approximately ≥16 on the MMSE. DS summated scores (range: 0–15) were compared to measures of cognition (MMSE), function (Blessed Dementia Rating Scale, BDRS, 0–17), behavior, extrapyramidal symptoms (EPS), and psychotic symptoms (illusions, delusions or hallucinations). Also, estimates for total cost (sum of direct medical cost, direct non-medical cost, and cost of informal caregivers’ time) were compared to DS scores. Results For the 172 patients in the analysis, mean baseline scores were: DS: 5.2 (SD: 2.0), MMSE: 23.0 (SD: 3.5), BDRS: 2.9 (SD: 1.3), EPS: 10.8%, behavior: 28.9% psychotic symptoms: 21.1%. After 4 years, mean scores were: DS: 8.9 (SD: 2.9), MMSE: 17.2 (SD: 4.7), BDRS: 5.2 (SD: 1.4), EPS: 37.5%, behavior: 60.0%, psychotic symptoms: 46.7%. At baseline, DS scores were significantly correlated with MMSE (r=−0.299, p<0

  14. The Functional Significance of Affect Recognition, Neurocognition, and Clinical Symptoms in Schizophrenia

    PubMed Central

    Hsiao, Sigmund

    2017-01-01

    Objectives The complex relationship and exact extent of the contribution of plausible indictors to social functional outcome in schizophrenia remain unclear. The present study aimed to explore the functional significance of clinical symptoms, neurocognition, and affect recognition simultaneously in schizophrenia. Methods The clinical symptoms, basic neurocognition, facial emotion recognition, and social functioning of 154 subjects, including 74 with schizophrenia and 80 nonclinical comparisons, were assessed. Results We observed that various subdomains of social functioning were extensively related to general intelligence, basic neurocognition, facial emotion recognition, and clinical symptoms, with different association patterns. Multivariate regression analyses revealed that years of education, age, sustained attention, working memory, and facial emotion recognition were significantly associated with global social functioning in schizophrenia. Conclusion Our findings suggest that affect recognition combined with nonsocial neurocognition demonstrated a crucial role in predicting global social function in schizophrenia. PMID:28099444

  15. An Automated System for Generating Situation-Specific Decision Support in Clinical Order Entry from Local Empirical Data

    ERIC Educational Resources Information Center

    Klann, Jeffrey G.

    2011-01-01

    Clinical Decision Support is one of the only aspects of health information technology that has demonstrated decreased costs and increased quality in healthcare delivery, yet it is extremely expensive and time-consuming to create, maintain, and localize. Consequently, a majority of health care systems do not utilize it, and even when it is…

  16. An Exploration of the Relationship between Clinical Decision-Making Ability and Educational Preparation among New Graduate Nurses

    ERIC Educational Resources Information Center

    Blount, Kamilah V.

    2013-01-01

    This study examined the impact of accelerated nursing direct entry master's programs on the development of clinical decision-making skills of new graduate nurses that completed the Performance Based Development System (PBDS) assessment during the study period of 2008-2012 at a healthcare organization. Healthcare today is practiced in a…

  17. The Need for Clinical Decision Support Integrated with the Electronic Health Record for the Clinical Application of Whole Genome Sequencing Information

    PubMed Central

    Welch, Brandon M.; Kawamoto, Kensaku

    2013-01-01

    Whole genome sequencing (WGS) is rapidly approaching widespread clinical application. Technology advancements over the past decade, since the first human genome was decoded, have made it feasible to use WGS for clinical care. Future advancements will likely drive down the price to the point wherein WGS is routinely available for care. However, were this to happen today, most of the genetic information available to guide clinical care would go unused due to the complexity of genetics, limited physician proficiency in genetics, and lack of genetics professionals in the clinical workforce. Furthermore, these limitations are unlikely to change in the future. As such, the use of clinical decision support (CDS) to guide genome-guided clinical decision-making is imperative. In this manuscript, we describe the barriers to widespread clinical application of WGS information, describe how CDS can be an important tool for overcoming these barriers, and provide clinical examples of how genome-enabled CDS can be used in the clinical setting. PMID:25411643

  18. Clinical Information System Services and Capabilities Desired for Scalable, Standards-Based, Service-oriented Decision Support: Consensus Assessment of the Health Level 7 Clinical Decision Support Work Group

    PubMed Central

    Kawamoto, Kensaku; Jacobs, Jason; Welch, Brandon M.; Huser, Vojtech; Paterno, Marilyn D.; Del Fiol, Guilherme; Shields, David; Strasberg, Howard R.; Haug, Peter J.; Liu, Zhijing; Jenders, Robert A.; Rowed, David W.; Chertcoff, Daryl; Fehre, Karsten; Adlassnig, Klaus-Peter; Curtis, A. Clayton

    2012-01-01

    A standards-based, service-oriented architecture for clinical decision support (CDS) has the potential to significantly enhance CDS scalability and robustness. To enable such a CDS architecture, the Health Level 7 CDS Work Group reviewed the literature, hosted multi-stakeholder discussions, and consulted domain experts to identify and prioritize the services and capabilities required from clinical information systems (CISs) to enable service-oriented CDS. In addition, relevant available standards were identified. Through this process, ten CIS services and eight CIS capabilities were identified as being important for enabling scalable, service-oriented CDS. In particular, through a survey of 46 domain experts, five services and capabilities were identified as being especially critical: 1) the use of standard information models and terminologies; 2) the ability to leverage a Decision Support Service (DSS); 3) support for a clinical data query service; 4) support for an event subscription and notification service; and 5) support for a user communication service. PMID:23304315

  19. Affecting African American men's prostate cancer screening decision-making through a mobile tablet-mediated intervention.

    PubMed

    Sultan, Dawood H; Rivers, Brian M; Osongo, Ben O; Wilson, Danyell S; Schenck, April; Carvajal, Rodrigo; Rivers, Desiree; Roetzheim, Richard; Green, B Lee

    2014-08-01

    African American men experience a 60% higher incidence of prostate cancer and are more than twice as likely to die from it than White men. Evidence is insufficient to conclude that definitively screening for prostate cancer reduces the likelihood of morbidity or death. Patients are encouraged to discuss screening alternatives with health care providers for informed decision-making (IDM). The extent of IDM in clinical or community setting is not known. This study uses data from a community-based, computer-mediated, IDM intervention that targeted 152 African American aged 40 to 70. Pretest-posttest differences in means for prostate cancer knowledge, screening decisional conflict, and screening decisional self-efficacy were examined by two-tailed t-tests. Overall, the intervention significantly improved respondents' prostate cancer knowledge (p<.0001), significantly improved decisional self-efficacy (p<.0001) and significantly reduced decisional conflict (p<.0001). Specifically, the intervention significantly promoted IDM among men who reported more education, being married, having financial resources, and younger age.

  20. Attitudes and factors affecting the decisions of men and women pediatrics residents toward having children during their residencies.

    PubMed

    Wilson, M D; Carpenter, R O; Radius, S M; Oski, F A

    1991-12-01

    This study examines attitudes and factors affecting the decisions of pediatrics residents of both sexes toward having children during their residencies. In 1987, the authors surveyed by mail all 742 pediatricians who had trained at eight university-based residencies from 1981 to 1987; 417 responded. Of these, the men were significantly more likely than the women to have had children during their residencies (p less than .001). At the time of their residencies, 265 of these pediatricians were married. Of those who were married but did not have children during their residencies (175), the women were significantly more likely than the men to believe that having a child during residency would have had a negative influence on their careers (p less than .001) and would have been associated with difficulties in arranging child care (p less than .001). By contrast, among those pediatricians who were married and did have children during their residencies (90), their perceptions concerning the impacts on their careers of having children and the difficulty in arranging child care did not differ significantly by gender. The authors suggest that programs might explore the possibilities of greater flexibility in scheduling and of making child care more available so that residents could more easily combine their careers with having children.

  1. Implementing shared decision-making in nutrition clinical practice: A theory-based approach and feasibility study

    PubMed Central

    Desroches, Sophie; Gagnon, Marie-Pierre; Tapp, Sylvie; Légaré, France

    2008-01-01

    Background There are a growing number of dietary treatment options to choose from for the management of many chronic diseases. Shared decision making represents a promising approach to improve the quality of the decision making process needed for dietary choices that are informed by the best evidence and value-based. However, there are no studies reporting on theory-based approaches that foster the implementation of shared decision making in health professions allied to medicine. The objectives of this study are to explore the integration of shared decision making within real nutritional consultations, and to design questionnaires to assess dieticians' intention to adopt two specific behaviors related to shared decision making using the Theory of Planned Behavior. Methods Forty dieticians will audiotape one clinical encounter to explore the presence of shared decision making within the consultation. They will also participate to one of five to six focus groups that aim to identify the salient beliefs underlying the determinants of their intention to present evidence-based dietary treatment options to their patients, and clarify the values related to dietary choices that are important to their patients. These salient beliefs will be used to elaborate the items of two questionnaires. The internal consistency of theoretical constructs and the temporal stability of their measurement will be checked using the test-retest method by asking 35 dieticians to complete the questionnaire twice within a two-week interval. Discussion The proposed research project will be the first study to: provide preliminary data about the adoption of shared decision making by dieticians and theirs patients; elicit dieticians' salient beliefs regarding the intention to adopt shared decision making behaviors, report on the development of a specific questionnaire; explore dieticians' views on the implementation of shared decision making; and compare their views regarding the implementation of

  2. The problem-oriented system, problem-knowledge coupling, and clinical decision making.

    PubMed

    Weed, L L; Zimny, N J

    1989-07-01

    The information tool to aid us in making the clinical decisions discussed in this presentation is called the PKC. Our goal with patients should be to couple the knowledge of the unique patient to the knowledge in the literature and get the best possible match. This approach requires combinatorial versus probabilistic thinking. In the real world, ideal matches are not found. Therefore, it is critical to exhaust the patient's uniqueness first and only then use probabilities to settle further uncertainties. It is an error to teach people how to deal with uncertainty instead of teaching them to clean up a great deal of the uncertainty first. Patients must be involved in this endeavor. In essence, they have a PhD in their own uniqueness, and it is this uniqueness that is very powerful in solving complex problems. This method of patient evaluation and management cannot be used with the unaided mind. It requires new and powerful information tools like the PKC. All information that is relevant to a problem should be included in the coupler. It should encompass differing points of view, and the rationale should be made explicit to clinician and patient alike. When complete, the coupler should represent an interdisciplinary compilation of questions and tests that are expected to be collected every time in the clinic for the type of problem the coupler represents. This method will provide a basis for quality control because the contents of the coupler now have defined what we expect to occur in every patient encounter.(ABSTRACT TRUNCATED AT 250 WORDS)

  3. From Value Assessment to Value Cocreation: Informing Clinical Decision-Making with Medical Claims Data.

    PubMed

    Thompson, Steven; Varvel, Stephen; Sasinowski, Maciek; Burke, James P

    2016-09-01

    Big data and advances in analytical processes represent an opportunity for the healthcare industry to make better evidence-based decisions on the value generated by various tests, procedures, and interventions. Value-based reimbursement is the process of identifying and compensating healthcare providers based on whether their services improve quality of care without increasing cost of care or maintain quality of care while decreasing costs. In this article, we motivate and illustrate the potential opportunities for payers and providers to collaborate and evaluate the clinical and economic efficacy of different healthcare services. We conduct a case study of a firm that offers advanced biomarker and disease state management services for cardiovascular and cardiometabolic conditions. A value-based analysis that comprised a retrospective case/control cohort design was conducted, and claims data for over 7000 subjects who received these services were compared to a matched control cohort. Study subjects were commercial and Medicare Advantage enrollees with evidence of CHD, diabetes, or a related condition. Analysis of medical claims data showed a lower proportion of patients who received biomarker testing and disease state management services experienced a MI (p < 0.01) or diabetic complications (p < 0.001). No significant increase in cost of care was found between the two cohorts. Our results illustrate the opportunity healthcare payers such as Medicare and commercial insurance companies have in terms of identifying value-creating healthcare interventions. However, payers and providers also need to pursue system integration efforts to further automate the identification and dissemination of clinically and economically efficacious treatment plans to ensure at-risk patients receive the treatments and interventions that will benefit them the most.

  4. An ontology-driven, case-based clinical decision support model for removable partial denture design

    NASA Astrophysics Data System (ADS)

    Chen, Qingxiao; Wu, Ji; Li, Shusen; Lyu, Peijun; Wang, Yong; Li, Miao

    2016-06-01

    We present the initial work toward developing a clinical decision support model for specific design of removable partial dentures (RPDs) in dentistry. We developed an ontological paradigm to represent knowledge of a patient’s oral conditions and denture component parts. During the case-based reasoning process, a cosine similarity algorithm was applied to calculate similarity values between input patients and standard ontology cases. A group of designs from the most similar cases were output as the final results. To evaluate this model, the output designs of RPDs for 104 randomly selected patients were compared with those selected by professionals. An area under the curve of the receiver operating characteristic (AUC-ROC) was created by plotting true-positive rates against the false-positive rate at various threshold settings. The precision at position 5 of the retrieved cases was 0.67 and at the top of the curve it was 0.96, both of which are very high. The mean average of precision (MAP) was 0.61 and the normalized discounted cumulative gain (NDCG) was 0.74 both of which confirmed the efficient performance of our model. All the metrics demonstrated the efficiency of our model. This methodology merits further research development to match clinical applications for designing RPDs. This paper is organized as follows. After the introduction and description of the basis for the paper, the evaluation and results are presented in Section 2. Section 3 provides a discussion of the methodology and results. Section 4 describes the details of the ontology, similarity algorithm, and application.

  5. Clinical Decision Support System to Enhance Quality Control of Spirometry Using Information and Communication Technologies

    PubMed Central

    2014-01-01

    Background We recently demonstrated that quality of spirometry in primary care could markedly improve with remote offline support from specialized professionals. It is hypothesized that implementation of automatic online assessment of quality of spirometry using information and communication technologies may significantly enhance the potential for extensive deployment of a high quality spirometry program in integrated care settings. Objective The objective of the study was to elaborate and validate a Clinical Decision Support System (CDSS) for automatic online quality assessment of spirometry. Methods The CDSS was done through a three step process including: (1) identification of optimal sampling frequency; (2) iterations to build-up an initial version using the 24 standard spirometry curves recommended by the American Thoracic Society; and (3) iterations to refine the CDSS using 270 curves from 90 patients. In each of these steps the results were checked against one expert. Finally, 778 spirometry curves from 291 patients were analyzed for validation purposes. Results The CDSS generated appropriate online classification and certification in 685/778 (88.1%) of spirometry testing, with 96% sensitivity and 95% specificity. Conclusions Consequently, only 93/778 (11.9%) of spirometry testing required offline remote classification by an expert, indicating a potential positive role of the CDSS in the deployment of a high quality spirometry program in an integrated care setting. PMID:25600957

  6. Automated/integrated real-time clinical decision support in acute kidney injury

    PubMed Central

    Goldstein, Stuart L.

    2016-01-01

    Purpose of review Health information technology (HIT) advancements have resulted in recent increased sophistication of the electronic health record (EHR), whereby patient demographic, physiological and laboratory data can be extracted real-time and integrated into clinical decision support (CDS). Recent findings The implementation of HIT advancements into CDS in the renal realm have been focused mainly on assessment of kidney function, to guide medication dosing in the setting of reduced function, or to reactively detect acute kidney injury (AKI), heralded by an abrupt increase in serum creatinine. More recent work has combined risk stratification algorithms to guide proactive diagnostic or therapeutic intervention to prevent AKI or reduce its severity. Summary Early, real-time identification and notification to health care providers of patients at risk for, or with, acute or chronic kidney disease can drive simple interventions to reduce harm. Similarly, screening patients at risk for AKI with these platforms to alert research personnel will lead to improve study subject recruitment. However, sole reliance on EHR generated alerts without active health care team integration and assessment represents a major barrier to the realization of the potential of CDS to improve health care quality and outcomes. PMID:26539921

  7. Dose coefficients and derived guidance and clinical decision levels for contaminated wounds

    SciTech Connect

    Bertelli, Luiz; Toohey, Richard E

    2009-01-01

    The NCRP Wound Model describing the retention of selected radionuclides at the site of a contaminated wound and their uptake into the transfer compartment has been combined with the ICRP element-specific systemic models for those radionuclides to derive dose coefficients for intakes via contaminated wounds. Those coefficients have been used to generate derived guidance levels (i.e., the activity in a wound that would result in an effective dose of 20 or 50 mSv, or in some cases, a committed organ equivalent dose of 500 mSv), and clinical decision levels (i.e., activity levels that would indicate the need for consideration of medical intervention to remove activity from the wound site or administration of decorporation therapy or both), typically set at 5 times the derived guidance levels. Data are provided for the radionuclides commonly encountered at nuclear power plants and nuclear weapons, fuel fabrication or recycling, waste disposal, medical and research facilities. These include: {sup 60}Co, {sup 90}Sr, {sup 99m}Tc, {sup 131}I, {sup 137}Cs, {sup 192}Ir, {sup 210}Po, {sup 226,228}Ra, {sup 228,232}Th, {sup 235,238}U, {sup 237}Np, {sup 238,239}Pu, {sup 241}Am, {sup 242,244}Cm, and {sup 252}Cf.

  8. Recommendations for a Clinical Decision Support for the Management of Individuals with Chronic Kidney Disease

    PubMed Central

    Patwardhan, Meenal B.; Kawamoto, Kensaku; Lobach, David; Patel, Uptal D.; Matchar, David B.

    2009-01-01

    Background and objectives: Care for advanced CKD patients is suboptimal. CKD practice guidelines aim to close gaps in care, but making providers aware of guidelines is an ineffective implementation strategy. The Institute of Medicine has endorsed the use of clinical decision support (CDS) for implementing guidelines. The authors’ objective was to identify the requirements of an optimal CDS system for CKD management. Design, setting, participants, and measurements: The aims of this study expanded on those of previous work that used the facilitated process improvement (FPI) methodology. In FPI, an expert workgroup develops a set of quality improvement tools that can subsequently be utilized by practicing physicians. The authors conducted a discussion with a group of multidisciplinary experts to identify requirements for an optimal CDS system. Results: The panel considered the process of patient identification and management, associated barriers, and elements by which CDS could address these barriers. The panel also discussed specific knowledge needs in the context of a typical scenario in which CDS would be used. Finally, the group developed a set of core requirements that will likely facilitate the implementation of a CDS system aimed at improving the management of any chronic medical condition. Conclusions: Considering the growing burden of CKD and the potential healthcare and resource impact of guideline implementation through CDS, the relevance of this systematic process, consistent with Institute of Medicine recommendations, cannot be understated. The requirements described in this report could serve as a basis for the design of a CKD-specific CDS. PMID:19176797

  9. MACVIA clinical decision algorithm in adolescents and adults with allergic rhinitis.

    PubMed

    Bousquet, Jean; Schünemann, Holger J; Hellings, Peter W; Arnavielhe, Sylvie; Bachert, Claus; Bedbrook, Anna; Bergmann, Karl-Christian; Bosnic-Anticevich, Sinthia; Brozek, Jan; Calderon, Moises; Canonica, G Walter; Casale, Thomas B; Chavannes, Niels H; Cox, Linda; Chrystyn, Henry; Cruz, Alvaro A; Dahl, Ronald; De Carlo, Giuseppe; Demoly, Pascal; Devillier, Phillipe; Dray, Gérard; Fletcher, Monica; Fokkens, Wytske J; Fonseca, Joao; Gonzalez-Diaz, Sandra N; Grouse, Lawrence; Keil, Thomas; Kuna, Piotr; Larenas-Linnemann, Désirée; Lodrup Carlsen, Karin C; Meltzer, Eli O; Mullol, Jaoquim; Muraro, Antonella; Naclerio, Robert N; Palkonen, Susanna; Papadopoulos, Nikolaos G; Passalacqua, Giovanni; Price, David; Ryan, Dermot; Samolinski, Boleslaw; Scadding, Glenis K; Sheikh, Aziz; Spertini, François; Valiulis, Arunas; Valovirta, Erkka; Walker, Samantha; Wickman, Magnus; Yorgancioglu, Arzu; Haahtela, Tari; Zuberbier, Torsten

    2016-08-01

    The selection of pharmacotherapy for patients with allergic rhinitis (AR) depends on several factors, including age, prominent symptoms, symptom severity, control of AR, patient preferences, and cost. Allergen exposure and the resulting symptoms vary, and treatment adjustment is required. Clinical decision support systems (CDSSs) might be beneficial for the assessment of disease control. CDSSs should be based on the best evidence and algorithms to aid patients and health care professionals to jointly determine treatment and its step-up or step-down strategy depending on AR control. Contre les MAladies Chroniques pour un VIeillissement Actif en Languedoc-Roussillon (MACVIA-LR [fighting chronic diseases for active and healthy ageing]), one of the reference sites of the European Innovation Partnership on Active and Healthy Ageing, has initiated an allergy sentinel network (the MACVIA-ARIA Sentinel Network). A CDSS is currently being developed to optimize AR control. An algorithm developed by consensus is presented in this article. This algorithm should be confirmed by appropriate trials.

  10. Design, Implementation, Use, and Preliminary Evaluation of SEBASTIAN, a Standards-Based Web Service for Clinical Decision Support

    PubMed Central

    Kawamoto, Kensaku; Lobach, David F.

    2005-01-01

    Despite their demonstrated ability to improve care quality, clinical decision support systems are not widely used. In part, this limited use is due to the difficulty of sharing medical knowledge in a machine-executable format. To address this problem, we developed a decision support Web service known as SEBASTIAN. In SEBASTIAN, individual knowledge modules define the data requirements for assessing a patient, the conclusions that can be drawn using that data, and instructions on how to generate those conclusions. Using standards-based XML messages transmitted over HTTP, client decision support applications provide patient data to SEBASTIAN and receive patient-specific assessments and recommendations. SEBASTIAN has been used to implement four distinct decision support systems; an architectural overview is provided for one of these systems. Preliminary assessments indicate that SEBASTIAN fulfills all original design objectives, including the re-use of executable medical knowledge across diverse applications and care settings, the straightforward authoring of knowledge modules, and use of the framework to implement decision support applications with significant clinical utility. PMID:16779066

  11. A biomechanical sorting of clinical risk factors affecting osteoporotic hip fracture.

    PubMed

    Luo, Y

    2016-02-01

    Osteoporotic fracture has been found associated with many clinical risk factors, and the associations have been explored dominantly by evidence-based and case-control approaches. The major challenges emerging from the studies are the large number of the risk factors, the difficulty in quantification, the incomplete list, and the interdependence of the risk factors. A biomechanical sorting of the risk factors may shed lights on resolving the above issues. Based on the definition of load-strength ratio (LSR), we first identified the four biomechanical variables determining fracture risk, i.e., the risk of fall, impact force, bone quality, and bone geometry. Then, we explored the links between the FRAX clinical risk factors and the biomechanical variables by looking for evidences in the literature. To accurately assess fracture risk, none of the four biomechanical variables can be ignored and their values must be subject-specific. A clinical risk factor contributes to osteoporotic fracture by affecting one or more of the biomechanical variables. A biomechanical variable represents the integral effect from all the clinical risk factors linked to the variable. The clinical risk factors in FRAX mostly stand for bone quality. The other three biomechanical variables are not adequately represented by the clinical risk factors. From the biomechanical viewpoint, most clinical risk factors are interdependent to each other as they affect the same biomechanical variable(s). As biomechanical variables must be expressed in numbers before their use in calculating LSR, the numerical value of a biomechanical variable can be used as a gauge of the linked clinical risk factors to measure their integral effect on fracture risk, which may be more efficient than to study each individual risk factor.

  12. Emerging medical informatics with case-based reasoning for aiding clinical decision in multi-agent system.

    PubMed

    Shen, Ying; Colloc, Joël; Jacquet-Andrieu, Armelle; Lei, Kai

    2015-08-01

    This research aims to depict the methodological steps and tools about the combined operation of case-based reasoning (CBR) and multi-agent system (MAS) to expose the ontological application in the field of clinical decision support. The multi-agent architecture works for the consideration of the whole cycle of clinical decision-making adaptable to many medical aspects such as the diagnosis, prognosis, treatment, therapeutic monitoring of gastric cancer. In the multi-agent architecture, the ontological agent type employs the domain knowledge to ease the extraction of similar clinical cases and provide treatment suggestions to patients and physicians. Ontological agent is used for the extension of domain hierarchy and the interpretation of input requests. Case-based reasoning memorizes and restores experience data for solving similar problems, with the help of matching approach and defined interfaces of ontologies. A typical case is developed to illustrate the implementation of the knowledge acquisition and restitution of medical experts.

  13. Amatoxin poisoning treatment decision-making: pharmaco-therapeutic clinical strategy assessment using multidimensional multivariate statistic analysis.

    PubMed

    Poucheret, Patrick; Fons, Françoise; Doré, Jean Christophe; Michelot, Didier; Rapior, Sylvie

    2010-06-15

    Ninety percent of fatal higher fungus poisoning is due to amatoxin-containing mushroom species. In addition to absence of antidote, no chemotherapeutic consensus was reported. The aim of the present study is to perform a retrospective multidimensional multivariate statistic analysis of 2110 amatoxin poisoning clinical cases, in order to optimize therapeutic decision-making. Our results allowed to classify drugs as a function of their influence on one major parameter: patient survival. Active principles were classified as first intention, second intention, adjuvant or controversial pharmaco-therapeutic clinical intervention. We conclude that (1) retrospective multidimensional multivariate statistic analysis of complex clinical dataset might help future therapeutic decision-making and (2) drugs such as silybin, N-acetylcystein and putatively ceftazidime are clearly associated, in amatoxin poisoning context, with higher level of patient survival.

  14. Proposal for Development of EBM-CDSS (Evidence-Based Clinical Decision Support System) to Aid Prognostication in Terminally Ill Patients

    DTIC Science & Technology

    2010-10-01

    regarding continuation of life-sustaining vs. palliative care . Finally, using regret DCA, the optimal decision for the specific patient is suggested...is to develop an Evidence-based Clinical Decision Support (CDSS-EBM) system and make it available at the point of care to improve prognostication of...Analysis and Regret theory to compare multiple decision strategies based on the decision maker’s personal attitudes towards each strategy

  15. Enabling cross-platform clinical decision support through Web-based decision support in commercial electronic health record systems: proposal and evaluation of initial prototype implementations.

    PubMed

    Zhang, Mingyuan; Velasco, Ferdinand T; Musser, R Clayton; Kawamoto, Kensaku

    2013-01-01

    Enabling clinical decision support (CDS) across multiple electronic health record (EHR) systems has been a desired but largely unattained aim of clinical informatics, especially in commercial EHR systems. A potential opportunity for enabling such scalable CDS is to leverage vendor-supported, Web-based CDS development platforms along with vendor-supported application programming interfaces (APIs). Here, we propose a potential staged approach for enabling such scalable CDS, starting with the use of custom EHR APIs and moving towards standardized EHR APIs to facilitate interoperability. We analyzed three commercial EHR systems for their capabilities to support the proposed approach, and we implemented prototypes in all three systems. Based on these analyses and prototype implementations, we conclude that the approach proposed is feasible, already supported by several major commercial EHR vendors, and potentially capable of enabling cross-platform CDS at scale.

  16. Factors that Affect the Decision of Refugee and Immigrant Students to Pursue Higher Education in Tennessee: The Case of Egyptian, Somali, Kurdish and Mexican Students

    ERIC Educational Resources Information Center

    Weldegebriel, Mengistu H.

    2011-01-01

    Refugee and immigrant students face challenges in pursuing higher education. This study examined factors that affect the decision of refugees and immigrant students to pursue higher education in Tennessee. The factors included cultural capital these students acquire from their parents and families; cultural difference they have with the mainstream…

  17. A Qualitative Study of How Cultural Capital Affects Low-Income Undergraduate Students' Decisions to Participate in Highly Ranked Research Institutions in the State of Texas

    ERIC Educational Resources Information Center

    Walker, Gloria Jean

    2014-01-01

    The purpose of this basic qualitative study was to understand how cultural capital affected low-income undergraduate students' decisions to participate in higher education at highly ranked research institutions in the State of Texas. To fulfill this purpose, four research questions were formulated as the foundation for this investigation: a/ What…

  18. How Performance Information Affects Human-Capital Investment Decisions: The Impact of Test-Score Labels on Educational Outcomes. NBER Working Paper No. 17120

    ERIC Educational Resources Information Center

    Papay, John P.; Murnane, Richard J.; Willett, John B.

    2011-01-01

    Students receive abundant information about their educational performance, but how this information affects future educational-investment decisions is not well understood. Increasingly common sources of information are state-mandated standardized tests. On these tests, students receive a score and a label that summarizes their performance. Using a…

  19. Can You Hear Me? The Right of Young Children to Participate in Decisions Affecting Them. Working Papers in Early Childhood Development, No. 36

    ERIC Educational Resources Information Center

    Lansdown, Gerison

    2005-01-01

    "Can You Hear Me? The Right of Young Children to Participate in Decisions Affecting Them" emphasises that participation enhances children's self-esteem and confidence, promotes their overall capacities, produces better outcomes, strengthens understanding of and commitment to democratic processes and protects children more effectively.…

  20. The effect of multimedia replacing text in resident clinical decision-making assessment.

    PubMed

    Chang, Todd P; Schrager, Sheree M; Rake, Alyssa J; Chan, Michael W; Pham, Phung K; Christman, Grant

    2016-10-17

    Multimedia in assessing clinical decision-making skills (CDMS) has been poorly studied, particularly in comparison to traditional text-based assessments. The literature suggests multimedia is more difficult for trainees. We hypothesize that pediatric residents score lower in diagnostic skill when clinical vignettes use multimedia rather than text for patient findings. A standardized method was developed to write text-based questions from 60 high-resolution, quality multimedia; a series of expert panels selected 40 questions with both a multimedia and text-based counterpart, and two online tests were developed. Each test featured 40 identical questions with reciprocal and alternating modality (multimedia vs. text). Pediatric residents and rising 4th year medical students (MS-IV) at a single residency were randomized to complete either test stratified by postgraduate training year (PGY). A mixed between-within subjects ANOVA analyzed differences in score due to modality and PGY. Secondary analyses ascertained modality effect in dermatology and respiratory questions using Mann-Whitney U tests, and correlations on test performance to In-service Training Exam (ITE) scores using Spearman rank. Eighty-eight residents and rising interns completed the study. Overall multimedia scores were lower than text-based scores (p = 0.047, η p(2)  = 0.04), with highest disparity in rising interns (MS-IV); however, PGY had a greater effect on scores (p = 0.001, η p(2)  = 0.16). Respiratory questions were not significantly lower with multimedia (n = 9, median 0.71 vs. 0.86, p = 0.09) nor dermatology questions (n = 13, p = 0.41). ITEs correlated significantly with text-based scores (ρ = 0.23-0.25, p = 0.04-0.06) but not with multimedia scores. In physician trainees with less clinical experience, multimedia-based case vignettes are associated with significantly lower scores. These results help shed light on the role of multimedia versus text-based information in

  1. Modeling the Innovation-Decision Process: Dissemination and Adoption of a Motivational Interviewing Preparatory Procedure In Addiction Outpatient Clinics.

    PubMed

    Walitzer, Kimberly S; Dermen, Kurt H; Barrick, Christopher; Shyhalla, Kathleen

    2015-10-01

    Widespread adoption of empirically-supported treatment innovations has the potential to improve effectiveness of treatment received by individuals with substance use disorders. However, the process of disseminating such innovations has been complex, slow, and difficult. We empirically describe the dissemination and adoption of a treatment innovation--an alcohol-treatment preparatory therapeutic procedure based on motivational interviewing (MI)--in the context of Rogers' (2003) five stages of innovation-decision process (knowledge, persuasion, decision, implementation and confirmation). To this end, 145 randomly-chosen outpatient addiction treatment clinics in New York State received an onsite visit from a project trainer delivering one of three randomly-assigned dissemination intensities: a 15-minute, a half-day or a full-day presentation. Across these clinics, 141 primary administrators and 837 clinicians completed questionnaires assessing aspects of five innovation-decision stages. At each clinic, questionnaire administration occurred immediately pre- and post-dissemination, as well as 1 and 6 months after dissemination. Consistent with Rogers' theory, earlier stages of the innovation-decision process predicted later stages. As hypothesized, dissemination intensity predicted clinicians' post-dissemination knowledge. Clinician baseline characteristics (including gender, pre-dissemination knowledge regarding the MI preparatory technique, education, case load, beliefs regarding the nature of alcohol problems, and beliefs and behavior with regard to therapeutic style) predicted knowledge and persuasion stage variables. One baseline clinic characteristic (i.e., clinic mean beliefs and behavior regarding an MI-consistent therapeutic style) predicted implementation stage variables. Findings suggest that dissemination strategies should accommodate clinician and clinic characteristics.

  2. Modeling the Innovation-Decision Process: Dissemination and Adoption of a Motivational Interviewing Preparatory Procedure in Addiction Outpatient Clinics

    PubMed Central

    Walitzer, Kimberly S.; Dermen, Kurt H.; Barrick, Christopher; Shyhalla, Kathleen

    2015-01-01

    Widespread adoption of empirically-supported treatment innovations has the potential to improve effectiveness of treatment received by individuals with substance use disorders. However, the process of disseminating such innovations has been complex, slow, and difficult. We empirically describe the dissemination and adoption of a treatment innovation – an alcohol-treatment preparatory therapeutic procedure based on motivational interviewing (MI) – in the context of Rogers’ (2003) five stages of innovation-decision process (knowledge, persuasion, decision, implementation and confirmation). To this end, 145 randomly-chosen outpatient addiction treatment clinics in New York State received an onsite visit from a project trainer delivering one of three randomly-assigned dissemination intensities: a 15-minute, a half-day or a full-day presentation. Across these clinics, 141 primary administrators and 837 clinicians completed questionnaires assessing aspects of five innovation-decision stages. At each clinic, questionnaire administration occurred immediately pre- and post-dissemination, as well as one and six months after dissemination. Consistent with Rogers’ theory, earlier stages of the innovation-decision process predicted later stages. As hypothesized, dissemination intensity predicted clinicians’ post-dissemination knowledge. Clinician baseline characteristics (including gender, pre-dissemination knowledge regarding the MI preparatory technique, education, case load, beliefs regarding the nature of alcohol problems, and beliefs and behavior with regard to therapeutic style) predicted knowledge and persuasion stage variables. One baseline clinic characteristic (i.e., clinic mean beliefs and behavior regarding an MI-consistent therapeutic style) predicted implementation stage variables. Findings suggest that dissemination strategies should accommodate clinician and clinic characteristics. PMID:25934460

  3. Does Physical Loading Affect The Speed and Accuracy of Tactical Decision-Making in Elite Junior Soccer Players?

    PubMed Central

    Frýbort, Pavel; Kokštejn, Jakub; Musálek, Martin; Süss, Vladimír

    2016-01-01

    A soccer player’s capability to control and manage his behaviour in a game situation is a prerequisite, reflecting not only swift and accurate tactical decision-making, but also prompt implementation of a motor task during intermittent exercise conditions. The purpose of this study was to analyse the relationship between varying exercise intensity and the visual-motor response time and the accuracy of motor response in an offensive game situation in soccer. The participants (n = 42) were male, semi-professional, soccer players (M age 18.0 ± 0.9 years) and trained five times a week. Each player performed four different modes of exercise intensity on the treadmill (motor inactivity, aerobic, intermittent and anaerobic activity). After the end of each exercise, visual-motor response time and accuracy of motor response were assessed. Players’ motion was captured by digital video camera. ANOVA indicated no significant difference (p = 0.090) in the accuracy of motor response between the four exercise intensity modes. Practical significance (Z-test = 0.31) was found in visual-motor response time between exercise with dominant involvement of aerobic metabolism, and intense intermittent exercise. A medium size effect (Z-test = 0.34) was also found in visual-motor response time between exercise with dominant involvement of aerobic metabolism and exercise with dominant involvement of anaerobic metabolism, which was confirmed by ANOVA (897.02 ± 57.46 vs. 940.95 ± 71.14; p = 0.002). The results showed that different modes of exercise intensity do not adversely affect the accuracy of motor responses; however, high-intensity exercise has a negative effect on visual-motor response time in comparison to moderate intensity exercise. Key points Different exercise intensity modes did not affect the accuracy of motor response. Anaerobic, highly intensive short-term exercise significantly decreased the visual-motor response time in comparison with aerobic exercise. Further

  4. Comprehension of Randomization and Uncertainty in Cancer Clinical Trials Decision Making Among Rural, Appalachian Patients.

    PubMed

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

    2015-12-01

    Comprehension of randomization is a vital, but understudied, component of informed consent to participate in cancer randomized clinical trials (RCTs). This study examines patient comprehension of the randomization process as well as sources of ongoing uncertainty that may inhibit a patient's ability to provide informed consent to participate in RCTs. Cancer patients living in rural Appalachia who were offered an opportunity to participate in a cancer treatment RCT completed in-depth interviews and a brief survey. No systematic differences in randomization comprehension between patients who consented and those who declined participation in a cancer RCT were detected. Comprehension is conceptually distinct from uncertainty, with patients who had both high and low comprehension experiencing randomization-related uncertainty. Uncertainty about randomization was found to have cognitive and affective dimensions. Not all patients enrolling in RCTs have a sufficient understanding of the randomization process to provide informed consent. Healthcare providers need to be aware of the different types of randomization-related uncertainty. Efforts to improve informed consent to participate in RCTs should focus on having patients teach back their understanding of randomization. This practice could yield valuable information about the patient's cognitive and affective understanding of randomization as well as opportunities to correct misperceptions. Education about RCTs should reflect patient expectations of individualized care by explaining how all treatments being compared are appropriate to the specifics of a patient's disease.

  5. Comprehension of Randomization and Uncertainty in Cancer Clinical Trials Decision-Making among Rural, Appalachian Patients

    PubMed Central

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

    2015-01-01

    Objective Comprehension of randomization is a vital, but understudied, component of informed consent to participate in cancer randomized clinical trials (RCTs). This study examines patient comprehension of the randomization process as well as sources of ongoing uncertainty that may inhibit a patient's ability to provide informed consent to participate in RCTs. Methods Cancer patients living in rural Appalachia who were offered an opportunity to participate in cancer treatment RCT completed in-depth interviews and a brief survey. Results No systematic differences in randomization comprehension between patients who consented and those who declined participation in a cancer RCT were detected. Comprehension is conceptually distinct from uncertainty, with patients who had both high and low comprehension experiencing randomization-related uncertainty. Uncertainty about randomization was found to have cognitive and affective dimensions. Conclusion Not all patients enrolling in RCTs have sufficient understanding of the randomization process to provide informed consent. Healthcare providers need to be aware of the different types of randomization-related uncertainty. Efforts to improve informed consent to participate in RCTs should focus on having patients “teach back” their understanding of randomization. This practice could yield valuable information about the patient's cognitive and affective understanding of randomization as well as opportunities to correct misperceptions. Education about RCTs should reflect patient expectations of individualized care by explaining how all treatments being compared are appropriate to the specifics of a patient's disease. PMID:25608719

  6. OrderRex: clinical order decision support and outcome predictions by data-mining electronic medical records

    PubMed Central

    Chen, Jonathan H; Podchiyska, Tanya

    2016-01-01

    Objective: To answer a “grand challenge” in clinical decision support, the authors produced a recommender system that automatically data-mines inpatient decision support from electronic medical records (EMR), analogous to Netflix or Amazon.com’s product recommender. Materials and Methods: EMR data were extracted from 1 year of hospitalizations (>18K patients with >5.4M structured items including clinical orders, lab results, and diagnosis codes). Association statistics were counted for the ∼1.5K most common items to drive an order recommender. The authors assessed the recommender’s ability to predict hospital admission orders and outcomes based on initial encounter data from separate validation patients. Results: Compared to a reference benchmark of using the overall most common orders, the recommender using temporal relationships improves precision at 10 recommendations from 33% to 38% (P < 10−10) for hospital admission orders. Relative risk-based association methods improve inverse frequency weighted recall from 4% to 16% (P < 10−16). The framework yields a prediction receiver operating characteristic area under curve (c-statistic) of 0.84 for 30 day mortality, 0.84 for 1 week need for ICU life support, 0.80 for 1 week hospital discharge, and 0.68 for 30-day readmission. Discussion: Recommender results quantitatively improve on reference benchmarks and qualitatively appear clinically reasonable. The method assumes that aggregate decision making converges appropriately, but ongoing evaluation is necessary to discern common behaviors from “correct” ones. Conclusions: Collaborative filtering recommender algorithms generate clinical decision support that is predictive of real practice patterns and clinical outcomes. Incorporating temporal relationships improves accuracy. Different evaluation metrics satisfy different goals (predicting likely events vs. “interesting” suggestions). PMID:26198303

  7. Clinical decision making in spinal fusion for chronic low back pain. Results of a nationwide survey among spine surgeons

    PubMed Central

    de Bie, Rob; Öner, Cumhur; Castelein, René; de Kleuver, Marinus

    2011-01-01

    Objectives To assess the use of prognostic patient factors and predictive tests in clinical decision making for spinal fusion in patients with chronic low back pain. Design and setting Nationwide survey among spine surgeons in the Netherlands. Participants Surgeon members of the Dutch Spine Society were questioned on their surgical treatment strategy for chronic low back pain. Primary and secondary outcome measures The surgeons' opinion on the use of prognostic patient factors and predictive tests for patient selection were addressed on Likert scales, and the degree of uniformity was assessed. In addition, the influence of surgeon-specific factors, such as clinical experience and training, on decision making was determined. Results The comments from 62 surgeons (70% response rate) were analysed. Forty-four surgeons (71%) had extensive clinical experience. There was a statistically significant lack of uniformity of opinion in seven of the 11 items on prognostic factors and eight of the 11 items on predictive tests, respectively. Imaging was valued much higher than predictive tests, psychological screening or patient preferences (all p<0.01). Apart from the use of discography and long multisegment fusions, differences in training or clinical experience did not appear to be of significant influence on treatment strategy. Conclusions The present survey showed a lack of consensus among spine surgeons on the appreciation and use of predictive tests. Prognostic patient factors were not consistently incorporated in their treatment strategy either. Clinical decision making for spinal fusion to treat chronic low back pain does not have a uniform evidence base in practice. Future research should focus on identifying subgroups of patients for whom spinal fusion is an effective treatment, as only a reliable prediction of surgical outcome, combined with the implementation of individual patient factors, may enable the instalment of consensus guidelines for surgical decision

  8. Use of Biomarkers to Guide Decisions on Adjuvant Systemic Therapy for Women With Early-Stage Invasive Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline

    PubMed Central

    Harris, Lyndsay N.; McShane, Lisa M.; Andre, Fabrice; Collyar, Deborah E.; Gonzalez-Angulo, Ana M.; Hammond, Elizabeth H.; Kuderer, Nicole M.; Liu, Minetta C.; Mennel, Robert G.; Van Poznak, Catherine; Bast, Robert C.; Hayes, Daniel F.

    2016-01-01

    Purpose To provide recommendations on appropriate use of breast tumor biomarker assay results to guide decisions on adjuvant systemic therapy for women with early-stage invasive breast cancer. Methods A literature search and prospectively defined study selection sought systematic reviews, meta-analyses, randomized controlled trials, prospective-retrospective studies, and prospective comparative observational studies published from 2006 through 2014. Outcomes of interest included overall survival and disease-free or recurrence-free survival. Expert panel members used informal consensus to develop evidence-based guideline recommendations. Results The literature search identified 50 relevant studies. One randomized clinical trial and 18 prospective-retrospective studies were found to have evaluated the clinical utility, as defined by the guideline, of specific biomarkers for guiding decisions on the need for adjuvant systemic therapy. No studies that met guideline criteria for clinical utility were found to guide choice of specific treatments or regimens. Recommendations In addition to estrogen and progesterone receptors and human epidermal growth factor receptor 2, the panel found sufficient evidence of clinical utility for the biomarker assays Oncotype DX, EndoPredict, PAM50, Breast Cancer Index, and urokinase plasminogen activator and plasminogen activator inhibitor type 1 in specific subgroups of breast cancer. No biomarker except for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 was found to guide choices of specific treatment regimens. Treatment decisions should also consider disease stage, comorbidities, and patient preferences. PMID:26858339

  9. [On the importance of the "decision-making model" view of diagnosis as a clinical framework in psychiatry].

    PubMed

    Ota, T

    2000-01-01

    After the advent of DSM-III, operational diagnostic criteria, along with the classification of disorders using such criteria, received considerable attention, and many studies on the reliability and validity of psychiatric diagnosis were conducted worldwide. Operational methodology was applied to diagnosis and classification, especially, in the area of research, and has contributed greatly to advances in reliable and refined clinical research. Such methodology, however, has not necessarily been accepted as a guiding principle in the area of clinical practice by all psychiatrists. Rather, some psychiatrists, especially more experienced psychiatrists, took a somewhat negative attitude toward the use of operational methodology. The author contends that one of the causes for the relatively poor acceptance of operational methodology in the area of clinical practice lies in the "classification model" view of diagnosis that forms the implicit background for the methodology. From a clinical perspective, it is not from the "classification model" basis but rather, from the "decision-making model" basis that the actual process of clinical diagnosis in psychiatry is explained properly. This is a very important point, because the latter model is potentially more useful both to psychiatric patients and to researchers in psychiatry than the former model. There have been however, few reports in psychiatry that highlight the importance of this model as the clinical framework. The author analyzes the limitations of the "classification model" view, and then, based on this analysis, lists prerequisites that a model for the framework of clinical practice should possess. The prerequisites listed are: that clinical information not sufficient to meet the disease criteria should be used as effectively as possible, that diseases low in probability but high in seriousness should be considered by clinicians in the differential diagnoses; that diagnosis should be readily changed when necessary

  10. The Effects of Clinical Decision Support Systems on Medication Safety: An Overview

    PubMed Central

    Jia, Pengli; Zhang, Longhao; Chen, Jingjing; Zhao, Pujing; Zhang, Mingming

    2016-01-01

    Background The clinical decision support system(CDSS) has potential to improving medication safety. However, the effects of the intervention were conflicting and uncertain. Meanwhile, the reporting and methodological quality of this field were unknown. Objective The aim of this overview is to evaluate the effects of CDSS on medication safety and to examine the methodological and reporting quality. Methods PubMed, Embase and Cochrane Library were searched to August 2015. Systematic reviews (SRs) investigating the effects of CDSS on medication safety were included. Outcomes were det