Strategies to facilitate shared decision-making about pediatric oncology clinical trial enrollment: A systematic review.

PubMed

Robertson, Eden G; Wakefield, Claire E; Signorelli, Christina; Cohn, Richard J; Patenaude, Andrea; Foster, Claire; Pettit, Tristan; Fardell, Joanna E

2018-07-01

We conducted a systematic review to identify the strategies that have been recommended in the literature to facilitate shared decision-making regarding enrolment in pediatric oncology clinical trials. We searched seven databases for peer-reviewed literature, published 1990-2017. Of 924 articles identified, 17 studies were eligible for the review. We assessed study quality using the 'Mixed-Methods Appraisal Tool'. We coded the results and discussions of papers line-by-line using nVivo software. We categorized strategies thematically. Five main themes emerged: 1) decision-making as a process, 2) individuality of the process; 3) information provision, 4) the role of communication, or 5) decision and psychosocial support. Families should have adequate time to make a decision. HCPs should elicit parents' and patients' preferences for level of information and decision involvement. Information should be clear and provided in multiple modalities. Articles also recommended providing training for healthcare professionals and access to psychosocial support for families. High quality, individually-tailored information, open communication and psychosocial support appear vital in supporting decision-making regarding enrollment in clinical trials. These data will usefully inform future decision-making interventions/tools to support families making clinical trial decisions. A solid evidence-base for effective strategies which facilitate shared decision-making is needed. Copyright © 2018 Elsevier B.V. All rights reserved.

Incorporating uncertainty regarding applicability of evidence from meta-analyses into clinical decision making.

PubMed

Kriston, Levente; Meister, Ramona

2014-03-01

Judging applicability (relevance) of meta-analytical findings to particular clinical decision-making situations remains challenging. We aimed to describe an evidence synthesis method that accounts for possible uncertainty regarding applicability of the evidence. We conceptualized uncertainty regarding applicability of the meta-analytical estimates to a decision-making situation as the result of uncertainty regarding applicability of the findings of the trials that were included in the meta-analysis. This trial-level applicability uncertainty can be directly assessed by the decision maker and allows for the definition of trial inclusion probabilities, which can be used to perform a probabilistic meta-analysis with unequal probability resampling of trials (adaptive meta-analysis). A case study with several fictitious decision-making scenarios was performed to demonstrate the method in practice. We present options to elicit trial inclusion probabilities and perform the calculations. The result of an adaptive meta-analysis is a frequency distribution of the estimated parameters from traditional meta-analysis that provides individually tailored information according to the specific needs and uncertainty of the decision maker. The proposed method offers a direct and formalized combination of research evidence with individual clinical expertise and may aid clinicians in specific decision-making situations. Copyright © 2014 Elsevier Inc. All rights reserved.

[Clinical reasoning in undergraduate nursing education: a scoping review].

PubMed

Menezes, Sáskia Sampaio Cipriano de; Corrêa, Consuelo Garcia; Silva, Rita de Cássia Gengo E; Cruz, Diná de Almeida Monteiro Lopes da

2015-12-01

This study aimed at analyzing the current state of knowledge on clinical reasoning in undergraduate nursing education. A systematic scoping review through a search strategy applied to the MEDLINE database, and an analysis of the material recovered by extracting data done by two independent reviewers. The extracted data were analyzed and synthesized in a narrative manner. From the 1380 citations retrieved in the search, 23 were kept for review and their contents were summarized into five categories: 1) the experience of developing critical thinking/clinical reasoning/decision-making process; 2) teaching strategies related to the development of critical thinking/clinical reasoning/decision-making process; 3) measurement of variables related to the critical thinking/clinical reasoning/decision-making process; 4) relationship of variables involved in the critical thinking/clinical reasoning/decision-making process; and 5) theoretical development models of critical thinking/clinical reasoning/decision-making process for students. The biggest challenge for developing knowledge on teaching clinical reasoning seems to be finding consistency between theoretical perspectives on the development of clinical reasoning and methodologies, methods, and procedures in research initiatives in this field.

How do community pharmacists make decisions? Results of an exploratory qualitative study in Ontario.

PubMed

Gregory, Paul A M; Whyte, Brenna; Austin, Zubin

2016-03-01

As the complexity of pharmacy practice increases, pharmacists are required to make more decisions under ambiguous or information-deficient conditions. There is scant literature examining how pharmacists make decisions and what factors or values influence their choices. The objective of this exploratory research was to characterize decision-making patterns in the clinical setting of community pharmacists in Ontario. The think-aloud decision-making method was used for this study. Community pharmacists with 3 or more years' experience were presented with 2 clinical case studies dealing with challenging situations and were asked to verbally reason through their decision-making process while being probed by an interviewer for clarification, justification and further explication. Verbatim transcripts were analyzed using a protocol analysis method. A total of 12 pharmacists participated in this study. Participants experienced cognitive dissonance in attempting to reconcile their desire for a clear and confrontation-free conclusion to the case discussion and the reality of the challenge presented within each case. Strategies for resolving this cognitive dissonance included strong emphasis on the educational (rather than decision-making) role of the pharmacist, the value of strong interpersonal relationships as a way to avoid conflict and achieve desired outcomes, the desire to seek external advice or defer to others' authority to avoid making a decision and the use of strict interpretations of rules to avoid ambiguity and contextual interpretation. This research was neither representative nor generalizable but was indicative of patterns of decisional avoidance and fear of assuming responsibility for outcomes that warrant further investigation. The think-aloud method functioned effectively in this context and provided insights into pharmacists' decision-making patterns in the clinical setting. Can Pharm J (Ott) 2016;149:90-98.

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

PubMed

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

2015-02-01

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

What is a “good” treatment decision?: Decisional control, knowledge, treatment decision-making, and quality of life in men with clinically localized prostate cancer

PubMed Central

Orom, Heather; Biddle, Caitlin; Underwood, Willie; Nelson, Christian J.; Homish, D. Lynn

2016-01-01

Objective We explored whether active patient involvement in decision making and greater patient knowledge are associated with better treatment decision making experiences and better quality of life (QOL) among men with clinically localized prostate cancer. Localized prostate cancer treatment decision-making is an advantageous model for studying patient treatment decision-making dynamics as there are multiple treatment options and a lack of empirical evidence to recommend one over the other; consequently, it is recommended that patients be fully involved in making the decision. Methods Men with newly diagnosed clinically localized prostate cancer (N=1529) completed measures of decisional control, prostate cancer knowledge, and their decision-making experience (decisional conflict, and decision-making satisfaction and difficulty) shortly after they made their treatment decision. Prostate cancer-specific QOL was assessed 6-months after treatment. Results More active involvement in decision making and greater knowledge were associated with lower decisional conflict and higher decision-making satisfaction, but greater decision-making difficulty. An interaction between decisional control and knowledge revealed that greater knowledge was only associated with greater difficulty for men actively involved in making the decision (67% of sample). Greater knowledge, but not decisional control predicted better QOL 6-months post-treatment. Conclusion Although men who are actively involved in decision making and more knowledgeable may make more informed decisions, they could benefit from decisional support (e.g., decision-making aids, emotional support from providers, strategies for reducing emotional distress) to make the process easier. Men who were more knowledgeable about prostate cancer and treatment side effects at the time they made their treatment decision may have appraised their QOL as higher because they had realistic expectations about side effects. PMID:26957566

Right For Me: protocol for a cluster randomised trial of two interventions for facilitating shared decision-making about contraceptive methods.

PubMed

Thompson, Rachel; Manski, Ruth; Donnelly, Kyla Z; Stevens, Gabrielle; Agusti, Daniela; Banach, Michelle; Boardman, Maureen B; Brady, Pearl; Colón Bradt, Christina; Foster, Tina; Johnson, Deborah J; Li, Zhongze; Norsigian, Judy; Nothnagle, Melissa; Olson, Ardis L; Shepherd, Heather L; Stern, Lisa F; Tosteson, Tor D; Trevena, Lyndal; Upadhya, Krishna K; Elwyn, Glyn

2017-10-22

Despite the observed and theoretical advantages of shared decision-making in a range of clinical contexts, including contraceptive care, there remains a paucity of evidence on how to facilitate its adoption. This paper describes the protocol for a study to assess the comparative effectiveness of patient-targeted and provider-targeted interventions for facilitating shared decision-making about contraceptive methods. We will conduct a 2×2 factorial cluster randomised controlled trial with four arms: (1) video+prompt card, (2) decision aids+training, (3) video+prompt card and decision aids+training and (4) usual care. The clusters will be clinics in USA that deliver contraceptive care. The participants will be people who have completed a healthcare visit at a participating clinic, were assigned female sex at birth, are aged 15-49 years, are able to read and write English or Spanish and have not previously participated in the study. The primary outcome will be shared decision-making about contraceptive methods. Secondary outcomes will be the occurrence of a conversation about contraception in the healthcare visit, satisfaction with the conversation about contraception, intended contraceptive method(s), intention to use a highly effective method, values concordance of the intended method(s), decision regret, contraceptive method(s) used, use of a highly effective method, use of the intended method(s), adherence, satisfaction with the method(s) used, unintended pregnancy and unwelcome pregnancy. We will collect study data via longitudinal patient surveys administered immediately after the healthcare visit, four weeks later and six months later. We will disseminate results via presentations at scientific and professional conferences, papers published in peer-reviewed, open-access journals and scientific and lay reports. We will also make an anonymised copy of the final participant-level dataset available to others for research purposes. ClinicalTrials.gov Identifier: NCT02759939. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

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

PubMed

Gillespie, Mary

2010-11-01

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

Consultant psychiatrists’ experiences of and attitudes towards shared decision making in antipsychotic prescribing, a qualitative study

PubMed Central

2014-01-01

Background Shared decision making represents a clinical consultation model where both clinician and service user are conceptualised as experts; information is shared bilaterally and joint treatment decisions are reached. Little previous research has been conducted to assess experience of this model in psychiatric practice. The current project therefore sought to explore the attitudes and experiences of consultant psychiatrists relating to shared decision making in the prescribing of antipsychotic medications. Methods A qualitative research design allowed the experiences and beliefs of participants in relation to shared decision making to be elicited. Purposive sampling was used to recruit participants from a range of clinical backgrounds and with varying length of clinical experience. A semi-structured interview schedule was utilised and was adapted in subsequent interviews to reflect emergent themes. Data analysis was completed in parallel with interviews in order to guide interview topics and to inform recruitment. A directed analysis method was utilised for interview analysis with themes identified being fitted to a framework identified from the research literature as applicable to the practice of shared decision making. Examples of themes contradictory to, or not adequately explained by, the framework were sought. Results A total of 26 consultant psychiatrists were interviewed. Participants expressed support for the shared decision making model, but also acknowledged that it was necessary to be flexible as the clinical situation dictated. A number of potential barriers to the process were perceived however: The commonest barrier was the clinician’s beliefs regarding the service users’ insight into their mental disorder, presented in some cases as an absolute barrier to shared decision making. In addition factors external to the clinician - service user relationship were identified as impacting on the decision making process, including; environmental factors, financial constraints as well as societal perceptions of mental disorder in general and antipsychotic medication in particular. Conclusions This project has allowed identification of potential barriers to shared decision making in psychiatric practice. Further work is necessary to observe the decision making process in clinical practice and also to identify means in which the identified barriers, in particular ‘lack of insight’, may be more effectively managed. PMID:24886121

A Novel Approach to Study Medical Decision Making in the Clinical Setting: The "Own-point-of-view" Perspective.

PubMed

Pelaccia, Thierry; Tardif, Jacques; Triby, Emmanuel; Charlin, Bernard

2017-07-01

Making diagnostic and therapeutic decisions is a critical activity among physicians. It relies on the ability of physicians to use cognitive processes and specific knowledge in the context of a clinical reasoning. This ability is a core competency in physicians, especially in the field of emergency medicine where the rate of diagnostic errors is high. Studies that explore medical decision making in an authentic setting are increasing significantly. They are based on the use of qualitative methods that are applied at two separate times: 1) a video recording of the subject's actual activity in an authentic setting and 2) an interview with the subject, supported by the video recording. Traditionally, activity is recorded from an "external perspective"; i.e., a camera is positioned in the room in which the consultation takes place. This approach has many limits, both technical and with respect to the validity of the data collected. The article aims at 1) describing how decision making is currently being studied, especially from a qualitative standpoint, and the reasons why new methods are needed, and 2) reporting how we used an original, innovative approach to study decision making in the field of emergency medicine and findings from these studies to guide further the use of this method. The method consists in recording the subject's activity from his own point of view, by fixing a microcamera on his temple or the branch of his glasses. An interview is then held on the basis of this recording, so that the subject being interviewed can relive the situation, to facilitate the explanation of his reasoning with respect to his decisions and actions. We describe how this method has been used successfully in investigating medical decision making in emergency medicine. We provide details on how to use it optimally, taking into account the constraints associated with the practice of emergency medicine and the benefits in the study of clinical reasoning. The "own-point-of-view" video technique is a promising method to study clinical decision making in emergency medicine. It is a powerful tool to stimulate recall and help physicians make their reasoning explicit, thanks to a greater psychological immersion. © 2017 by the Society for Academic Emergency Medicine.

ACL Return to Sport Guidelines and Criteria.

PubMed

Davies, George J; McCarty, Eric; Provencher, Matthew; Manske, Robert C

2017-09-01

Because of the epidemiological incidence of anterior cruciate ligament (ACL) injuries, the high reinjury rates that occur when returning back to sports, the actual number of patients that return to the same premorbid level of competition, the high incidence of osteoarthritis at 5-10-year follow-ups, and the effects on the long-term health of the knee and the quality of life for the patient, individualizing the return to sports after ACL reconstruction (ACL-R) is critical. However, one of the challenging but unsolved dilemmas is what criteria and clinical decision making should be used to return an athlete back to sports following an ACL-R. This article describes an example of a functional testing algorithm (FTA) as one method for clinical decision making based on quantitative and qualitative testing and assessment utilized to make informed decisions to return an athlete to their sports safely and without compromised performance. The methods were a review of the best current evidence to support a FTA. In order to evaluate all the complicated domains of the clinical decision making for individualizing the return to sports after ACL-R, numerous assessments need to be performed including the biopsychosocial concepts, impairment testing, strength and power testing, functional testing, and patient-reported outcomes (PROs). The optimum criteria to use for individualizing the return to sports after ACL-R remain elusive. However, since this decision needs to be made on a regular basis with the safety and performance factors of the patient involved, this FTA provides one method of quantitatively and qualitatively making the decisions. Admittedly, there is no predictive validity of this system, but it does provide practical guidelines to facilitate the clinical decision making process for return to sports. The clinical decision to return an athlete back into competition has significant implications ranging from the safety of the athlete, to performance factors and actual litigation issues. By using a multifactorial FTA, such as the one described, provides quantitative and qualitatively criteria to make an informed decision in the best interests of the athlete.

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.

Decision Making on the Labor and Delivery Unit: An Investigation of Influencing Factors.

PubMed

Gregory, Megan E; Sonesh, Shirley C; Feitosa, Jennifer; Benishek, Lauren E; Hughes, Ashley M; Salas, Eduardo

2017-09-01

Objective The aim of this study was to describe the relationship between negative affect (NA), decision-making style, time stress, and decision quality in health care. Background Health care providers must often make swift, high-stakes decisions. Influencing factors of the decision-making process in this context have been understudied. Method Within a sample of labor and delivery nurses, physicians, and allied personnel, we used self-report measures to examine the impact of trait factors, including NA, decision-making style, and perceived time stress, on decision quality in a situational judgment test (Study 1). In Study 2, we observed the influence of state NA, state decision-making style, state time stress, and their relationship with decision quality on real clinical decisions. Results In Study 1, we found that trait NA significantly predicted avoidant decision-making style. Furthermore, those who were higher on trait time stress and trait avoidant decision-making style exhibited poorer decisions. In Study 2, we observed associations between state NA with state avoidant and analytical decision-making styles. We also observed that these decision-making styles, when considered in tandem with time stress, were influential in predicting clinical decision quality. Conclusion NA predicts some decision-making styles, and decision-making style can affect decision quality under time stress. This is particularly true for state factors. Application Individual differences, such as affect and decision-making style, should be considered during selection. Training to reduce time stress perceptions should be provided.

Enhancing decision making about participation in cancer clinical trials: development of a question prompt list

PubMed Central

Brown, Richard F.; Shuk, Elyse; Leighl, Natasha; Butow, Phyllis; Ostroff, Jamie; Edgerson, Shawna; Tattersall, Martin

2016-01-01

Purpose Slow accrual to cancer clinical trials impedes the progress of effective new cancer treatments. Poor physician–patient communication has been identified as a key contributor to low trial accrual. Question prompt lists (QPLs) have demonstrated a significant promise in facilitating communication in general, surgical, and palliative oncology settings. These simple patient interventions have not been tested in the oncology clinical trial setting. We aimed to develop a targeted QPL for clinical trials (QPL-CT). Method Lung, breast, and prostate cancer patients who either had (trial experienced) or had not (trial naive) participated in a clinical trial were invited to join focus groups to help develop and explore the acceptability of a QPL-CT. Focus groups were audio-recorded and transcribed. A research team, including a qualitative data expert, analyzed these data to explore patients’ decision-making processes and views about the utility of the QPL-CT prompt to aid in trial decision making. Results Decision making was influenced by the outcome of patients’ comparative assessment of perceived risks versus benefits of a trial, and the level of trust patients had in their doctors’ recommendation about the trial. Severity of a patient’s disease influenced trial decision making only for trial-naive patients. Conclusion Although patients were likely to prefer a paternalistic decision-making style, they expressed valuation of the QPL as an aid to decision making. QPL-CT utility extended beyond the actual consultation to include roles both before and after the clinical trial discussion. PMID:20593202

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

PubMed

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

2017-01-01

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

Development and evaluation of learning module on clinical decision-making in Prosthodontics.

PubMed

Deshpande, Saee; Lambade, Dipti; Chahande, Jayashree

2015-01-01

Best practice strategies for helping students learn the reasoning skills of problem solving and critical thinking (CT) remain a source of conjecture, particularly with regard to CT. The dental education literature is fundamentally devoid of research on the cognitive components of clinical decision-making. This study was aimed to develop and evaluate the impact of blended learning module on clinical decision-making skills of dental graduates for planning prosthodontics rehabilitation. An interactive teaching module consisting of didactic lectures on clinical decision-making and a computer-assisted case-based treatment planning software was developed Its impact on cognitive knowledge gain in clinical decision-making was evaluated using an assessment involving problem-based multiple choice questions and paper-based case scenarios. Mean test scores were: Pretest (17 ± 1), posttest 1 (21 ± 2) and posttest 2 (43 ± 3). Comparison of mean scores was done with one-way ANOVA test. There was overall significant difference in between mean scores at all the three points (P < 0.001). A pair-wise comparison of mean scores was done with Bonferroni test. The mean difference is significant at the 0.05 level. The pair-wise comparison shows that posttest 2 score is significantly higher than posttest 1 and posttest 1 is significantly higher than pretest that is, pretest 2 > posttest 1 > pretest. Blended teaching methods employing didactic lectures on the clinical decision-making as well as computer assisted case-based learning can be used to improve quality of clinical decision-making in prosthodontic rehabilitation for dental graduates.

A Synthesis Of Knowledge About Caregiver Decision Making Finds Gaps In Support For Those Who Care For Aging Loved Ones.

PubMed

Garvelink, Mirjam M; Ngangue, Patrice A G; Adekpedjou, Rheda; Diouf, Ndeye T; Goh, Larissa; Blair, Louisa; Légaré, France

2016-04-01

We conducted a mixed-methods knowledge synthesis to assess the effectiveness of interventions to improve caregivers' involvement in decision making with seniors, and to describe caregivers' experiences of decision making in the absence of interventions. We analyzed forty-nine qualitative, fourteen quantitative, and three mixed-methods studies. The qualitative studies indicated that caregivers had unmet needs for information, discussions of values and needs, and decision support, which led to negative sentiments after decision making. Our results indicate that there have been insufficient quantitative evaluations of interventions to involve caregivers in decision making with seniors and that the evaluations that do exist found few clinically significant effects. Elements of usual care that received positive evaluations were the availability of a decision coach and a supportive decision-making environment. Additional rigorously evaluated interventions are needed to help caregivers be more involved in decision making with seniors. Project HOPE—The People-to-People Health Foundation, Inc.

Exploring the clinical decision-making used by experienced cardiorespiratory physiotherapists: A mixed method qualitative design of simulation, video recording and think aloud techniques.

PubMed

Thackray, Debbie; Roberts, Lisa

2017-02-01

The ability of physiotherapists to make clinical decisions is a vital component of being an autonomous practitioner, yet this complex phenomenon has been under-researched in cardiorespiratory physiotherapy. The purpose of this study was to explore clinical decision-making (CDM) by experienced physiotherapists in a scenario of a simulated patient experiencing acute deterioration of their respiratory function. The main objective of this observational study was to identify the actions, thoughts, and behaviours used by experienced cardiorespiratory physiotherapists in their clinical decision-making processes. A mixed-methods (qualitative) design employing observation and think-aloud, was adopted using a computerised manikin in a simulated environment. The participants clinically assessed the manikin programmed with the same clinical signs, under standardised conditions in the clinical skills practice suite, which was set up as a ward environment. Experienced cardiorespiratory physiotherapists, recruited from clinical practice within a 50-mile radius of the University(*). Participants were video-recorded throughout the assessment and treatment and asked to verbalise their thought processes using the 'think-aloud' method. The recordings were transcribed verbatim and managed using a Framework approach. Eight cardiorespiratory physiotherapists participated (mean 7years clinical experience, range 3.5-16years. CDM was similar to the collaborative hypothetico-deductive model, five-rights nursing model, reasoning strategies, inductive reasoning and pattern recognition. However, the CDM demonstrated by the physiotherapists was complex, interactive and iterative. Information processing occurred continuously throughout the whole interaction with the patient, and the specific cognitive skills of recognition, matching, discriminating, relating, inferring, synthesising and prediction were identified as being used sequentially. The findings from this study were used to develop a new conceptual model of clinical decision-making for cardiorespiratory physiotherapy. This conceptual model can be used to inform future educational strategies to prepare physiotherapists and nurses for working in acute respiratory care. Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.

Patient involvement in decision-making: a cross-sectional study in a Malaysian primary care clinic

PubMed Central

Ambigapathy, Ranjini; Ng, Chirk Jenn

2016-01-01

Objective Shared decision-making has been advocated as a useful model for patient management. In developing Asian countries such as Malaysia, there is a common belief that patients prefer a passive role in clinical consultation. As such, the objective of this study was to determine Malaysian patients’ role preference in decision-making and the associated factors. Design A cross-sectional study. Setting Study was conducted at an urban primary care clinic in Malaysia in 2012. Participants Patients aged >21 years were chosen using systematic random sampling. Methods Consenting patients answered a self-administered questionnaire, which included demographic data and their preferred and actual role before and after consultation. Doctors were asked to determine patients’ role preference. The Control Preference Scale was used to assess patients’ role preference. Primary outcome Prevalence of patients’ preferred role in decision-making. Secondary outcomes (1) Actual role played by the patient in decision-making. (2) Sociodemographic factors associated with patients’ preferred role in decision-making. (3) Doctors’ perception of patients’ involvement in decision-making. Results The response rate was 95.1% (470/494). Shared decision-making was preferred by 51.9% of patients, followed by passive (26.3%) and active (21.8%) roles in decision-making. Higher household income was significantly associated with autonomous role preference (p=0.018). Doctors’ perception did not concur with patients’ preferred role. Among patients whom doctors perceived to prefer a passive role, 73.5% preferred an autonomous role (p=0.900, κ=0.006). Conclusions The majority of patients attending the primary care clinic preferred and played an autonomous role in decision-making. Doctors underestimated patients’ preference to play an autonomous role. PMID:26729393

Barriers to and facilitators of implementing shared decision making and decision support in a paediatric hospital: A descriptive study

PubMed Central

Boland, Laura; McIsaac, Daniel I; Lawson, Margaret L

2016-01-01

OBJECTIVE: To explore multiple stakeholders’ perceived barriers to and facilitators of implementing shared decision making and decision support in a tertiary paediatric hospital. METHODS: An interpretive descriptive qualitative study was conducted using focus groups and interviews to examine senior hospital administrators’, clinicians’, parents’ and youths’ perceived barriers to and facilitators of shared decision making and decision support implementation. Data were analyzed using inductive thematic analysis. RESULTS: Fifty-seven stakeholders participated. Six barrier and facilitator themes emerged. The main barrier was gaps in stakeholders’ knowledge of shared decision making and decision support. Facilitators included compatibility between shared decision making and the hospital’s culture and ideal practices, perceptions of positive patient and family outcomes associated with shared decision making, and positive attitudes regarding shared decision making and decision support. However, youth attitudes regarding the necessity and usefulness of a decision support program were a barrier. Two themes were both a barrier and a facilitator. First, stakeholder groups were uncertain which clinical situations are suitable for shared decision making (eg, new diagnoses, chronic illnesses, complex decisions or urgent decisions). Second, the clinical process may be hindered if shared decision making and decision support decrease efficiency and workflow; however, shared decision making may reduce repeat visits and save time over the long term. CONCLUSIONS: Specific knowledge translation strategies that improve shared decision making knowledge and match specific barriers identified by each stakeholder group may be required to promote successful shared decision making and decision support implementation in the authors’ paediatric hospital. PMID:27398058

In search of tools to aid logical thinking and communicating about medical decision making.

PubMed

Hunink, M G

2001-01-01

To have real-time impact on medical decision making, decision analysts need a wide variety of tools to aid logical thinking and communication. Decision models provide a formal framework to integrate evidence and values, but they are commonly perceived as complex and difficult to understand by those unfamiliar with the methods, especially in the context of clinical decision making. The theory of constraints, introduced by Eliyahu Goldratt in the business world, provides a set of tools for logical thinking and communication that could potentially be useful in medical decision making. The author used the concept of a conflict resolution diagram to analyze the decision to perform carotid endarterectomy prior to coronary artery bypass grafting in a patient with both symptomatic coronary and asymptomatic carotid artery disease. The method enabled clinicians to visualize and analyze the issues, identify and discuss the underlying assumptions, search for the best available evidence, and use the evidence to make a well-founded decision. The method also facilitated communication among those involved in the care of the patient. Techniques from fields other than decision analysis can potentially expand the repertoire of tools available to support medical decision making and to facilitate communication in decision consults.

Development of a Model of Interprofessional Shared Clinical Decision Making in the ICU: A Mixed-Methods Study.

PubMed

DeKeyser Ganz, Freda; Engelberg, Ruth; Torres, Nicole; Curtis, Jared Randall

2016-04-01

To develop a model to describe ICU interprofessional shared clinical decision making and the factors associated with its implementation. Ethnographic (observations and interviews) and survey designs. Three ICUs (two in Israel and one in the United States). A convenience sample of nurses and physicians. None. Observations and interviews were analyzed using ethnographic and grounded theory methodologies. Questionnaires included a demographic information sheet and the Jefferson Scale of Attitudes toward Physician-Nurse Collaboration. From observations and interviews, we developed a conceptual model of the process of shared clinical decision making that involves four stepped levels, proceeding from the lowest to the highest levels of collaboration: individual decision, information exchange, deliberation, and shared decision. This process is influenced by individual, dyadic, and system factors. Most decisions were made at the lower two levels. Levels of perceived collaboration were moderate with no statistically significant differences between physicians and nurses or between units. Both qualitative and quantitative data corroborated that physicians and nurses from all units were similarly and moderately satisfied with their level of collaboration and shared decision making. However, most ICU clinical decision making continues to take place independently, where there is some sharing of information but rarely are decisions made collectively. System factors, such as interdisciplinary rounds and unit culture, seem to have a strong impact on this process. This study provides a model for further study and improvement of interprofessional shared decision making.

Effects of additional team-based learning on students' clinical reasoning skills: a pilot study.

PubMed

Jost, Meike; Brüstle, Peter; Giesler, Marianne; Rijntjes, Michel; Brich, Jochen

2017-07-14

In the field of Neurology good clinical reasoning skills are essential for successful diagnosing and treatment. Team-based learning (TBL), an active learning and small group instructional strategy, is a promising method for fostering these skills. The aim of this pilot study was to examine the effects of a supplementary TBL-class on students' clinical decision-making skills. Fourth- and fifth-year medical students participated in this pilot study (static-group comparison design). The non-treatment group (n = 15) did not receive any additional training beyond regular teaching in the neurology course. The treatment group (n = 11) took part in a supplementary TBL-class optimized for teaching clinical reasoning in addition to the regular teaching in the neurology course. Clinical decision making skills were assessed using a key-feature problem examination. Factual and conceptual knowledge was assessed by a multiple-choice question examination. The TBL-group performed significantly better than the non-TBL-group (p = 0.026) in the key-feature problem examination. No significant differences between the results of the multiple-choice question examination of both groups were found. In this pilot study participants of a supplementary TBL-class significantly improved clinical decision-making skills, indicating that TBL may be an appropriate method for teaching clinical decision making in neurology. Further research is needed for replication in larger groups and other clinical fields.

Informed decision-making in elective major vascular surgery: analysis of 145 surgeon-patient consultations.

PubMed

Etchells, Edward; Ferrari, Michel; Kiss, Alex; Martyn, Nikki; Zinman, Deborah; Levinson, Wendy

2011-06-01

Prior studies show significant gaps in the informed decision-making process, a central goal of surgical care. These studies have been limited by their focus on low-risk decisions, single visits rather than entire consultations, or both. Our objectives were, first, to rate informed decision-making for major elective vascular surgery based on audiotapes of actual physician-patient conversations and, second, to compare ratings of informed decision-making for first visits to ratings for multiple visits by the same patient over time. We prospectively enrolled patients for whom vascular surgical treatment was a potential option at a tertiary care outpatient vascular surgery clinic. We audio-taped all surgeon-patient conversations, including multiple visits when necessary, until a decision was made. Using an existing method, we evaluated the transcripts for elements of decision-making, including basic elements (e.g., an explanation of the clinical condition), intermediate elements (e.g., risks and benefits) and complex elements (e.g., uncertainty around the decision). We analyzed 145 surgeon-patient consultations. Overall, 45% of consultations contained complex elements, whereas 23% did not contain the basic elements of decision-making. For the 67 consultations that involved multiple visits, ratings were significantly higher when evaluating all visits (50% complex elements) compared with evaluating only the first visit (33% complex elements, p < 0.001.) We found that 45% of consultations contained complex elements, which is higher than prior studies with similar methods. Analyzing decision-making over multiple visits yielded different results than analyzing decision-making for single visits.

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

PubMed

Banning, Maggi

2008-01-01

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

Clinical decision-making: predictors of patient participation in nursing care.

PubMed

Florin, Jan; Ehrenberg, Anna; Ehnfors, Margareta

2008-11-01

To investigate predictors of patients' preferences for participation in clinical decision-making in inpatient nursing care. Patient participation in decision-making in nursing care is regarded as a prerequisite for good clinical practice regarding the person's autonomy and integrity. A cross-sectional survey of 428 persons, newly discharged from inpatient care. The survey was conducted using the Control Preference Scale. Multiple logistic regression analysis was used for testing the association of patient characteristics with preferences for participation. Patients, in general, preferred adopting a passive role. However, predictors for adopting an active participatory role were the patient's gender (odds ratio = 1.8), education (odds ratio = 2.2), living condition (odds ratio = 1.8) and occupational status (odds ratio = 2.0). A probability of 53% was estimated, which female senior citizens with at least a high school degree and who lived alone would prefer an active role in clinical decision-making. At the same time, a working cohabiting male with less than a high school degree had a probability of 8% for active participation in clinical decision making in nursing care. Patient preferences for participation differed considerably and are best elicited by assessment of the individual patient. Relevance to clinical practice. The nurses have a professional responsibility to act in such a way that patients can participate and make decisions according to their own values from an informed position. Access to knowledge of patients'basic assumptions and preferences for participation is of great value for nurses in the care process. There is a need for nurses to use structured methods and tools for eliciting individual patient preferences regarding participation in clinical decision-making.

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

PubMed

Kim, Se Young

2010-12-01

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

Registered nurses' decision-making regarding documentation in patients' progress notes.

PubMed

Tower, Marion; Chaboyer, Wendy; Green, Quentine; Dyer, Kirsten; Wallis, Marianne

2012-10-01

To examine registered nurses' decision-making when documenting care in patients' progress notes. What constitutes effective nursing documentation is supported by available guidelines. However, ineffective documentation continues to be cited as a major cause of adverse events for patients. Decision-making in clinical practice is a complex process. To make an effective decision, the decision-maker must be situationally aware. The concept of situation awareness and its implications for making safe decisions has been examined extensively in air safety and more recently is being applied to health. The study was situated in a naturalistic paradigm. Purposive sampling was used to recruit 17 registered nurses who used think-aloud research methods when making decisions about documenting information in patients' progress notes. Follow-up interviews were conducted to validate interpretations. Data were analysed systematically for evidence of cues that demonstrated situation awareness as nurses made decisions about documentation. Three distinct decision-making scenarios were illuminated from the analysis: the newly admitted patient, the patient whose condition was as expected and the discharging patient. Nurses used mental models for decision-making in documenting in progress notes, and the cues nurses used to direct their assessment of patients' needs demonstrated situation awareness at different levels. Nurses demonstrate situation awareness at different levels in their decision-making processes. While situation awareness is important, it is also important to use an appropriate decision-making framework. Cognitive continuum theory is suggested as a decision-making model that could support situation awareness when nurses made decisions about documenting patient care. Because nurses are key decision-makers, it is imperative that effective decisions are made that translate into safe clinical care. Including situation awareness training, combined with employing cognitive continuum theory as a decision-making framework, provides a powerful means of guiding nurses' decision-making. © 2012 Blackwell Publishing Ltd.

Development and initial evaluation of a treatment decision dashboard

PubMed Central

2013-01-01

Background For many healthcare decisions, multiple alternatives are available with different combinations of advantages and disadvantages across several important dimensions. The complexity of current healthcare decisions thus presents a significant barrier to informed decision making, a key element of patient-centered care. Interactive decision dashboards were developed to facilitate decision making in Management, a field marked by similarly complicated choices. These dashboards utilize data visualization techniques to reduce the cognitive effort needed to evaluate decision alternatives and a non-linear flow of information that enables users to review information in a self-directed fashion. Theoretically, both of these features should facilitate informed decision making by increasing user engagement with and understanding of the decision at hand. We sought to determine if the interactive decision dashboard format can be successfully adapted to create a clinically realistic prototype patient decision aid suitable for further evaluation and refinement. Methods We created a computerized, interactive clinical decision dashboard and performed a pilot test of its clinical feasibility and acceptability using a multi-method analysis. The dashboard summarized information about the effectiveness, risks of side effects and drug-drug interactions, out-of-pocket costs, and ease of use of nine analgesic treatment options for knee osteoarthritis. Outcome evaluations included observations of how study participants utilized the dashboard, questionnaires to assess usability, acceptability, and decisional conflict, and an open-ended qualitative analysis. Results The study sample consisted of 25 volunteers - 7 men and 18 women - with an average age of 51 years. The mean time spent interacting with the dashboard was 4.6 minutes. Mean evaluation scores on scales ranging from 1 (low) to 7 (high) were: mechanical ease of use 6.1, cognitive ease of use 6.2, emotional difficulty 2.7, decision-aiding effectiveness 5.9, clarification of values 6.5, reduction in decisional uncertainty 6.1, and provision of decision-related information 6.0. Qualitative findings were similarly positive. Conclusions Interactive decision dashboards can be adapted for clinical use and have the potential to foster informed decision making. Additional research is warranted to more rigorously test the effectiveness and efficiency of patient decision dashboards for supporting informed decision making and other aspects of patient-centered care, including shared decision making. PMID:23601912

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

ERIC Educational Resources Information Center

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

2015-01-01

Background: Mental health professionals' decision-making practice is an area of increasing interest and importance, especially in the pediatric research and clinical communities. Objective: The present study explored the role of prior training in evidence-based treatments (EBTs) on clinicians' assessment and treatment formulations using…

Decision Making Impairment: A Shared Vulnerability in Obesity, Gambling Disorder and Substance Use Disorders?

PubMed Central

Mallorquí-Bagué, Nuria; Fagundo, Ana B.; Jimenez-Murcia, Susana; de la Torre, Rafael; Baños, Rosa M.; Botella, Cristina; Casanueva, Felipe F.; Crujeiras, Ana B.; Fernández-García, Jose C.; Fernández-Real, Jose M.; Frühbeck, Gema; Granero, Roser; Rodríguez, Amaia; Tolosa-Sola, Iris; Ortega, Francisco J.; Tinahones, Francisco J.; Alvarez-Moya, Eva; Ochoa, Cristian; Menchón, Jose M.

2016-01-01

Introduction Addictions are associated with decision making impairments. The present study explores decision making in Substance use disorder (SUD), Gambling disorder (GD) and Obesity (OB) when assessed by Iowa Gambling Task (IGT) and compares them with healthy controls (HC). Methods For the aims of this study, 591 participants (194 HC, 178 GD, 113 OB, 106 SUD) were assessed according to DSM criteria, completed a sociodemographic interview and conducted the IGT. Results SUD, GD and OB present impaired decision making when compared to the HC in the overall task and task learning, however no differences are found for the overall performance in the IGT among the clinical groups. Results also reveal some specific learning across the task patterns within the clinical groups: OB maintains negative scores until the third set where learning starts but with a less extend to HC, SUD presents an early learning followed by a progressive although slow improvement and GD presents more random choices with no learning. Conclusions Decision making impairments are present in the studied clinical samples and they display individual differences in the task learning. Results can help understanding the underlying mechanisms of OB and addiction behaviors as well as improve current clinical treatments. PMID:27690367

Consultant psychiatrists' experiences of and attitudes towards shared decision making in antipsychotic prescribing, a qualitative study.

PubMed

Shepherd, Andrew; Shorthouse, Oliver; Gask, Linda

2014-05-01

Shared decision making represents a clinical consultation model where both clinician and service user are conceptualised as experts; information is shared bilaterally and joint treatment decisions are reached. Little previous research has been conducted to assess experience of this model in psychiatric practice. The current project therefore sought to explore the attitudes and experiences of consultant psychiatrists relating to shared decision making in the prescribing of antipsychotic medications. A qualitative research design allowed the experiences and beliefs of participants in relation to shared decision making to be elicited. Purposive sampling was used to recruit participants from a range of clinical backgrounds and with varying length of clinical experience. A semi-structured interview schedule was utilised and was adapted in subsequent interviews to reflect emergent themes.Data analysis was completed in parallel with interviews in order to guide interview topics and to inform recruitment. A directed analysis method was utilised for interview analysis with themes identified being fitted to a framework identified from the research literature as applicable to the practice of shared decision making. Examples of themes contradictory to, or not adequately explained by, the framework were sought. A total of 26 consultant psychiatrists were interviewed. Participants expressed support for the shared decision making model, but also acknowledged that it was necessary to be flexible as the clinical situation dictated. A number of potential barriers to the process were perceived however: The commonest barrier was the clinician's beliefs regarding the service users' insight into their mental disorder, presented in some cases as an absolute barrier to shared decision making. In addition factors external to the clinician - service user relationship were identified as impacting on the decision making process, including; environmental factors, financial constraints as well as societal perceptions of mental disorder in general and antipsychotic medication in particular. This project has allowed identification of potential barriers to shared decision making in psychiatric practice. Further work is necessary to observe the decision making process in clinical practice and also to identify means in which the identified barriers, in particular 'lack of insight', may be more effectively managed.

What are the decision-making preferences of patients in vascular surgery? A mixed-methods study.

PubMed

Santema, T B Katrien; Stoffer, E Anniek; Kunneman, Marleen; Koelemay, Mark J W; Ubbink, Dirk T

2017-02-10

Shared decision-making (SDM) has been advocated as the preferred method of choosing a suitable treatment option. However, patient involvement in treatment decision-making is not yet common practice in the field of vascular surgery. The aim of this mixed-methods study was to explore patients' decision-making preferences and to investigate which facilitators and barriers patients perceive as important for the application of SDM in vascular surgery. Patients were invited to participate after visiting the vascular surgical outpatient clinic of an Academic Medical Center in the Netherlands. A treatment decision was made during the consultation for an abdominal aortic aneurysm or peripheral arterial occlusive disease. Patients filled in a number of questionnaires (quantitative part) and a random subgroup of patients participated in an in-depth interview (qualitative part). A total of 67 patients participated in this study. 58 per cent of them (n=39) indicated that they preferred a shared role in decision-making. In more than half of the patients (55%; n=37) their preferred role was in disagreement with what they had experienced. 31 per cent of the patients (n=21) preferred a more active role in the decision-making process than they had experienced. Patients indicated a good patient-doctor relationship as an important facilitator for the application of SDM. The vast majority of vascular surgical patients preferred, but did not experience a shared role in the decision-making process, although the concept of SDM was insufficiently clear to some patients. This emphasises the importance of explaining the concept of SDM and implementing it in the clinical encounter. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Maternal Decision-making During Pregnancy: Parental Obligations and Cultural Differences.

PubMed

Malek, Janet

2017-08-01

Decision-making during pregnancy can be ethically complex. This paper offers a framework for maternal decision-making and clinical counseling that can be used to approach such decisions in a systematic way. Three fundamental questions are addressed: (1) Who should make decisions? (2) How should decisions be made? and (3) What is the role of the clinician? The proposed framework emphasizes the decisional authority of the pregnant woman. It draws ethical support from the concept of a good parent and the requirements of parental obligations. It also describes appropriate counseling methods for clinicians in light of those parental obligations. Finally, the paper addresses how cultural differences may shape the framework's guidance of maternal decision-making during pregnancy. Copyright © 2017. Published by Elsevier Ltd.

Examining chronic care patient preferences for involvement in health-care decision making: the case of Parkinson's disease patients in a patient-centred clinic.

PubMed

Zizzo, Natalie; Bell, Emily; Lafontaine, Anne-Louise; Racine, Eric

2017-08-01

Patient-centred care is a recommended model of care for Parkinson's disease (PD). It aims to provide care that is respectful and responsive to patient preferences, values and perspectives. Provision of patient-centred care should entail considering how patients want to be involved in their care. To understand the participation preferences of patients with PD from a patient-centred care clinic in health-care decision-making processes. Mixed-methods study with early-stage Parkinson's disease patients from a patient-centred care clinic. Study involved a modified Autonomy Preference Index survey (N=65) and qualitative, semi-structured in-depth interviews, analysed using thematic qualitative content analysis (N=20, purposefully selected from survey participants). Interviews examined (i) the patient preferences for involvement in health-care decision making; (ii) patient perspectives on the patient-physician relationship; and (iii) patient preferences for communication of information relevant to decision making. Preferences for participation in decision making varied between individuals and also within individuals depending on decision type, relational and contextual factors. Patients had high preferences for communication of information, but with acknowledged limits. The importance of communication in the patient-physician relationship was emphasized. Patient preferences for involvement in decision making are dynamic and support shared decision making. Relational autonomy corresponds to how patients envision their participation in decision making. Clinicians may need to assess patient preferences on an on-going basis. Our results highlight the complexities of decision-making processes. Improved understanding of individual preferences could enhance respect for persons and make for patient-centred care that is truly respectful of individual patients' wants, needs and values. © 2016 The Authors. Health Expectations Published by John Wiley & Sons Ltd.

Quantitative imaging biomarkers: the application of advanced image processing and analysis to clinical and preclinical decision making.

PubMed

Prescott, Jeffrey William

2013-02-01

The importance of medical imaging for clinical decision making has been steadily increasing over the last four decades. Recently, there has also been an emphasis on medical imaging for preclinical decision making, i.e., for use in pharamaceutical and medical device development. There is also a drive towards quantification of imaging findings by using quantitative imaging biomarkers, which can improve sensitivity, specificity, accuracy and reproducibility of imaged characteristics used for diagnostic and therapeutic decisions. An important component of the discovery, characterization, validation and application of quantitative imaging biomarkers is the extraction of information and meaning from images through image processing and subsequent analysis. However, many advanced image processing and analysis methods are not applied directly to questions of clinical interest, i.e., for diagnostic and therapeutic decision making, which is a consideration that should be closely linked to the development of such algorithms. This article is meant to address these concerns. First, quantitative imaging biomarkers are introduced by providing definitions and concepts. Then, potential applications of advanced image processing and analysis to areas of quantitative imaging biomarker research are described; specifically, research into osteoarthritis (OA), Alzheimer's disease (AD) and cancer is presented. Then, challenges in quantitative imaging biomarker research are discussed. Finally, a conceptual framework for integrating clinical and preclinical considerations into the development of quantitative imaging biomarkers and their computer-assisted methods of extraction is presented.

Meta-analysis in evidence-based healthcare: a paradigm shift away from random effects is overdue.

PubMed

Doi, Suhail A R; Furuya-Kanamori, Luis; Thalib, Lukman; Barendregt, Jan J

2017-12-01

Each year up to 20 000 systematic reviews and meta-analyses are published whose results influence healthcare decisions, thus making the robustness and reliability of meta-analytic methods one of the world's top clinical and public health priorities. The evidence synthesis makes use of either fixed-effect or random-effects statistical methods. The fixed-effect method has largely been replaced by the random-effects method as heterogeneity of study effects led to poor error estimation. However, despite the widespread use and acceptance of the random-effects method to correct this, it too remains unsatisfactory and continues to suffer from defective error estimation, posing a serious threat to decision-making in evidence-based clinical and public health practice. We discuss here the problem with the random-effects approach and demonstrate that there exist better estimators under the fixed-effect model framework that can achieve optimal error estimation. We argue for an urgent return to the earlier framework with updates that address these problems and conclude that doing so can markedly improve the reliability of meta-analytical findings and thus decision-making in healthcare.

To pass or to fail? Understanding the factors considered by faculty in the clinical evaluation of nursing students.

PubMed

DeBrew, Jacqueline Kayler; Lewallen, Lynne Porter

2014-04-01

Making the decision to pass or to fail a nursing student is difficult for nurse educators, yet one that all educators face at some point in time. To make this decision, nurse educators draw from their past experiences and personal reflections on the situation. Using the qualitative method of critical incident technique, the authors asked educators to describe a time when they had to make a decision about whether to pass or fail a student in the clinical setting. The findings describe student and faculty factors important in clinical evaluation decisions, demonstrate the benefits of reflective practice to nurse educators, and support the utility of critical incident technique not only as research methodology, but also as a technique for reflective practice. Copyright © 2013 Elsevier Ltd. All rights reserved.

Use of handheld computers in clinical practice: a systematic review

PubMed Central

2014-01-01

Background Many healthcare professionals use smartphones and tablets to inform patient care. Contemporary research suggests that handheld computers may support aspects of clinical diagnosis and management. This systematic review was designed to synthesise high quality evidence to answer the question; Does healthcare professionals’ use of handheld computers improve their access to information and support clinical decision making at the point of care? Methods A detailed search was conducted using Cochrane, MEDLINE, EMBASE, PsycINFO, Science and Social Science Citation Indices since 2001. Interventions promoting healthcare professionals seeking information or making clinical decisions using handheld computers were included. Classroom learning and the use of laptop computers were excluded. Two authors independently selected studies, assessed quality using the Cochrane Risk of Bias tool and extracted data. High levels of data heterogeneity negated statistical synthesis. Instead, evidence for effectiveness was summarised narratively, according to each study’s aim for assessing the impact of handheld computer use. Results We included seven randomised trials investigating medical or nursing staffs’ use of Personal Digital Assistants. Effectiveness was demonstrated across three distinct functions that emerged from the data: accessing information for clinical knowledge, adherence to guidelines and diagnostic decision making. When healthcare professionals used handheld computers to access clinical information, their knowledge improved significantly more than peers who used paper resources. When clinical guideline recommendations were presented on handheld computers, clinicians made significantly safer prescribing decisions and adhered more closely to recommendations than peers using paper resources. Finally, healthcare professionals made significantly more appropriate diagnostic decisions using clinical decision making tools on handheld computers compared to colleagues who did not have access to these tools. For these clinical decisions, the numbers need to test/screen were all less than 11. Conclusion Healthcare professionals’ use of handheld computers may improve their information seeking, adherence to guidelines and clinical decision making. Handheld computers can provide real time access to and analysis of clinical information. The integration of clinical decision support systems within handheld computers offers clinicians the highest level of synthesised evidence at the point of care. Future research is needed to replicate these early results and to identify beneficial clinical outcomes. PMID:24998515

Decision-making capacity and competency in the elderly: a clinical and neuropsychological perspective.

PubMed

Moberg, Paul J; Rick, Jacqueline H

2008-01-01

With our ageing population, the number of older adults with cognitive impairment has also increased. There is both an acute and growing need for evidence-based assessments to identify their decision making capacity and competence. In the present article we (1) present definitions of decision-making capacity and competence, (2) review cognitive functions that are central to decision-making capacity as well as the methods and procedures commonly used to assess these domains, and (3) address the communication of assessment findings to patients and their loved ones. The importance of assessing decision-making capacity in the context of specific functions and of respecting the values and interests of older adults are emphasized.

The Evolution of an Interprofessional Shared Decision-Making Research Program: Reflective Case Study of an Emerging Paradigm

PubMed Central

Menear, Matthew; Stacey, Dawn; Brière, Nathalie; Légaré, France

2016-01-01

Introduction: Healthcare research increasingly focuses on interprofessional collaboration and on shared decision making, but knowledge gaps remain about effective strategies for implementing interprofessional collaboration and shared decision-making together in clinical practice. We used Kuhn’s theory of scientific revolutions to reflect on how an integrated interprofessional shared decision-making approach was developed and implemented over time. Methods: In 2007, an interdisciplinary team initiated a new research program to promote the implementation of an interprofessional shared decision-making approach in clinical settings. For this reflective case study, two new team members analyzed the team’s four projects, six research publications, one unpublished and two published protocols and organized them into recognizable phases according to Kuhn’s theory. Results: The merging of two young disciplines led to challenges characteristic of emerging paradigms. Implementation of interprofessional shared-decision making was hindered by a lack of conceptual clarity, a dearth of theories and models, little methodological guidance, and insufficient evaluation instruments. The team developed a new model, identified new tools, and engaged knowledge users in a theory-based approach to implementation. However, several unresolved challenges remain. Discussion: This reflective case study sheds light on the evolution of interdisciplinary team science. It offers new approaches to implementing emerging knowledge in the clinical context. PMID:28435417

Examining the relationship between critical-thinking skills and decision-making ability of emergency medicine students

PubMed Central

Heidari, Mohammad; Ebrahimi, Parvin

2016-01-01

Background and Aims: Critical-thinking ability would enable students to think creatively and make better decisions and makes them make a greater effort to concentrate on situations related to clinical matters and emergencies. This can bridge the gap between the clinical and theoretical training. Therefore, the aim of the present study is to examine the relationship between critical-thinking ability and decision-making skills of the students of Emergency Medicine. Materials and Methods: This descriptive and analytical research was conducted on all the students of medical emergency students (n = 86) in Shahrekord, Iran. The demographic information questionnaire, the California Critical Thinking Skills Test, and a decision-making researcher-made questionnaire were used to collect data. The data were analyzed by SPSS software version 16 using descriptive and analytical statistical tests and Pearson's correlation coefficient. Results: The results of the present study indicate that the total mean score for the critical thinking was 8.32 ± 2.03 and for decision making 8.66 ± 1.89. There is a significant statistical relationship between the critical-thinking score and decision-making score (P < 0.05). Conclusions: Although critical-thinking skills and decision-making ability are essential for medical emergency professional competence, the results of this study show that these skills are poor among the students. PMID:27829713

Advancing beyond the system: telemedicine nurses' clinical reasoning using a computerised decision support system for patients with COPD - an ethnographic study.

PubMed

Barken, Tina Lien; Thygesen, Elin; Söderhamn, Ulrika

2017-12-28

Telemedicine is changing traditional nursing care, and entails nurses performing advanced and complex care within a new clinical environment, and monitoring patients at a distance. Telemedicine practice requires complex disease management, advocating that the nurses' reasoning and decision-making processes are supported. Computerised decision support systems are being used increasingly to assist reasoning and decision-making in different situations. However, little research has focused on the clinical reasoning of nurses using a computerised decision support system in a telemedicine setting. Therefore, the objective of the study is to explore the process of telemedicine nurses' clinical reasoning when using a computerised decision support system for the management of patients with chronic obstructive pulmonary disease. The factors influencing the reasoning and decision-making processes were investigated. In this ethnographic study, a combination of data collection methods, including participatory observations, the think-aloud technique, and a focus group interview was employed. Collected data were analysed using qualitative content analysis. When telemedicine nurses used a computerised decision support system for the management of patients with complex, unstable chronic obstructive pulmonary disease, two categories emerged: "the process of telemedicine nurses' reasoning to assess health change" and "the influence of the telemedicine setting on nurses' reasoning and decision-making processes". An overall theme, termed "advancing beyond the system", represented the connection between the reasoning processes and the telemedicine work and setting, where being familiar with the patient functioned as a foundation for the nurses' clinical reasoning process. In the telemedicine setting, when supported by a computerised decision support system, nurses' reasoning was enabled by the continuous flow of digital clinical data, regular video-mediated contact and shared decision-making with the patient. These factors fostered an in-depth knowledge of the patients and acted as a foundation for the nurses' reasoning process. Nurses' reasoning frequently advanced beyond the computerised decision support system recommendations. Future studies are warranted to develop more accurate algorithms, increase system maturity, and improve the integration of the digital clinical information with clinical experiences, to support telemedicine nurses' reasoning process.

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

PubMed

Jefford, Elaine; Fahy, Kathleen; Sundin, Deborah

2011-06-01

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

Selection Practices of Group Leaders: A National Survey.

ERIC Educational Resources Information Center

Riva, Maria T.; Lippert, Laurel; Tackett, M. Jan

2000-01-01

Study surveys the selection practices of group leaders. Explores methods of selection, variables used to make selection decisions, and the types of selection errors that leaders have experienced. Results suggest that group leaders use clinical judgment to make selection decisions and endorse using some specific variables in selection. (Contains 22…

The Voice of the Patient Methodology: A Novel Mixed-Methods Approach to Identifying Treatment Goals for Men with Prostate Cancer.

PubMed

Saigal, Christopher S; Lambrechts, Sylvia I; Seenu Srinivasan, V; Dahan, Ely

2017-06-01

Many guidelines advocate the use of shared decision making for men with newly diagnosed prostate cancer. Decision aids can facilitate the process of shared decision making. Implicit in this approach is the idea that physicians understand which elements of treatment matter to patients. Little formal work exists to guide physicians or developers of decision aids in identifying these attributes. We use a mixed-methods technique adapted from marketing science, the 'Voice of the Patient', to describe and identify treatment elements of value for men with localized prostate cancer. We conducted semi-structured interviews with 30 men treated for prostate cancer in the urology clinic of the West Los Angeles Veteran Affairs Medical Center. We used a qualitative analysis to generate themes in patient narratives, and a quantitative approach, agglomerative hierarchical clustering, to identify attributes of treatment that were most relevant to patients making decisions about prostate cancer. We identified five 'traditional' prostate cancer treatment attributes: sexual dysfunction, bowel problems, urinary problems, lifespan, and others' opinions. We further identified two novel treatment attributes: a treatment's ability to validate a sense of proactivity and the need for an incision (separate from risks of surgery). Application of a successful marketing technique, the 'Voice of the Customer', in a clinical setting elicits non-obvious attributes that highlight unique patient decision-making concerns. Use of this method in the development of decision aids may result in more effective decision support.

Decision-Making Quality in Parents Considering Adenotonsillectomy or Tympanostomy Tube Insertion for Their Children.

PubMed

Hong, Paul; Maguire, Erin; Purcell, Mary; Ritchie, Krista C; Chorney, Jill

2017-03-01

Shared decision making is a process in which clinicians and patients make health care decisions in a collaborative manner using the most up-to-date evidence, while considering patient values and preferences. Shared decision making is thought to have a positive influence on the decision-making process in medicine. To describe the level of decisional conflict and decisional regret experienced by parents considering surgery for their children and to determine relations among decisional conflict, decisional regret, and shared decision making. A prospective cohort study was conducted at an academic pediatric otolaryngology clinic. Participants included 126 parents of children younger than 6 years who underwent consultation for adenotonsillectomy or tympanostomy tube insertion. Parent participants completed the Shared Decision Making Questionnaire-Parent version, Decisional Conflict Scale (DCS), and Decisional Regret Scale (DRS). Surgeons completed the Shared Decision Making Questionnaire-Physician version. This study included 126 parents; 102 women (mean [SD] age, 33.2 [5.1] years) and 24 men (mean [SD] age, 35.6 [6.3] years). Overall, 34 parents (26%) reported clinically significant decisional conflict. Only 1 parent experienced moderate to strong decisional regret; 28 parents (43.7%) had mild decisional regret. Both parent and physician ratings of shared decision making were significantly negatively correlated with total DCS scores. Parent SDM-Q-9 and total DCS scores were significantly negatively correlated (rs[118] = -0.582; P < .001). Similarly, physician SDM-Q-Doc and total DCS scores were also significantly negatively correlated (rs[118] = -0.221; P = .04). Only parent ratings of shared decision making were significantly negatively correlated with total DRS scores (rs[63] = -0.254; P = .045). Those parents with clinically significant decisional conflict had significantly higher DRS scores (P = .02). Many parents experienced significant decisional conflict when making decisions about their child's elective surgical treatment. Parents who perceived themselves as being more involved in the decision-making process reported less decisional conflict and decisional regret. Future research should explore the influence of decision quality on health outcomes and develop methods to improve shared decision making.

Congruence between Preferred and Actual Participation Roles Increases Satisfaction with Treatment Decision Making among Japanese Women with Breast Cancer

PubMed

Yamauchi, Keiko; Nakao, Motoyuki; Nakashima, Mitsuyo; Ishihara, Yoko

2017-04-01

Objective: This study investigated the correlation between participation in the treatment decision-making process and satisfaction with the process among Japanese women with breast cancer. The influence of sociodemographic and clinical characteristics on satisfaction with the treatment decision-making process was also examined. Methods: We conducted a cross-sectional, self-administered internet survey of 650 Japanese women with breast cancer in March 2016. Decisional role (active, collaborative, passive) in the treatment decision-making was elicited using the Japanese version of the Control Preference Scale. Satisfaction with the decision-making process was assessed. Result: About half of the participants preferred to play a collaborative role, while half of the participants perceived that they played an active role. Satisfaction among the participants who made their treatment choice collaboratively with their physicians was significantly higher than that of participants who made the choice by themselves or entrusted their physicians to make the decision. However, two-way ANOVA demonstrated that satisfaction level was associated with the congruence between the participants’ preferred and actual decisional roles, but not with the actual decisional roles that they played. This association had no interaction with sociodemographic and clinical status, except for education level. A majority of the participants who participated in the roles they preferred in choosing their treatment option indicated that they would participate in the same role if they were to face a similar decision-making situation in the future. Conclusion: Regardless of their role played in the cancer treatment decision-making process, and irrespective of their sociodemographic and clinical status, Japanese women with breast cancer are more satisfied with the treatment decision-making process when their participation in the process matches their preferred role in the process. Creative Commons Attribution License

Congruence between Preferred and Actual Participation Roles Increases Satisfaction with Treatment Decision Making among Japanese Women with Breast Cancer

PubMed Central

Yamauchi, Keiko; Nakao, Motoyuki; Nakashima, Mitsuyo; Ishihara, Yoko

2017-01-01

Objective: This study investigated the correlation between participation in the treatment decision-making process and satisfaction with the process among Japanese women with breast cancer. The influence of sociodemographic and clinical characteristics on satisfaction with the treatment decision-making process was also examined. Methods: We conducted a cross-sectional, self-administered internet survey of 650 Japanese women with breast cancer in March 2016. Decisional role (active, collaborative, passive) in the treatment decision-making was elicited using the Japanese version of the Control Preference Scale. Satisfaction with the decision-making process was assessed. Result: About half of the participants preferred to play a collaborative role, while half of the participants perceived that they played an active role. Satisfaction among the participants who made their treatment choice collaboratively with their physicians was significantly higher than that of participants who made the choice by themselves or entrusted their physicians to make the decision. However, two-way ANOVA demonstrated that satisfaction level was associated with the congruence between the participants’ preferred and actual decisional roles, but not with the actual decisional roles that they played. This association had no interaction with sociodemographic and clinical status, except for education level. A majority of the participants who participated in the roles they preferred in choosing their treatment option indicated that they would participate in the same role if they were to face a similar decision-making situation in the future. Conclusion: Regardless of their role played in the cancer treatment decision-making process, and irrespective of their sociodemographic and clinical status, Japanese women with breast cancer are more satisfied with the treatment decision-making process when their participation in the process matches their preferred role in the process. PMID:28545197

Use of statistical and pharmacokinetic-pharmacodynamic modeling and simulation to improve decision-making: A section summary report of the trends and innovations in clinical trial statistics conference.

PubMed

Kimko, Holly; Berry, Seth; O'Kelly, Michael; Mehrotra, Nitin; Hutmacher, Matthew; Sethuraman, Venkat

2017-01-01

The application of modeling and simulation (M&S) methods to improve decision-making was discussed during the Trends & Innovations in Clinical Trial Statistics Conference held in Durham, North Carolina, USA on May 1-4, 2016. Uses of both pharmacometric and statistical M&S were presented during the conference, highlighting the diversity of the methods employed by pharmacometricians and statisticians to address a broad range of quantitative issues in drug development. Five presentations are summarized herein, which cover the development strategy of employing M&S to drive decision-making; European initiatives on best practice in M&S; case studies of pharmacokinetic/pharmacodynamics modeling in regulatory decisions; estimation of exposure-response relationships in the presence of confounding; and the utility of estimating the probability of a correct decision for dose selection when prior information is limited. While M&S has been widely used during the last few decades, it is expected to play an essential role as more quantitative assessments are employed in the decision-making process. By integrating M&S as a tool to compile the totality of evidence collected throughout the drug development program, more informed decisions will be made.

A conceptual framework for automating the operational and strategic decision-making process in the health care delivery system.

PubMed

Ruohonen, Toni; Ennejmy, Mohammed

2013-01-01

Making reliable and justified operational and strategic decisions is a really challenging task in the health care domain. So far, the decisions have been made based on the experience of managers and staff, or they are evaluated with traditional methods, using inadequate data. As a result of this kind of decision-making process, attempts to improve operations usually have failed or led to only local improvements. Health care organizations have a lot of operational data, in addition to clinical data, which is the key element for making reliable and justified decisions. However, it is progressively problematic to access it and make usage of it. In this paper we discuss about the possibilities how to exploit operational data in the most efficient way in the decision-making process. We'll share our future visions and propose a conceptual framework for automating the decision-making process.

Diagnostic games: from adequate formalization of clinical experience to structure discovery.

PubMed

Shifrin, Michael A; Kasparova, Eva I

2008-01-01

A method of obtaining well-founded and reproducible results in clinical decision making is presented. It is based on "diagnostic games", a procedure of elicitation and formalization of experts' knowledge and experience. The use of this procedure allows formulating decision rules in the terms of an adequate language, that are both unambiguous and clinically clear.

Shared clinical decision making

PubMed Central

AlHaqwi, Ali I.; AlDrees, Turki M.; AlRumayyan, Ahmad; AlFarhan, Ali I.; Alotaibi, Sultan S.; AlKhashan, Hesham I.; Badri, Motasim

2015-01-01

Objectives: To determine preferences of patients regarding their involvement in the clinical decision making process and the related factors in Saudi Arabia. Methods: This cross-sectional study was conducted in a major family practice center in King Abdulaziz Medical City, Riyadh, Saudi Arabia, between March and May 2012. Multivariate multinomial regression models were fitted to identify factors associated with patients preferences. Results: The study included 236 participants. The most preferred decision-making style was shared decision-making (57%), followed by paternalistic (28%), and informed consumerism (14%). The preference for shared clinical decision making was significantly higher among male patients and those with higher level of education, whereas paternalism was significantly higher among older patients and those with chronic health conditions, and consumerism was significantly higher in younger age groups. In multivariate multinomial regression analysis, compared with the shared group, the consumerism group were more likely to be female [adjusted odds ratio (AOR) =2.87, 95% confidence interval [CI] 1.31-6.27, p=0.008] and non-dyslipidemic (AOR=2.90, 95% CI: 1.03-8.09, p=0.04), and the paternalism group were more likely to be older (AOR=1.03, 95% CI: 1.01-1.05, p=0.04), and female (AOR=2.47, 95% CI: 1.32-4.06, p=0.008). Conclusion: Preferences of patients for involvement in the clinical decision-making varied considerably. In our setting, underlying factors that influence these preferences identified in this study should be considered and tailored individually to achieve optimal treatment outcomes. PMID:26620990

How should treatment costs impact on physician's decisions?

PubMed

Neymark, N

1999-01-01

This article first discusses at what level of clinical decision making cost considerations may be most pertinent and important. It is argued that cost assessments will be of most relevance and value at an intermediate level of clinical decision making i.e. at a level where so-called policy decisions are made. These are decisions such as which drugs to include in a hospital formulary or which standard treatment 'protocols' to choose for particular types of patients. The personal encounter between individual patients and physicians will take place within the framework of available treatment options determined by these policy decisions, which must necessarily be based on a prior assessment of the expected costs and benefits of treatments. The article goes on to give a brief introduction to the various methods of economic evaluation that have been developed in order to provide the decision makers with the means to make policy decisions on the basis of the most reliable and pertinent information possible.

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

PubMed

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

2017-06-01

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

Development and initial evaluation of a treatment decision dashboard.

PubMed

Dolan, James G; Veazie, Peter J; Russ, Ann J

2013-04-21

For many healthcare decisions, multiple alternatives are available with different combinations of advantages and disadvantages across several important dimensions. The complexity of current healthcare decisions thus presents a significant barrier to informed decision making, a key element of patient-centered care.Interactive decision dashboards were developed to facilitate decision making in Management, a field marked by similarly complicated choices. These dashboards utilize data visualization techniques to reduce the cognitive effort needed to evaluate decision alternatives and a non-linear flow of information that enables users to review information in a self-directed fashion. Theoretically, both of these features should facilitate informed decision making by increasing user engagement with and understanding of the decision at hand. We sought to determine if the interactive decision dashboard format can be successfully adapted to create a clinically realistic prototype patient decision aid suitable for further evaluation and refinement. We created a computerized, interactive clinical decision dashboard and performed a pilot test of its clinical feasibility and acceptability using a multi-method analysis. The dashboard summarized information about the effectiveness, risks of side effects and drug-drug interactions, out-of-pocket costs, and ease of use of nine analgesic treatment options for knee osteoarthritis. Outcome evaluations included observations of how study participants utilized the dashboard, questionnaires to assess usability, acceptability, and decisional conflict, and an open-ended qualitative analysis. The study sample consisted of 25 volunteers - 7 men and 18 women - with an average age of 51 years. The mean time spent interacting with the dashboard was 4.6 minutes. Mean evaluation scores on scales ranging from 1 (low) to 7 (high) were: mechanical ease of use 6.1, cognitive ease of use 6.2, emotional difficulty 2.7, decision-aiding effectiveness 5.9, clarification of values 6.5, reduction in decisional uncertainty 6.1, and provision of decision-related information 6.0. Qualitative findings were similarly positive. Interactive decision dashboards can be adapted for clinical use and have the potential to foster informed decision making. Additional research is warranted to more rigorously test the effectiveness and efficiency of patient decision dashboards for supporting informed decision making and other aspects of patient-centered care, including shared decision making.

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

PubMed

Park, Seungmi; Kwon, In Gak

2007-10-01

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

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

PubMed

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

2014-01-01

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

Evaluating a mobile application for improving clinical laboratory test ordering and diagnosis.

PubMed

Meyer, Ashley N D; Thompson, Pamela J; Khanna, Arushi; Desai, Samir; Mathews, Benji K; Yousef, Elham; Kusnoor, Anita V; Singh, Hardeep

2018-04-20

Mobile applications for improving diagnostic decision making often lack clinical evaluation. We evaluated if a mobile application improves generalist physicians' appropriate laboratory test ordering and diagnosis decisions and assessed if physicians perceive it as useful for learning. In an experimental, vignette study, physicians diagnosed 8 patient vignettes with normal prothrombin times (PT) and abnormal partial thromboplastin times (PTT). Physicians made test ordering and diagnosis decisions for 4 vignettes using each resource: a mobile app, PTT Advisor, developed by the Centers for Disease Control and Prevention (CDC)'s Clinical Laboratory Integration into Healthcare Collaborative (CLIHC); and usual clinical decision support. Then, physicians answered questions regarding their perceptions of the app's usefulness for diagnostic decision making and learning using a modified Kirkpatrick Training Evaluation Framework. Data from 368 vignettes solved by 46 physicians at 7 US health care institutions show advantages for using PTT Advisor over usual clinical decision support on test ordering and diagnostic decision accuracy (82.6 vs 70.2% correct; P < .001), confidence in decisions (7.5 vs 6.3 out of 10; P < .001), and vignette completion time (3:02 vs 3:53 min.; P = .06). Physicians reported positive perceptions of the app's potential for improved clinical decision making, and recommended it be used to address broader diagnostic challenges. A mobile app, PTT Advisor, may contribute to better test ordering and diagnosis, serve as a learning tool for diagnostic evaluation of certain clinical disorders, and improve patient outcomes. Similar methods could be useful for evaluating apps aimed at improving testing and diagnosis for other conditions.

[Clinical bioethics for primary health care].

PubMed

González-de Paz, L

2013-01-01

The clinical decision making process with ethical implications in the area of primary healthcare differs from other healthcare areas. From the ethical perspective it is important to include these issues in the decision making model. This dissertation explains the need for a process of bioethical deliberation for Primary Healthcare, as well as proposing a method for doing so. The decision process method, adapted to this healthcare area, is flexible and requires a more participative Healthcare System. This proposal involves professionals and the patient population equally, is intended to facilitate the acquisition of responsibility for personal and community health. Copyright © 2012 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España. All rights reserved.

Patients' perceptions of sharing in decisions: a systematic review of interventions to enhance shared decision making in routine clinical practice.

PubMed

Légaré, France; Turcotte, Stéphane; Stacey, Dawn; Ratté, Stéphane; Kryworuchko, Jennifer; Graham, Ian D

2012-01-01

Shared decision making is the process in which a healthcare choice is made jointly by the health professional and the patient. Little is known about what patients view as effective or ineffective strategies to implement shared decision making in routine clinical practice. This systematic review evaluates the effectiveness of interventions to improve health professionals' adoption of shared decision making in routine clinical practice, as seen by patients. We searched electronic databases (PubMed, the Cochrane Library, EMBASE, CINAHL, and PsycINFO) from their inception to mid-March 2009. We found additional material by reviewing the reference lists of the studies found in the databases; systematic reviews of studies on shared decision making; the proceedings of various editions of the International Shared Decision Making Conference; and the transcripts of the Society for Medical Decision Making's meetings. In our study selection, we included randomized controlled trials, controlled clinical trials, controlled before-and-after studies, and interrupted time series analyses in which patients evaluated interventions to improve health professionals' adoption of shared decision making. The interventions in question consisted of the distribution of printed educational material; educational meetings; audit and feedback; reminders; and patient-mediated initiatives (e.g. patient decision aids). Two reviewers independently screened the studies and extracted data. Statistical analyses considered categorical and continuous process measures. We computed the standardized effect size for each outcome at the 95% confidence interval. The primary outcome of interest was health professionals' adoption of shared decision making as reported by patients in a self-administered questionnaire. Of the 6764 search results, 21 studies reported 35 relevant comparisons. Overall, the quality of the studies ranged from 0% to 83%. Only three of the 21 studies reported a clinically significant effect for the primary outcome that favored the intervention. The first study compared an educational meeting and a patient-mediated intervention with another patient-mediated intervention (median improvement of 74%). The second compared an educational meeting, a patient-mediated intervention, and audit and feedback with an educational meeting on an alternative topic (improvement of 227%). The third compared an educational meeting and a patient-mediated intervention with usual care (p = 0.003). All three studies were limited to the patient-physician dyad. To reduce bias, future studies should improve methods and reporting, and should analyze costs and benefits, including those associated with training of health professionals. Multifaceted interventions that include educating health professionals about sharing decisions with patients and patient-mediated interventions, such as patient decision aids, appear promising for improving health professionals' adoption of shared decision making in routine clinical practice as seen by patients.

Translational Cognition for Decision Support in Critical Care Environments: A Review

PubMed Central

Patel, Vimla L.; Zhang, Jiajie; Yoskowitz, Nicole A.; Green, Robert; Sayan, Osman R.

2008-01-01

The dynamic and distributed work environment in critical care requires a high level of collaboration among clinical team members and a sophisticated task coordination system to deliver safe, timely and effective care. A complex cognitive system underlies the decision-making process in such cooperative workplaces. This methodological review paper addresses the issues of translating cognitive research to clinical practice with a specific focus on decision-making in critical care, and the role of information and communication technology to aid in such decisions. Examples are drawn from studies of critical care in our own research laboratories. Critical care, in this paper, includes both intensive (inpatient) and emergency (outpatient) care. We define translational cognition as the research on basic and applied cognitive issues that contribute to our understanding of how information is stored, retrieved and used for problem-solving and decision-making. The methods and findings are discussed in the context of constraints on decision-making in real world complex environments and implications for supporting the design and evaluation of decision support tools for critical care health providers. PMID:18343731

Translational cognition for decision support in critical care environments: a review.

PubMed

Patel, Vimla L; Zhang, Jiajie; Yoskowitz, Nicole A; Green, Robert; Sayan, Osman R

2008-06-01

The dynamic and distributed work environment in critical care requires a high level of collaboration among clinical team members and a sophisticated task coordination system to deliver safe, timely and effective care. A complex cognitive system underlies the decision-making process in such cooperative workplaces. This methodological review paper addresses the issues of translating cognitive research to clinical practice with a specific focus on decision-making in critical care, and the role of information and communication technology to aid in such decisions. Examples are drawn from studies of critical care in our own research laboratories. Critical care, in this paper, includes both intensive (inpatient) and emergency (outpatient) care. We define translational cognition as the research on basic and applied cognitive issues that contribute to our understanding of how information is stored, retrieved and used for problem-solving and decision-making. The methods and findings are discussed in the context of constraints on decision-making in real-world complex environments and implications for supporting the design and evaluation of decision support tools for critical care health providers.

Quality improvement in multidisciplinary cancer teams: an investigation of teamwork and clinical decision-making and cross-validation of assessments.

PubMed

Lamb, B W; Sevdalis, N; Mostafid, H; Vincent, C; Green, J S A

2011-12-01

Teamworking and clinical decision-making are important in multidisciplinary cancer teams (MDTs). Our objective is to assess the quality of information presentation and MDT members' contribution to decision-making via expert observation and self-report, aiming to cross-validate the two methods and assess the insight of MDT members into their own team performance. Behaviors were scored using (i) a validated observational tool employing Likert scales with objective anchors, and (ii) a 29-question online self-report tool. Data were collected from observation of 164 cases in five MDTs, and 47 surveys from MDT members (response rate 70%). Presentation of information (case history, radiological, pathological, comorbidities, psychosocial, and patients' views) and quality of contribution to decision-making of MDT members (surgeons, oncologists, radiologists, pathologists, nurses, and MDT coordinators) were analyzed via descriptive statistics and the Jonckheere-Terpstra test. Correlation between observational and self-report assessments was assessed with Spearman's correlations. Quality of information presentation: Case histories and radiology information rated highest; patients' views and comorbidities/psychosocial issues rated lowest (observed: Z = 14.80, P ≤ 0.001; self-report: Z = 3.70, P < 0.001). Contribution to decision-making: Surgeons and oncologists rated highest, nurses and MDT coordinators rated lowest, and others in between (observed: Z = 20.00, P ≤ 0.001; self-report: Z = 8.10, P < 0.001). Correlations between observational and self-report assessments: Median Spearman's rho = 0.74 (range = 0.66-0.91; P < 0.05). The quality of teamworking and clinical decision-making in MDTs can reliably be assessed using observational and self-report metrics. MDT members have good insight into their own team performance. Such robust assessment methods could provide the basis of a toolkit for MDT team evaluation and improvement.

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

PubMed

Jefford, Elaine; Fahy, Kathleen; Sundin, Deborah

2010-12-01

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

Impact of a clinical decision making module on the attitudes and perceptions of surgical trainees.

PubMed

Bhatt, Nikita R; Doherty, Eva M; Mansour, Ehab; Traynor, Oscar; Ridgway, Paul F

2016-09-01

Decision making, a cognitive non-technical skill, is a key element for clinical practice in surgery. Specific teaching about methods in clinical decision making (CDM) is a very recent addition to surgical training curricula in the UK and Ireland. Baseline trainee opinion on decision-making modules is unknown. The Royal College of Surgeons in Ireland's postgraduate training boot camp inaugural CDM module was investigated to elucidate the impact on the attitudes of CDM naïf trainees. Three standardized two-hour workshops for three trainee groups were delivered. The trainees were assessed by an anonymous questionnaire before and after the module. Change in attitude of the trainees was determined by comparing Likert scale ratings using the Wilcoxon signed-rank test. Fifty-seven newly appointed basic surgical trainees attended these workshops. A statistically significant rise in the proportion of candidates recognizing the importance of being taught CDM skills (P == 0.002) revealed the positive impact of the module, as did the increased understanding of different aspects of CDM like shared decision making (P == 0.035) and different styles of decision making (P == 0.013). These observed positive changes in trainee understanding and attitude toward CDM teaching supports the adoption of standardized modules into the curricula. More study is needed to define whether these modules will have measurable sustained enhancements of CDM skills. © 2016 Royal Australasian College of Surgeons.

Structured assessment of mental capacity to make financial decisions in Chinese older persons with mild cognitive impairment and mild Alzheimer disease.

PubMed

Lui, Victor W C; Lam, Linda C W; Chau, Rachel C M; Fung, Ada W T; Wong, Billy M L; Leung, Grace T Y; Leung, K F; Chiu, Helen F K; Karlawish, Jason H T; Appelbaum, Paul S

2013-06-01

Previous studies suggested that patients with mild cognitive impairment (MCI) or dementia can have impaired and declining financial skills and abilities. The purpose of this study is to test a clinically applicable method, based on the contemporary legal standard, to examine directly the mental capacity to make financial decisions and its component decision-making abilities among patients with MCI and early dementia. A total of 90 patients with mild Alzheimer disease (AD), 92 participants with MCI, and 93 cognitively normal control participants were recruited for this study. Their mental capacity to make everyday financial decisions was assessed by clinician ratings and the Chinese version of the Assessment of Capacity for Everyday Decision-Making (ACED). Based on the clinician ratings, only 53.5% were found to be mentally competent in the AD group, compared with 94.6% in the MCI group. However, participants with MCI had mild but significant impairment in understanding, appreciating, and reasoning abilities as measured by the ACED. The ACED provided a reliable and clinically applicable structured framework for assessment of mental capacity to make financial decisions.

A Qualitative Exploration of Clinician Views and Experiences of Treatment Decision-Making in Bipolar II Disorder.

PubMed

Fisher, Alana; Manicavasagar, Vijaya; Sharpe, Louise; Laidsaar-Powell, Rebekah; Juraskova, Ilona

2017-11-01

This study qualitatively explored clinicians' views and experiences of treatment decision-making in BPII. Semi-structured interviews were conducted with 20 practising clinicians (n = 10 clinical psychologists, n = 6 GPs, n = 4 psychiatrists) with experience in treating adult outpatients with BPII. Interviews were audiotaped, transcribed verbatim and thematically analysed using framework methods. Professional experience, and preferences for patient involvement in decision-making were also assessed. Qualitative analyses yielded four inter-related themes: (1) (non-)acceptance of diagnosis and treatment; (2) types of decisions; (3) treatment uncertainty and balancing act; and (4) decision-making in consultations. Clinician preferences for treatment, professional experience, and self-reported preferences for patient/family involvement seemed to influence decision-making. This study is the first to explore clinician views and experiences of treatment decision-making in BPII. Findings demonstrate how clinician-related factors may shape treatment decision-making, and suggest potential problems such as patient perceptions of lower-than-preferred involvement.

The development of a decision aid for tinnitus.

PubMed

Pryce, Helen; Durand, Marie-Anne; Hall, Amanda; Shaw, Rachel; Culhane, Beth-Anne; Swift, Sarah; Straus, Jean; Marks, Elizabeth; Ward, Melanie; Chilvers, Katie

2018-05-09

To develop a decision aid for tinnitus care that would meet international consensus for decision aid quality. A mixed methods design that included qualitative in-depth interviews, literature review, focus groups, user testing and readability checking. Patients and clinicians who have clinical experience of tinnitus. A decision aid for tinnitus care was developed. This incorporates key evidence of efficacy for the most frequently used tinnitus care options, together with information derived from patient priorities when deciding which choice to make. The decision aid has potential to enable shared decision making between clinicians and patients in audiology. The decision aid meets consensus standards.

An integrated, ethically driven environmental model of clinical decision making in emergency settings.

PubMed

Wolf, Lisa

2013-02-01

To explore the relationship between multiple variables within a model of critical thinking and moral reasoning. A quantitative descriptive correlational design using a purposive sample of 200 emergency nurses. Measured variables were accuracy in clinical decision-making, moral reasoning, perceived care environment, and demographics. Analysis was by bivariate correlation using Pearson's product-moment correlation coefficients, chi square and multiple linear regression analysis. The elements as identified in the integrated ethically-driven environmental model of clinical decision-making (IEDEM-CD) corrected depict moral reasoning and environment of care as factors significantly affecting accuracy in decision-making. The integrated, ethically driven environmental model of clinical decision making is a framework useful for predicting clinical decision making accuracy for emergency nurses in practice, with further implications in education, research and policy. A diagnostic and therapeutic framework for identifying and remediating individual and environmental challenges to accurate clinical decision making. © 2012, The Author. International Journal of Nursing Knowledge © 2012, NANDA International.

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

PubMed

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

2016-02-01

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

Does intuition have a role in psychiatric diagnosis?

PubMed

Srivastava, Anil; Grube, Michael

2009-06-01

Psychiatric diagnosis is invariably guided by self-report. When such self-report is questioned, reliance on formalized testing predominates. The situation is less certain, however, when such methods and clinical "feel", or intuition, conflict. While many argue for the supremacy of actuarial methods, fields such as Management have increasingly emphasized the importance of intuition; Psychiatry, although with few objective tests and reliance on the clinical encounter, offers surprisingly few answers. We explore here the use of intuition in decision-making through a case example and suggest that it is not inferior to other diagnostic methods: intuition should be used to suggest, guide, and modify psychiatric diagnosis. Mostly, there is a need for greater discussion among Psychiatrists including consideration to the clinical, legal, and ethical implications of the use of intuition in psychiatric decision-making.

Linking data to decision-making: applying qualitative data analysis methods and software to identify mechanisms for using outcomes data.

PubMed

Patel, Vaishali N; Riley, Anne W

2007-10-01

A multiple case study was conducted to examine how staff in child out-of-home care programs used data from an Outcomes Management System (OMS) and other sources to inform decision-making. Data collection consisted of thirty-seven semi-structured interviews with clinicians, managers, and directors from two treatment foster care programs and two residential treatment centers, and individuals involved with developing the OMS; and observations of clinical and quality management meetings. Case study and grounded theory methodology guided analyses. The application of qualitative data analysis software is described. Results show that although staff rarely used data from the OMS, they did rely on other sources of systematically collected information to inform clinical, quality management, and program decisions. Analyses of how staff used these data suggest that improving the utility of OMS will involve encouraging staff to participate in data-based decision-making, and designing and implementing OMS in a manner that reflects how decision-making processes operate.

Shared decision-making during surgical consultation for gallstones at a safety-net hospital.

PubMed

Mueck, Krislynn M; Leal, Isabel M; Wan, Charlie C; Goldberg, Braden F; Saunders, Tamara E; Millas, Stefanos G; Liang, Mike K; Ko, Tien C; Kao, Lillian S

2018-04-01

Understanding patient perspectives regarding shared decision-making is crucial to providing informed, patient-centered care. Little is known about perceptions of vulnerable patients regarding shared decision-making during surgical consultation. The purpose of this study was to evaluate whether a validated tool reflects perceptions of shared decision-making accurately among patients seeking surgical consultation for gallstones at a safety-net hospital. A mixed methods study was conducted in a sample of adult patients with gallstones evaluated at a safety-net surgery clinic between May to July 2016. Semi-structured interviews were conducted after their initial surgical consultation and analyzed for emerging themes. Patients were administered the Shared Decision-Making Questionnaire and Autonomy Preference Scale. Univariate analyses were performed to identify factors associated with shared decision-making and to compare the results of the surveys to those of the interviews. The majority of patients (N = 30) were female (90%), Hispanic (80%), Spanish-speaking (70%), and middle-aged (45.7 ± 16 years). The proportion of patients who perceived shared decision-making was greater in the Shared Decision-Making Questionnaire versus the interviews (83% vs 27%, P < .01). Age, sex, race/ethnicity, primary language, diagnosis, Autonomy Preference Scale score, and decision for operation was not associated with shared decision-making. Contributory factors to this discordance include patient unfamiliarity with shared decision-making, deference to surgeon authority, lack of discussion about different treatments, and confusion between aligned versus shared decisions. Available questionnaires may overestimate shared decision-making in vulnerable patients suggesting the need for alternative or modifications to existing methods. Furthermore, such metrics should be assessed for correlation with patient-reported outcomes, such as satisfaction with decisions and health status. Copyright © 2017 Elsevier Inc. All rights reserved.

External audit of clinical practice and medical decision making in a new Asian oncology center: Results and implications for both developing and developed nations

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

Shakespeare, Thomas P.; Back, Michael F.; Lu, Jiade J.

2006-03-01

Purpose: The external audit of oncologist clinical practice is increasingly important because of the incorporation of audits into national maintenance of certification (MOC) programs. However, there are few reports of external audits of oncology practice or decision making. Our institution (The Cancer Institute, Singapore) was asked to externally audit an oncology department in a developing Asian nation, providing a unique opportunity to explore the feasibility of such a process. Methods and Materials: We audited 100 randomly selected patients simulated for radiotherapy in 2003, using a previously reported audit instrument assessing clinical documentation/quality assurance and medical decision making. Results: Clinical documentation/qualitymore » assurance, decision making, and overall performance criteria were adequate 74.4%, 88.3%, and 80.2% of the time, respectively. Overall 52.0% of cases received suboptimal management. Multivariate analysis revealed palliative intent was associated with improved documentation/clinical quality assurance (p = 0.07), decision making (p 0.007), overall performance (p = 0.003), and optimal treatment rates (p 0.07); non-small-cell lung cancer or central nervous system primary sites were associated with better decision making (p = 0.001), overall performance (p = 0.03), and optimal treatment rates (p = 0.002). Conclusions: Despite the poor results, the external audit had several benefits. It identified learning needs for future targeting, and the auditor provided facilitating feedback to address systematic errors identified. Our experience was also helpful in refining our national revalidation audit instrument. The feasibility of the external audit supports the consideration of including audit in national MOC programs.« less

Bayesian methodology for the design and interpretation of clinical trials in critical care medicine: a primer for clinicians.

PubMed

Kalil, Andre C; Sun, Junfeng

2014-10-01

To review Bayesian methodology and its utility to clinical decision making and research in the critical care field. Clinical, epidemiological, and biostatistical studies on Bayesian methods in PubMed and Embase from their inception to December 2013. Bayesian methods have been extensively used by a wide range of scientific fields, including astronomy, engineering, chemistry, genetics, physics, geology, paleontology, climatology, cryptography, linguistics, ecology, and computational sciences. The application of medical knowledge in clinical research is analogous to the application of medical knowledge in clinical practice. Bedside physicians have to make most diagnostic and treatment decisions on critically ill patients every day without clear-cut evidence-based medicine (more subjective than objective evidence). Similarly, clinical researchers have to make most decisions about trial design with limited available data. Bayesian methodology allows both subjective and objective aspects of knowledge to be formally measured and transparently incorporated into the design, execution, and interpretation of clinical trials. In addition, various degrees of knowledge and several hypotheses can be tested at the same time in a single clinical trial without the risk of multiplicity. Notably, the Bayesian technology is naturally suited for the interpretation of clinical trial findings for the individualized care of critically ill patients and for the optimization of public health policies. We propose that the application of the versatile Bayesian methodology in conjunction with the conventional statistical methods is not only ripe for actual use in critical care clinical research but it is also a necessary step to maximize the performance of clinical trials and its translation to the practice of critical care medicine.

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

PubMed

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

2017-05-01

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

Mobile learning app: A novel method to teach clinical decision making in prosthodontics.

PubMed

Deshpande, Saee; Chahande, Jaishree; Rathi, Akhil

2017-01-01

Prosthodontics involves replacing lost dentofacial structures using artificial substitutes. Due to availability of many materials and techniques, clinician's clinical decision-making regarding appropriate selection of prosthesis requires critical thinking abilities and is demanding. Especially during graduate training years, learners do not receive the exposure to a variety of cases, thus their clinical reasoning skills are not developed optimally. Therefore, using the trend of incorporating technology in education, we developed a mobile learning app for this purpose. The aim of this study was to evaluate learners' perceptions of this app's utility and impact on their clinical decision-making skills. After taking informed consent, interns of the Department of Prosthodontics of VSPM Dental College, Nagpur, India, during the academic year May 2015-May 2016 were sent the link for the app to be installed in their Android smartphones. Their perceptions were recorded on a feedback questionnaire using 5-point Likert scale. The script concordance test (SCT) was used to check for changes in clinical reasoning abilities. Out of 120 students who were sent the link, 102 downloaded the link and 92 completed the feedback questionnaire and appeared for the SCT (response rate: 76%). The overall response to the app was positive for more than two-thirds of interns, who reported a greater confidence in their clinical decision-making around prostheses through this app and 94% of the students felt that this app should be regularly used along with conventional teaching techniques. Mean SCT scores were pretest 41.5 (±1.7) and posttest 63 (±2.4) (P < 0.005). Clinical decision-making in prosthodontics, a mobile learning app, is an effective way to improve clinical reasoning skills for planning prosthodontic rehabilitation. It is well received by students.

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

Clinical decision making by nurses when faced with third-space fluid shift. How well do they fare?

PubMed

Redden, M; Wotton, K

2001-01-01

Nurses' use of knowledge, the connection of this knowledge to treatment decisions and information actually used to reach such decisions, delineates nurses' level of expertise. Previous research has shown that nurses in their clinical decision-making use the hypothetico-deductive method and intuitive judgment or pattern recognition. This interpretive study explored experienced critical care nurses' (n = 5) and gastrointestinal surgical nurses' (n = 5) clinical decision-making processes through ascertaining their knowledge and understanding of third-space fluid shift in elderly patients undergoing major gastrointestinal surgery. Both groups of nurses, because of their experience with elderly patients undergoing gastrointestinal surgery, were assumed to be experts. Data collection techniques included semi-structured interviews and the use of think aloud protocol for clinical scenario analysis. The findings demonstrated that the gastrointestinal surgical nurses used the hypothetico-deductive method to recognize critical cues and the existence of a problem but could not name the problem. The critical care nurses, on the other hand, used a combination of the hypothetico-deductive method and pattern recognition as a basis for identification of critical cues. The critical care nurses also possessed in depth knowledge of third-space fluid shift and were able to use pivotal cues to identify the actual phenomenon. Ultimately, it would appear that the structure of critical care nurses' work, their increased educational qualifications and the culture of the critical care unit promote a more proactive approach to reasoning in the physiological domain. The findings have implications for the development of practice guidelines and curriculum development in both tertiary and continuing nurse education.

Clinical decision making and the expected value of information.

PubMed

Willan, Andrew R

2007-01-01

The results of the HOPE study, a randomized clinical trial, provide strong evidence that 1) ramipril prevents the composite outcome of cardiovascular death, myocardial infarction or stroke in patients who are at high risk of a cardiovascular event and 2) ramipril is cost-effective at a threshold willingness-to-pay of $10,000 to prevent an event of the composite outcome. In this report the concept of the expected value of information is used to determine if the information provided by the HOPE study is sufficient for decision making in the US and Canada. and results Using the cost-effectiveness data from a clinical trial, or from a meta-analysis of several trials, one can determine, based on the number of future patients that would benefit from the health technology under investigation, the expected value of sample information (EVSI) of a future trial as a function of proposed sample size. If the EVSI exceeds the cost for any particular sample size then the current information is insufficient for decision making and a future trial is indicated. If, on the other hand, there is no sample size for which the EVSI exceeds the cost, then there is sufficient information for decision making and no future trial is required. Using the data from the HOPE study these concepts are applied for various assumptions regarding the fixed and variable cost of a future trial and the number of patients who would benefit from ramipril. Expected value of information methods provide a decision-analytic alternative to the standard likelihood methods for assessing the evidence provided by cost-effectiveness data from randomized clinical trials.

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

PubMed

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

2013-03-06

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

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

PubMed

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

2017-12-15

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

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

PubMed

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

2014-11-01

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

A qualitative analysis of how advanced practice nurses use clinical decision support systems.

PubMed

Weber, Scott

2007-12-01

The purpose of this study was to generate a grounded theory that will reflect the experiences of advanced practice nurses (APNs) working as critical care nurse practitioners (NPs) and clinical nurse specialists (CNS) with computer-based decision-making systems. A study design using grounded theory qualitative research methods and convenience sampling was employed in this study. Twenty-three APNs (13 CNS and 10 NPs) were recruited from 16 critical care units located in six large urban medical centers in the U.S. Midwest. Single-structured in-depth interviews with open-ended audio-taped questions were conducted with each APN. Through this process, APNs defined what they consider to be relevant themes and patterns of clinical decision system use in their critical care practices, and they identified the interrelatedness of the conceptual categories that emerged from the results. Data were analyzed using the constant comparative analysis method of qualitative research. APN participants were predominantly female, white/non-Hispanic, had a history of access to the clinical decision system used in their critical care settings for an average of 14 months, and had attended a formal training program to learn how to use clinical decision systems. "Forecasting decision outcomes," which was defined as the voluntary process employed to forecast the outcomes of patient care decisions in critical care prior to actual decision making, was the core variable describing system use that emerged from the responses. This variable consisted of four user constructs or components: (a) users' perceptions of their initial system learning experience, (b) users' sense of how well they understand how system technology works, (c) users' understanding of how system inferences are created or derived, and (d) users' relative trust of system-derived data. Each of these categories was further described through the grounded theory research process, and the relationships between the categories were identified. The findings of this study suggest that the main reason critical care APNs choose to integrate clinical decision systems into their practices is to provide an objective, scientifically derived, technology-based backup for human forecasting of the outcomes of patient care decisions prior to their actual decision making. Implications for nursing, health care, and technology research are presented.

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

PubMed

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

2017-03-01

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

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

Decision Making in the PICU: An Examination of Factors Influencing Participation Decisions in Phase III Randomized Clinical Trials

PubMed Central

Slosky, Laura E.; Burke, Natasha L.; Siminoff, Laura A.

2014-01-01

Background. In stressful situations, decision making processes related to informed consent may be compromised. Given the profound levels of distress that surrogates of children in pediatric intensive care units (PICU) experience, it is important to understand what factors may be influencing the decision making process beyond the informed consent. The purpose of this study was to evaluate the role of clinician influence and other factors on decision making regarding participation in a randomized clinical trial (RCT). Method. Participants were 76 children under sedation in a PICU and their surrogate decision makers. Measures included the Post Decision Clinician Survey, observer checklist, and post-decision interview. Results. Age of the pediatric patient was related to participation decisions in the RCT such that older children were more likely to be enrolled. Mentioning the sponsoring institution was associated with declining to participate in the RCT. Type of health care provider and overt recommendations to participate were not related to enrollment. Conclusion. Decisions to participate in research by surrogates of children in the PICU appear to relate to child demographics and subtleties in communication; however, no modifiable characteristics were related to increased participation, indicating that the informed consent process may not be compromised in this population. PMID:25161672

Development and validation of the Family Decision-Making Self-Efficacy Scale

PubMed Central

NOLAN, MARIE T.; HUGHES, MARK T.; KUB, JOAN; TERRY, PETER B.; ASTROW, ALAN; THOMPSON, RICHARD E.; CLAWSON, LORA; TEXEIRA, KENNETH; SULMASY, DANIEL P.

2010-01-01

Objective Several studies have reported high levels of distress in family members who have made health care decisions for loved ones at the end of life. A method is needed to assess the readiness of family members to take on this important role. Therefore, the purpose of this study was to develop and validate a scale to measure family member confidence in making decisions with (conscious patient scenario) and for (unconscious patient scenario) a terminally ill loved one. Methods On the basis of a survey of family members of patients with amyotrophic lateral sclerosis (ALS) enriched by in-depth interviews guided by Self-Efficacy Theory, we developed six themes within family decision making self-efficacy. We then created items reflecting these themes that were refined by a panel of end-of-life research experts. With 30 family members of patients in an outpatient ALS and a pancreatic cancer clinic, we tested the tool for internal consistency using Cronbach’s alpha and for consistency from one administration to another using the test–retest reliability assessment in a subset of 10 family members. Items with item to total scale score correlations of less than .40 were eliminated. Results A 26-item scale with two 13-item scenarios resulted, measuring family self-efficacy in decision making for a conscious or unconscious patient with a Cronbach’s alphas of .91 and .95, respectively. Test–retest reliability was r = .96, p = .002 in the conscious senario and r = .92, p = .009 in the unconscious scenario. Significance of results The Family Decision-Making Self-Efficacy Scale is valid, reliable, and easily completed in the clinic setting. It may be used in research and clinical care to assess the confidence of family members in their ability to make decisions with or for a terminally ill loved one. PMID:19788773

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

PubMed

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

2018-01-01

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

Approach to risk identification in undifferentiated mental disorders

PubMed Central

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

2016-01-01

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

Approach to risk identification in undifferentiated mental disorders.

PubMed

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

2016-12-01

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

Effect of experience on clinical decision making by cardiorespiratory physiotherapists in acute care settings.

PubMed

Smith, Megan; Higgs, Joy; Ellis, Elizabeth

2010-02-01

This article investigates clinical decision making in acute care hospitals by cardiorespiratory physiotherapists with differing degrees of clinical experience. Participants were observed as they engaged in their everyday practice and were interviewed about their decision making. Texts of the data were interpreted by using a hermeneutic approach that involved repeated reading and analysis of fieldnotes and interview transcripts to develop an understanding of the effect of experience on clinical decision making. Participants were classified into categories of cardiorespiratory physiotherapy experience: less experienced (<2 years), intermediate experience (2.5-4 years), and more experienced (>7 years). Four dimensions characteristic of increasing experience in cardiorespiratory physiotherapy clinical decision making were identified: 1) an individual practice model, 2) refined approaches to clinical decision making, 3) working in context, and 4) social and emotional capability. Underpinning these dimensions was evidence of reflection on practice, motivation to achieve best practice, critique of new knowledge, increasing confidence, and relationships with knowledgeable colleagues. These findings reflect characteristics of physiotherapy expertise that have been described in the literature. This study adds knowledge about the field of cardiorespiratory physiotherapy to the existing body of research on clinical decision making and broadens the existing understanding of characteristics of physiotherapy expertise.

How Qualitative Research Informs Clinical and Policy Decision Making in Transplantation: A Review.

PubMed

Tong, Allison; Morton, Rachael L; Webster, Angela C

2016-09-01

Patient-centered care is no longer just a buzzword. It is now widely touted as a cornerstone in delivering quality care across all fields of medicine. However, patient-centered strategies and interventions necessitate evidence about patients' decision-making processes, values, priorities, and needs. Qualitative research is particularly well suited to understanding the experience and perspective of patients, donors, clinicians, and policy makers on a wide range of transplantation-related topics including organ donation and allocation, adherence to prescribed therapy, pretransplant and posttransplant care, implementation of clinical guidelines, and doctor-patient communication. In transplantation, evidence derived from qualitative research has been integrated into strategies for shared decision-making, patient educational resources, process evaluations of trials, clinical guidelines, and policies. The aim of this article is to outline key concepts and methods used in qualitative research, guide the appraisal of qualitative studies, and assist clinicians to understand how qualitative research may inform their practice and policy.

A qualitative exploration of patient and family views and experiences of treatment decision-making in bipolar II disorder.

PubMed

Fisher, Alana; Manicavasagar, Vijaya; Sharpe, Louise; Laidsaar-Powell, Rebekah; Juraskova, Ilona

2018-02-01

Treatment decision-making in bipolar II disorder (BPII) is challenging, yet the decision support needs of patients and family remain unknown. To explore patient and family perspectives of treatment decision-making in BPII. Semistructured, qualitative interviews were conducted with 28 patients with BPII-diagnosis and 13 family members with experience in treatment decision-making in the outpatient setting. Interviews were audiotaped, transcribed verbatim and analysed thematically using framework methods. Participant demographics, clinical characteristics and preferences for patient decision-making involvement were assessed. Four inter-related themes emerged: (1) Attitudes and response to diagnosis and treatment; (2) Influences on decision-making; (3) The nature and flow of decision-making; (4) Decision support and challenges. Views differed according to patient involvement preferences, time since diagnosis and patients' current mood symptoms. This is the first known study to provide in-depth patient and family insights into the key factors influencing BPII treatment decision-making, and potential improvements and challenges to this process. Findings will inform the development of BPII treatment decision-making resources that better meet the informational and decision-support priorities of end users. This research was partly funded by a Postgraduate Research Grant awarded to the first author by the University of Sydney. No conflicts of interest declared.

The impact of simulation sequencing on perceived clinical decision making.

PubMed

Woda, Aimee; Hansen, Jamie; Paquette, Mary; Topp, Robert

2017-09-01

An emerging nursing education trend is to utilize simulated learning experiences as a means to optimize competency and decision making skills. The purpose of this study was to examine differences in students' perception of clinical decision making and clinical decision making-related self-confidence and anxiety based on the sequence (order) in which they participated in a block of simulated versus hospital-based learning experiences. A quasi-experimental crossover design was used. Between and within group differences were found relative to self-confidence with the decision making process. When comparing groups, at baseline the simulation followed by hospital group had significantly higher self-confidence scores, however, at 14-weeks both groups were not significantly different. Significant within group differences were found in the simulation followed by hospital group only, demonstrating a significant decrease in clinical decision making related anxiety across the semester. Finally, there were no significant difference in; perceived clinical decision making within or between the groups at the two measurement points. Preliminary findings suggest that simulated learning experiences can be offered with alternating sequences without impacting the process, anxiety or confidence with clinical decision making. This study provides beginning evidence to guide curriculum development and allow flexibility based on student needs and available resources. Copyright © 2017. Published by Elsevier Ltd.

Comparativism and the Grounds for Person-Centered Care and Shared Decision Making.

PubMed

Herlitz, Anders

2017-01-01

This article provides a new argument and a new value-theoretical ground for person-centered care and shared decision making that ascribes to it the role of enabling rational choice in situations involving clinical choice. Rather than referring to good health outcomes and/or ethical grounds such as patient autonomy, it argues that a plausible justification and ground for person-centered care and shared decision making is preservation of rationality in the face of comparative non-determinacy in clinical settings. Often, no alternative treatment will be better than or equal to every other alternative. In the face of such comparative non-determinacy, Ruth Chang has argued that we can make rational decisions by invoking reasons that are created through acts of willing. This article transfers this view to clinical decision making and argues that shared decision making provides a solution to non-determinacy problems in clinical settings. This view of the role of shared decision making provides a new understanding of its nature, and it also allows us to better understand when caregivers should engage in shared decision making and when they should not. Copyright 2017 The Journal of Clinical Ethics. All rights reserved.

The use of economic evaluation in CAM: an introductory framework

PubMed Central

2010-01-01

Background For CAM to feature prominently in health care decision-making there is a need to expand the evidence-base and to further incorporate economic evaluation into research priorities. In a world of scarce health care resources and an emphasis on efficiency and clinical efficacy, CAM, as indeed do all other treatments, requires rigorous evaluation to be considered in budget decision-making. Methods Economic evaluation provides the tools to measure the costs and health consequences of CAM interventions and thereby inform decision making. This article offers CAM researchers an introductory framework for understanding, undertaking and disseminating economic evaluation. The types of economic evaluation available for the study of CAM are discussed, and decision modelling is introduced as a method for economic evaluation with much potential for use in CAM. Two types of decision models are introduced, decision trees and Markov models, along with a worked example of how each method is used to examine costs and health consequences. This is followed by a discussion of how this information is used by decision makers. Conclusions Undoubtedly, economic evaluation methods form an important part of health care decision making. Without formal training it can seem a daunting task to consider economic evaluation, however, multidisciplinary teams provide an opportunity for health economists, CAM practitioners and other interested researchers, to work together to further develop the economic evaluation of CAM. PMID:21067622

Application of evidence-based dentistry: from research to clinical periodontal practice.

PubMed

Kwok, Vivien; Caton, Jack G; Polson, Alan M; Hunter, Paul G

2012-06-01

Dentists need to make daily decisions regarding patient care, and these decisions should essentially be scientifically sound. Evidence-based dentistry is meant to empower clinicians to provide the most contemporary treatment. The benefits of applying the evidence-based method in clinical practice include application of the most updated treatment and stronger reasoning to justify the treatment. A vast amount of information is readily accessible with today's digital technology, and a standardized search protocol can be developed to ensure that a literature search is valid, specific and repeatable. It involves developing a preset question (population, intervention, comparison and outcome; PICO) and search protocol. It is usually used academically to perform commissioned reviews, but it can also be applied to answer simple clinical queries. The scientific evidence thus obtained can then be considered along with patient preferences and values, clinical patient circumstances and the practitioner's experience and judgment in order to make the treatment decision. This paper describes how clinicians can incorporate evidence-based methods into patient care and presents a clinical example to illustrate the process. © 2012 John Wiley & Sons A/S.

[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.

Considering Information Up-to-Dateness to Increase the Accuracy of Therapy Decision Support Systems.

PubMed

Gaebel, Jan; Cypko, Mario A; Oeltze-Jafra, Steffen

2017-01-01

During the diagnostic process a lot of information is generated. All this information is assessed when making a final diagnosis and planning the therapy. While some patient information is stable, e.g., gender, others may become outdated, e.g., tumor size derived from CT data. Quantifying this information up-to-dateness and deriving consequences are difficult. Especially for the implementation in clinical decision support systems, this has not been studied. When information entities tend to become outdated, in practice, clinicians intuitively reduce their impact when making decisions. Therefore, in a system's calculations their impact should be reduced as well. We propose a method of decreasing the certainty of information entities based on their up-to-dateness. The method is tested in a decision support system for TNM staging based on Bayesian networks. We compared the actual N-state in records of 39 patients to the N-state calculated with and without decreasing data certainty. The results under decreased certainty correlated better with the actual states (r=0.958, p=0.008). We conclude that the up-to-dateness must be considered when processing clinical information to enhance decision making and ensure more patient safety.

Incorporating the patient experience into regulatory decision making in the USA, Europe, and Canada.

PubMed

Kluetz, Paul G; O'Connor, Daniel J; Soltys, Katherine

2018-05-01

The clinical development of cancer therapeutics is a global undertaking, and incorporation of the patient experience into the clinical decision-making process is of increasing interest to the international regulatory and health policy community. Disease and treatment-related symptoms and their effect on patient function and health-related quality of life are important outcomes to consider. The identification of methods to scientifically assess, analyse, interpret, and present these clinical outcomes requires sustained international collaboration by multiple stakeholders including patients, clinicians, scientists, and policy makers. Several data sources can be considered to capture the patient experience, including patient-reported outcome (PRO) measures, performance measures, wearable devices, and biosensors, as well as the careful collection and analysis of clinical events and supportive care medications. In this Policy Review, we focus on PRO measures and present the perspectives of three international regulatory scientists to identify areas of common ground regarding opportunities to incorporate rigorous PRO data into the regulatory decision-making process. Copyright © 2018 Elsevier Ltd. All rights reserved.

Information in medical decision making: how consistent is our management?

PubMed

Lorence, Daniel P; Spink, Amanda; Jameson, Robert

2002-01-01

The use of outcomes data in clinical environments requires a correspondingly greater variety of information used in decision making, the measurement of quality, and clinical performance. As information becomes integral in the decision-making process, trustworthy decision support data are required. Using data from a national census of certified health information managers, variation in automated data quality management practices was examined. Relatively low overall adoption of automated data management exists in health care organizations, with significant geographic and practice setting variation. Nonuniform regional adoption of computerized data management exists, despite national mandates that promote and in some cases require uniform adoption. Overall, a significant number of respondents (42.7%) indicated that they had not adopted policies and procedures to direct the timeliness of data capture, with 57.3% having adopted such practices. The inconsistency of patient data policy suggests that provider organizations do not use uniform information management methods, despite growing federal mandates to do so.

Decision making in asthma exacerbation: a clinical judgement analysis

PubMed Central

Jenkins, John; Shields, Mike; Patterson, Chris; Kee, Frank

2007-01-01

Background Clinical decisions which impact directly on patient safety and quality of care are made during acute asthma attacks by individual doctors based on their knowledge and experience. Decisions include administration of systemic corticosteroids (CS) and oral antibiotics, and admission to hospital. Clinical judgement analysis provides a methodology for comparing decisions between practitioners with different training and experience, and improving decision making. Methods Stepwise linear regression was used to select clinical cues based on visual analogue scale assessments of the propensity of 62 clinicians to prescribe a short course of oral CS (decision 1), a course of antibiotics (decision 2), and/or admit to hospital (decision 3) for 60 “paper” patients. Results When compared by specialty, paediatricians' models for decision 1 were more likely to include level of alertness as a cue (54% vs 16%); for decision 2 they were more likely to include presence of crepitations (49% vs 16%) and less likely to include inhaled CS (8% vs 40%), respiratory rate (0% vs 24%) and air entry (70% vs 100%). When compared to other grades, the models derived for decision 3 by consultants/general practitioners were more likely to include wheeze severity as a cue (39% vs 6%). Conclusions Clinicians differed in their use of individual cues and the number included in their models. Patient safety and quality of care will benefit from clarification of decision‐making strategies as general learning points during medical training, in the development of guidelines and care pathways, and by clinicians developing self‐awareness of their own preferences. PMID:17428817

How can clinical practice guidelines be adapted to facilitate shared decision making? A qualitative key-informant study.

PubMed

van der Weijden, Trudy; Pieterse, Arwen H; Koelewijn-van Loon, Marije S; Knaapen, Loes; Légaré, France; Boivin, Antoine; Burgers, Jako S; Stiggelbout, Anne M; Faber, Marjan; Elwyn, Glyn

2013-10-01

To explore how clinical practice guidelines can be adapted to facilitate shared decision making. This was a qualitative key-informant study with group discussions and semi-structured interviews. First, 75 experts in guideline development or shared decision making participated in group discussions at two international conferences. Next, health professionals known as experts in depression or breast cancer, experts on clinical practice guidelines and/or shared decision making, and patient representatives were interviewed (N=20). Using illustrative treatment decisions on depression or breast cancer, we asked the interviewees to indicate as specifically as they could how guidelines could be used to facilitate shared decision making. Interviewees suggested some generic strategies, namely to include a separate chapter on the importance of shared decision making, to use language that encourages patient involvement, and to develop patient versions of guidelines. Recommendation-specific strategies, related to specific decision points in the guideline, were also suggested: These include structuring the presentation of healthcare options to increase professionals' option awareness; structuring the deliberation process between professionals and patients; and providing relevant patient support tools embedded at important decision points in the guideline. This study resulted in an overview of strategies to adapt clinical practice guidelines to facilitate shared decision making. Some strategies seemed more contentious than others. Future research should assess the feasibility and impact of these strategies to make clinical practice guidelines more conducive to facilitate shared decision making.

Shared Decision Making and Motivational Interviewing: Achieving Patient-Centered Care Across the Spectrum of Health Care Problems

PubMed Central

Elwyn, Glyn; Dehlendorf, Christine; Epstein, Ronald M.; Marrin, Katy; White, James; Frosch, Dominick L.

2014-01-01

Patient-centered care requires different approaches depending on the clinical situation. Motivational interviewing and shared decision making provide practical and well-described methods to accomplish patient-centered care in the context of situations where medical evidence supports specific behavior changes and the most appropriate action is dependent on the patient’s preferences. Many clinical consultations may require elements of both approaches, however. This article describes these 2 approaches—one to address ambivalence to medically indicated behavior change and the other to support patients in making health care decisions in cases where there is more than one reasonable option—and discusses how clinicians can draw on these approaches alone and in combination to achieve patient-centered care across the range of health care problems. PMID:24821899

Patients’ priorities for treatment decision making during periods of incapacity: quantitative survey

PubMed Central

RID, ANNETTE; WESLEY, ROBERT; PAVLICK, MARK; MAYNARD, SHARON; ROTH, KATALIN; WENDLER, DAVID

2017-01-01

Objective Clinical practice aims to respect patient autonomy by basing treatment decisions for incapacitated patients on their own preferences. Yet many patients do not complete an advance directive, and those who do frequently just designate a family member to make decisions for them. This finding raises the concern that clinical practice may be based on a mistaken understanding of patient priorities. The present study aimed to collect systematic data on how patients prioritize the goals of treatment decision making. Method We employed a self-administered, quantitative survey of patients in a tertiary care center. Results Some 80% or more of the 1169 respondents (response rate = 59.8%) ranked six of eight listed goals for treatment decision making as important. When asked which goal was most important, 38.8% identified obtaining desired or avoiding unwanted treatments, 20.0% identified minimizing stress or financial burden on their family, and 14.6% identified having their family help to make treatment decisions. No single goal was designated as most important by 25.0% of participants. Significance of Results Patients endorsed three primary goals with respect to decision making during periods of incapacity: being treated consistent with their own preferences; minimizing the burden on their family; and involving their family in the decision-making process. However, no single goal was prioritized by a clear majority of patients. These findings suggest that advance care planning should not be limited to documenting patients’ treatment preferences. Clinicians should also discuss and document patients’ priorities for how decisions are to be made. Moreover, future research should evaluate ways to modify current practice to promote all three of patients primary goals for treatment decision making. PMID:25273677

“Kinect-ing” With Clinicians: A Knowledge Translation Resource to Support Decision Making About Video Game Use in Rehabilitation

PubMed Central

Levac, Danielle; Espy, Deborah; Fox, Emily; Pradhan, Sujata

2015-01-01

Microsoft's Kinect for Xbox 360 virtual reality (VR) video games are promising rehabilitation options because they involve motivating, full-body movement practice. However, these games were designed for recreational use, which creates challenges for clinical implementation. Busy clinicians require decision-making support to inform game selection and implementation that address individual therapeutic goals. This article describes the development and preliminary evaluation of a knowledge translation (KT) resource to support clinical decision making about selection and use of Kinect games in physical therapy. The knowledge-to-action framework guided the development of the Kinecting With Clinicians (KWiC) resource. Five physical therapists with VR and video game expertise analyzed the Kinect Adventure games. A consensus-building method was used to arrive at categories to organize clinically relevant attributes guiding game selection and game play. The process and results of an exploratory usability evaluation of the KWiC resource by clinicians through interviews and focus groups at 4 clinical sites is described. Subsequent steps in the evaluation and KT process are proposed, including making the KWiC resource Web-based and evaluating the utility of the online resource in clinical practice. PMID:25256741

"Kinect-ing" with clinicians: a knowledge translation resource to support decision making about video game use in rehabilitation.

PubMed

Levac, Danielle; Espy, Deborah; Fox, Emily; Pradhan, Sujata; Deutsch, Judith E

2015-03-01

Microsoft's Kinect for Xbox 360 virtual reality (VR) video games are promising rehabilitation options because they involve motivating, full-body movement practice. However, these games were designed for recreational use, which creates challenges for clinical implementation. Busy clinicians require decision-making support to inform game selection and implementation that address individual therapeutic goals. This article describes the development and preliminary evaluation of a knowledge translation (KT) resource to support clinical decision making about selection and use of Kinect games in physical therapy. The knowledge-to-action framework guided the development of the Kinecting With Clinicians (KWiC) resource. Five physical therapists with VR and video game expertise analyzed the Kinect Adventure games. A consensus-building method was used to arrive at categories to organize clinically relevant attributes guiding game selection and game play. The process and results of an exploratory usability evaluation of the KWiC resource by clinicians through interviews and focus groups at 4 clinical sites is described. Subsequent steps in the evaluation and KT process are proposed, including making the KWiC resource Web-based and evaluating the utility of the online resource in clinical practice. © 2015 American Physical Therapy Association.

A predictive approach to selecting the size of a clinical trial, based on subjective clinical opinion.

PubMed

Spiegelhalter, D J; Freedman, L S

1986-01-01

The 'textbook' approach to determining sample size in a clinical trial has some fundamental weaknesses which we discuss. We describe a new predictive method which takes account of prior clinical opinion about the treatment difference. The method adopts the point of clinical equivalence (determined by interviewing the clinical participants) as the null hypothesis. Decision rules at the end of the study are based on whether the interval estimate of the treatment difference (classical or Bayesian) includes the null hypothesis. The prior distribution is used to predict the probabilities of making the decisions to use one or other treatment or to reserve final judgement. It is recommended that sample size be chosen to control the predicted probability of the last of these decisions. An example is given from a multi-centre trial of superficial bladder cancer.

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

PubMed

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

2018-06-01

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

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.

How are evidence and knowledge used in orthopaedic decision-making? Three comparative case studies of different approaches to implementation of clinical guidance in practice.

PubMed

Grove, Amy; Clarke, Aileen; Currie, Graeme

2018-05-31

The uptake and use of clinical guidelines is often insufficient to change clinical behaviour and reduce variation in practice. As a consequence of diverse organisational contexts, the simple provision of guidelines cannot ensure fidelity or guarantee their use when making decisions. Implementation research in surgery has focused on understanding what evidence exists for clinical practice decisions but limits understanding to the technical, educational and accessibility issues. This research aims to identify where, when and how evidence and knowledge are used in orthopaedic decision-making and how variation in these factors contributes to different approaches to implementation of clinical guidance in practice. We used in-depth case studies to examine guideline implementation in real-life surgical practice. We conducted comparative case studies in three English National Health Service hospitals over a 12-month period. Each in-depth case study consisted of a mix of qualitative methods including interviews, observations and document analysis. Data included field notes from observations of day-to-day practice, 64 interviews with NHS surgeons and staff and the collection of 121 supplementary documents. Case studies identified 17 sources of knowledge and evidence which influenced clinical decisions in elective orthopaedic surgery. A comparative analysis across cases revealed that each hospital had distinct approaches to decision-making. Decision-making is described as occurring as a result of how 17 types of knowledge and evidence were privileged and of how they interacted and changed in context. Guideline implementation was contingent and mediated through four distinct contextual levels. Implementation could be assessed for individual surgeons, groups of surgeons or the organisation as a whole, but it could also differ between these levels. Differences in how evidence and knowledge were used contributed to variations in practice from guidelines. A range of complex and competing sources of evidence and knowledge exists which influence the working practices of healthcare professionals. The dynamic selection, combination and use of each type of knowledge and evidence influence the implementation and use of clinical guidance in practice. Clinical guidelines are a fundamental part of practice, but represent only one type of evidence influencing clinical decisions. In the orthopaedic speciality, other distinct sources of evidence and knowledge are selected and used which impact on how guidelines are implemented. New approaches to guideline implementation need to appreciate and incorporate this diverse range of knowledge and evidence which influences clinical decisions and to take account of the changing contexts in which decisions are made.

Evolutions in clinical reasoning assessment: The Evolving Script Concordance Test.

PubMed

Cooke, Suzette; Lemay, Jean-François; Beran, Tanya

2017-08-01

Script concordance testing (SCT) is a method of assessment of clinical reasoning. We developed a new type of SCT case design, the evolving SCT (E-SCT), whereby the patient's clinical story is "evolving" and with thoughtful integration of new information at each stage, decisions related to clinical decision-making become increasingly clear. We aimed to: (1) determine whether an E-SCT could differentiate clinical reasoning ability among junior residents (JR), senior residents (SR), and pediatricians, (2) evaluate the reliability of an E-SCT, and (3) obtain qualitative feedback from participants to help inform the potential acceptability of the E-SCT. A 12-case E-SCT, embedded within a 24-case pediatric SCT (PaedSCT), was administered to 91 pediatric residents (JR: n = 50; SR: n = 41). A total of 21 pediatricians served on the panel of experts (POE). A one-way analysis of variance (ANOVA) was conducted across the levels of experience. Participants' feedback on the E-SCT was obtained with a post-test survey and analyzed using two methods: percentage preference and thematic analysis. Statistical differences existed across levels of training: F = 19.31 (df = 2); p < 0.001. The POE scored higher than SR (mean difference = 10.34; p < 0.001) and JR (mean difference = 16.00; p < 0.001). SR scored higher than JR (mean difference = 5.66; p < 0.001). Reliability (Cronbach's α) was 0.83. Participants found the E-SCT engaging, easy to follow and true to the daily clinical decision-making process. The E-SCT demonstrated very good reliability and was effective in distinguishing clinical reasoning ability across three levels of experience. Participants found the E-SCT engaging and representative of real-life clinical reasoning and decision-making processes. We suggest that further refinement and utilization of the evolving style case will enhance SCT as a robust, engaging, and relevant method for the assessment of clinical reasoning.

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

PubMed

Hajjaj, F M; Salek, M S; Basra, M K A; Finlay, A Y

2010-05-01

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.

[The effects of case-based learning using video on clinical decision making and learning motivation in undergraduate nursing students].

PubMed

Yoo, Moon-Sook; Park, Jin-Hee; Lee, Si-Ra

2010-12-01

The purpose of this study was to examine the effects of case-base learning (CBL) using video on clinical decision-making and learning motivation. This research was conducted between June 2009 and April 2010 as a nonequivalent control group non-synchronized design. The study population was 44 third year nursing students who enrolled in a college of nursing, A University in Korea. The nursing students were divided into the CBL and the control group. The intervention was the CBL with three cases using video. The controls attended a traditional live lecture on the same topics. With questionnaires objective clinical decision-making, subjective clinical decision-making, and learning motivation were measured before the intervention, and 10 weeks after the intervention. Significant group differences were observed in clinical decision-making and learning motivation. The post-test scores of clinical decision-making in the CBL group were statistically higher than the control group. Learning motivation was also significantly higher in the CBL group than in the control group. These results indicate that CBL using video is effective in enhancing clinical decision-making and motivating students to learn by encouraging self-directed learning and creating more interest and curiosity in learning.

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

PubMed

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

2014-09-01

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

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

PubMed Central

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

2009-01-01

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

The impact of decision aids to enhance shared decision making for diabetes (the DAD study): protocol of a cluster randomized trial.

PubMed

LeBlanc, Annie; Ruud, Kari L; Branda, Megan E; Tiedje, Kristina; Boehmer, Kasey R; Pencille, Laurie J; Van Houten, Holly; Matthews, Marc; Shah, Nilay D; May, Carl R; Yawn, Barbara P; Montori, Victor M

2012-05-28

Shared decision making contributes to high quality healthcare by promoting a patient-centered approach. Patient involvement in selecting the components of a diabetes medication program that best match the patient's values and preferences may also enhance medication adherence and improve outcomes. Decision aids are tools designed to involve patients in shared decision making, but their adoption in practice has been limited. In this study, we propose to obtain a preliminary estimate of the impact of patient decision aids vs. usual care on measures of patient involvement in decision making, diabetes care processes, medication adherence, glycemic and cardiovascular risk factor control, and resource utilization. In addition, we propose to identify, describe, and explain factors that promote or inhibit the routine embedding of decision aids in practice. We will be conducting a mixed-methods study comprised of a cluster-randomized, practical, multicentered trial enrolling clinicians and their patients (n = 240) with type 2 diabetes from rural and suburban primary care practices (n = 8), with an embedded qualitative study to examine factors that influence the incorporation of decision aids into routine practice. The intervention will consist of the use of a decision aid (Statin Choice and Aspirin Choice, or Diabetes Medication Choice) during the clinical encounter. The qualitative study will include analysis of video recordings of clinical encounters and in-depth, semi-structured interviews with participating patients, clinicians, and clinic support staff, in both trial arms. Upon completion of this trial, we will have new knowledge about the effectiveness of diabetes decision aids in these practices. We will also better understand the factors that promote or inhibit the successful implementation and normalization of medication choice decision aids in the care of chronic patients in primary care practices. NCT00388050.

Shared decision-making in epilepsy management.

PubMed

Pickrell, W O; Elwyn, G; Smith, P E M

2015-06-01

Policy makers, clinicians, and patients increasingly recognize the need for greater patient involvement in clinical decision-making. Shared decision-making helps address these concerns by providing a framework for clinicians and patients to make decisions together using the best evidence. Shared decision-making is applicable to situations where several acceptable options exist (clinical equipoise). Such situations occur commonly in epilepsy, for example, in decisions regarding the choice of medication, treatment in pregnancy, and medication withdrawal. A talk model is a way of implementing shared decision-making during consultations, and decision aids are useful tools to assist in the process. Although there is limited evidence available for shared decision-making in epilepsy, there are several benefits of shared decision-making in general including improved decision quality, more informed choices, and better treatment concordance. Copyright © 2015 Elsevier Inc. All rights reserved.

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

PubMed

Ludin, Salizar Mohamed

2018-02-01

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

How do small groups make decisions? : A theoretical framework to inform the implementation and study of clinical competency committees.

PubMed

Chahine, Saad; Cristancho, Sayra; Padgett, Jessica; Lingard, Lorelei

2017-06-01

In the competency-based medical education (CBME) approach, clinical competency committees are responsible for making decisions about trainees' competence. However, we currently lack a theoretical model for group decision-making to inform this emerging assessment phenomenon. This paper proposes an organizing framework to study and guide the decision-making processes of clinical competency committees.This is an explanatory, non-exhaustive review, tailored to identify relevant theoretical and evidence-based papers related to small group decision-making. The search was conducted using Google Scholar, Web of Science, MEDLINE, ERIC, and PsycINFO for relevant literature. Using a thematic analysis, two researchers (SC & JP) met four times between April-June 2016 to consolidate the literature included in this review.Three theoretical orientations towards group decision-making emerged from the review: schema, constructivist, and social influence. Schema orientations focus on how groups use algorithms for decision-making. Constructivist orientations focus on how groups construct their shared understanding. Social influence orientations focus on how individual members influence the group's perspective on a decision. Moderators of decision-making relevant to all orientations include: guidelines, stressors, authority, and leadership.Clinical competency committees are the mechanisms by which groups of clinicians will be in charge of interpreting multiple assessment data points and coming to a shared decision about trainee competence. The way in which these committees make decisions can have huge implications for trainee progression and, ultimately, patient care. Therefore, there is a pressing need to build the science of how such group decision-making works in practice. This synthesis suggests a preliminary organizing framework that can be used in the implementation and study of clinical competency committees.

What Is a "Good" Treatment Decision? Decisional Control, Knowledge, Treatment Decision Making, and Quality of Life in Men with Clinically Localized Prostate Cancer.

PubMed

Orom, Heather; Biddle, Caitlin; Underwood, Willie; Nelson, Christian J; Homish, D Lynn

2016-08-01

We explored whether active patient involvement in decision making and greater patient knowledge are associated with better treatment decision-making experiences and better quality of life (QOL) among men with clinically localized prostate cancer. Localized prostate cancer treatment decision making is an advantageous model for studying patient treatment decision-making dynamics because there are multiple treatment options and a lack of empirical evidence to recommend one over the other; consequently, it is recommended that patients be fully involved in making the decision. Men with newly diagnosed clinically localized prostate cancer (N = 1529) completed measures of decisional control, prostate cancer knowledge, and decision-making experiences (decisional conflict and decision-making satisfaction and difficulty) shortly after they made their treatment decision. Prostate cancer-specific QOL was assessed at 6 months after treatment. More active involvement in decision making and greater knowledge were associated with lower decisional conflict and higher decision-making satisfaction but greater decision-making difficulty. An interaction between decisional control and knowledge revealed that greater knowledge was only associated with greater difficulty for men actively involved in making the decision (67% of sample). Greater knowledge, but not decisional control, predicted better QOL 6 months after treatment. Although men who are actively involved in decision making and more knowledgeable may make more informed decisions, they could benefit from decisional support (e.g., decision-making aids, emotional support from providers, strategies for reducing emotional distress) to make the process easier. Men who were more knowledgeable about prostate cancer and treatment side effects at the time that they made their treatment decision may have appraised their QOL as higher because they had realistic expectations about side effects. © The Author(s) 2016.

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

PubMed

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

2009-05-01

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

Relationship between Student Pharmacist Decision Making Preferences and Experiential Learning.

PubMed

Williams, Charlene R; McLaughlin, Jacqueline E; Cox, Wendy C; Shepherd, Greene

2016-09-25

Objective. To determine if student pharmacists' preferences towards experiential and rational thinking are associated with performance on advanced pharmacy practice experiences (APPEs) and whether thinking style preference changes following APPEs. Methods. The Rational Experiential Inventory (REI), a validated survey of thinking style, was administered to student pharmacists before starting APPEs and re-administered after completing APPEs. APPE grades were compared to initial REI scores. Results. Rational Experiential Inventory scores remained consistent before and after APPEs. Overall, APPE grades were independent of REI scores. In a regression model, the REI experiential score was a significant negative predictor of hospital APPE grades. Conclusion. These findings suggest that overall APPE performance is independent of decision-making preference, and decision-making style does not change following immersion into APPEs. Instead of targeting teaching strategies towards a specific decision-making style, preceptors may use pedagogical approaches that promote sound clinical decision-making skills through critical thinking and reflection.

Relationship between Student Pharmacist Decision Making Preferences and Experiential Learning

PubMed Central

McLaughlin, Jacqueline E.; Cox, Wendy C.; Shepherd, Greene

2016-01-01

Objective. To determine if student pharmacists’ preferences towards experiential and rational thinking are associated with performance on advanced pharmacy practice experiences (APPEs) and whether thinking style preference changes following APPEs. Methods. The Rational Experiential Inventory (REI), a validated survey of thinking style, was administered to student pharmacists before starting APPEs and re-administered after completing APPEs. APPE grades were compared to initial REI scores. Results. Rational Experiential Inventory scores remained consistent before and after APPEs. Overall, APPE grades were independent of REI scores. In a regression model, the REI experiential score was a significant negative predictor of hospital APPE grades. Conclusion. These findings suggest that overall APPE performance is independent of decision-making preference, and decision-making style does not change following immersion into APPEs. Instead of targeting teaching strategies towards a specific decision-making style, preceptors may use pedagogical approaches that promote sound clinical decision-making skills through critical thinking and reflection. PMID:27756927

Decision tools in health care: focus on the problem, not the solution.

PubMed

Liu, Joseph; Wyatt, Jeremy C; Altman, Douglas G

2006-01-20

Systematic reviews or randomised-controlled trials usually help to establish the effectiveness of drugs and other health technologies, but are rarely sufficient by themselves to ensure actual clinical use of the technology. The process from innovation to routine clinical use is complex. Numerous computerised decision support systems (DSS) have been developed, but many fail to be taken up into actual use. Some developers construct technologically advanced systems with little relevance to the real world. Others did not determine whether a clinical need exists. With NHS investing 5 billion pounds sterling in computer systems, also occurring in other countries, there is an urgent need to shift from a technology-driven approach to one that identifies and employs the most cost-effective method to manage knowledge, regardless of the technology. The generic term, 'decision tool' (DT), is therefore suggested to demonstrate that these aids, which seem different technically, are conceptually the same from a clinical viewpoint. Many computerised DSSs failed for various reasons, for example, they were not based on best available knowledge; there was insufficient emphasis on their need for high quality clinical data; their development was technology-led; or evaluation methods were misapplied. We argue that DSSs and other computer-based, paper-based and even mechanical decision aids are members of a wider family of decision tools. A DT is an active knowledge resource that uses patient data to generate case specific advice, which supports decision making about individual patients by health professionals, the patients themselves or others concerned about them. The identification of DTs as a consistent and important category of health technology should encourage the sharing of lessons between DT developers and users and reduce the frequency of decision tool projects focusing only on technology. The focus of evaluation should become more clinical, with the impact of computer-based DTs being evaluated against other computer, paper- or mechanical tools, to identify the most cost effective tool for each clinical problem. We suggested the generic term 'decision tool' to demonstrate that decision-making aids, such as computerised DSSs, paper algorithms, and reminders are conceptually the same, so the methods to evaluate them should be the same.

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…

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

PubMed

Ortendahl, Monica

2008-10-01

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

Clinician’s use of automated reports of estimated glomerular filtration rate: A qualitative study

PubMed Central

2012-01-01

Background There is a growing awareness in primary care of the importance of identifying patients with chronic kidney disease (CKD) so that they can receive appropriate clinical care; one method that has been widely embraced is the use of automated reporting of estimated glomerular filtration rate (eGFR) by clinical laboratories. We undertook a qualitative study to examine how clinicians use eGFR in clinical decision making, patient communication issues, barriers to use of eGFR, and suggestions to improve the clinical usefulness of eGFR reports. Methods Our study used qualitative methods with structured interviews among primary care clinicians including both physicians and allied health providers, recruited from Kaiser Permanente Northwest, a non-profit health maintenance organization. Results We found that clinicians generally held favorable views toward eGFR reporting but did not use eGFR to replace serum creatinine in their clinical decision-making. Clinicians used eGFR as a tool to help identify CKD, educate patients about their kidney function and make treatment decisions. Barriers noted by several clinicians included a desire for greater education regarding care for patients with CKD and tools to facilitate discussion of eGFR findings with patients. Conclusions The manner in which clinicians use eGFRs appears to be more complex than previously understood, and our study illustrates some of the efforts that might be usefully undertaken (e.g. specific clinician education) when encouraging further promulgation of eGFR reporting and usage. PMID:23173944

Factors that impact on emergency nurses' ethical decision-making ability.

PubMed

Alba, Barbara

2016-11-10

Reliance on moral principles and professional codes has given nurses direction for ethical decision-making. However, rational models do not capture the emotion and reality of human choice. Intuitive response must be considered. Supporting intuition as an important ethical decision-making tool for nurses, the aim of this study was to determine relationships between intuition, years of worked nursing experience, and perceived ethical decision-making ability. A secondary aim explored the relationships between rational thought to years of worked nursing experience and perceived ethical decision-making ability. A non-experimental, correlational research design was used. The Rational Experiential Inventory measured intuition and rational thought. The Clinical Decision Making in Nursing Scale measured perceived ethical decision-making ability. Pearson's r was the statistical method used to analyze three primary and two secondary research questions. A sample of 182 emergency nurses was recruited electronically through the Emergency Nurses Association. Participants were self-selected. Approval to conduct this study was obtained by the Adelphi University Institutional Review Board. A relationship between intuition and perceived ethical decision-making ability (r = .252, p = .001) was a significant finding in this study. This study is one of the first of this nature to make a connection between intuition and nurses' ethical decision-making ability. This investigation contributes to a broader understanding of the different thought processes used by emergency nurses to make ethical decisions. © The Author(s) 2016.

Evidence summaries (decision boxes) to prepare clinicians for shared decision-making with patients: a mixed methods implementation study.

PubMed

Giguere, Anik M C; Labrecque, Michel; Haynes, R Brian; Grad, Roland; Pluye, Pierre; Légaré, France; Cauchon, Michel; Greenway, Matthew; Carmichael, Pierre-Hugues

2014-10-05

Decision boxes (Dboxes) provide clinicians with research evidence about management options for medical questions that have no single best answer. Dboxes fulfil a need for rapid clinical training tools to prepare clinicians for clinician-patient communication and shared decision-making. We studied the barriers and facilitators to using the Dbox information in clinical practice. We used a mixed methods study with sequential explanatory design. We recruited family physicians, residents, and nurses from six primary health-care clinics. Participants received eight Dboxes covering various questions by email (one per week). For each Dbox, they completed a web questionnaire to rate clinical relevance and cognitive impact and to assess the determinants of their intention to use what they learned from the Dbox to explain to their patients the advantages and disadvantages of the options, based on the theory of planned behaviour (TPB). Following the 8-week delivery period, we conducted focus groups with clinicians and interviews with clinic administrators to explore contextual factors influencing the use of the Dbox information. One hundred clinicians completed the web surveys. In 54% of the 496 questionnaires completed, they reported that their practice would be improved after having read the Dboxes, and in 40%, they stated that they would use this information for their patients. Of those who would use the information for their patients, 89% expected it would benefit their patients, especially in that it would allow the patient to make a decision more in keeping with his/her personal circumstances, values, and preferences. They intended to use the Dboxes in practice (mean 5.6±1.2, scale 1-7, with 7 being "high"), and their intention was significantly related to social norm, perceived behavioural control, and attitude according to the TPB (P<0.0001). In focus groups, clinicians mentioned that co-interventions such as patient decision aids and training in shared decision-making would facilitate the use of the Dbox information. Some participants would have liked a clear "bottom line" statement for each Dbox and access to printed Dboxes in consultation rooms. Dboxes are valued by clinicians. Tailoring of Dboxes to their needs would facilitate their implementation in practice.

[Clinical decision making: Fostering critical thinking in the nursing diagnostic process through case studies].

PubMed

Müller-Staub, Maria; Stuker-Studer, Ursula

2006-10-01

Case studies, based on actual patients' situations, provide a method of clinical decision making to foster critical thinking in nurses. This paper describes the method and process of group case studies applied in continuous education settings. This method bases on Balints' case supervision and was further developed and combined with the nursing diagnostic process. A case study contains different phases: Pre-phase, selection phase, case delineation and case work. The case provider narratively tells the situation of a patient. This allows the group to analyze and cluster signs and symptoms, to state nursing diagnoses and to derive nursing interventions. Results of the case study are validated by applying the theoretical background and critical appraisal of the case provider. Learning effects of the case studies were evaluated by means of qualitative questionnaires and analyzed according to Mayring. Findings revealed the following categories: a) Patients' problems are perceived in a patient centred way, accurate nursing diagnoses are stated and effective nursing interventions implemented. b) Professional nursing tasks are more purposefully perceived and named more precise. c) Professional nursing relationship, communication and respectful behaviour with patients were perceived in differentiated ways. The theoretical framework is described in the paper "Clinical decision making and critical thinking in the nursing diagnostic process". (Müller-Staub, 2006).

Towards knowledge-based systems in clinical practice: development of an integrated clinical information and knowledge management support system.

PubMed

Kalogeropoulos, Dimitris A; Carson, Ewart R; Collinson, Paul O

2003-09-01

Given that clinicians presented with identical clinical information will act in different ways, there is a need to introduce into routine clinical practice methods and tools to support the scientific homogeneity and accountability of healthcare decisions and actions. The benefits expected from such action include an overall reduction in cost, improved quality of care, patient and public opinion satisfaction. Computer-based medical data processing has yielded methods and tools for managing the task away from the hospital management level and closer to the desired disease and patient management level. To this end, advanced applications of information and disease process modelling technologies have already demonstrated an ability to significantly augment clinical decision making as a by-product. The wide-spread acceptance of evidence-based medicine as the basis of cost-conscious and concurrently quality-wise accountable clinical practice suffices as evidence supporting this claim. Electronic libraries are one-step towards an online status of this key health-care delivery quality control environment. Nonetheless, to date, the underlying information and knowledge management technologies have failed to be integrated into any form of pragmatic or marketable online and real-time clinical decision making tool. One of the main obstacles that needs to be overcome is the development of systems that treat both information and knowledge as clinical objects with same modelling requirements. This paper describes the development of such a system in the form of an intelligent clinical information management system: a system which at the most fundamental level of clinical decision support facilitates both the organised acquisition of clinical information and knowledge and provides a test-bed for the development and evaluation of knowledge-based decision support functions.

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…

Behavioral medicine perspectives on the design of health information technology to improve decision-making, guideline adherence, and care coordination in chronic pain management.

PubMed

Midboe, Amanda M; Lewis, Eleanor T; Cronkite, Ruth C; Chambers, Dallas; Goldstein, Mary K; Kerns, Robert D; Trafton, Jodie A

2011-03-01

Development of clinical decision support systems (CDSs) has tended to focus on facilitating medication management. An understanding of behavioral medicine perspectives on the usefulness of a CDS for patient care can expand CDSs to improve management of chronic disease. The purpose of this study is to explore feedback from behavioral medicine providers regarding the potential for CDSs to improve decision-making, care coordination, and guideline adherence in pain management. Qualitative methods were used to analyze semi-structured interview responses from behavioral medicine stakeholders following demonstration of an existing CDS for opioid prescribing, ATHENA-OT. Participants suggested that a CDS could assist with decision-making by educating providers, providing recommendations about behavioral therapy, facilitating risk assessment, and improving referral decisions. They suggested that a CDS could improve care coordination by facilitating division of workload, improving patient education, and increasing consideration and knowledge of options in other disciplines. Clinical decision support systems are promising tools for improving behavioral medicine care for chronic pain.

Clinical decision-making of rural novice nurses.

PubMed

Seright, T J

2011-01-01

Nurses in rural settings are often the first to assess and interpret the patient's clinical presentations. Therefore, an understanding of how nurses experience decision-making is important in terms of educational preparation, resource allocation to rural areas, institutional cultures, and patient outcomes. Theory development was based on the in-depth investigation of 12 novice nurses practicing in rural critical access hospitals in a north central state. This grounded theory study consisted of face-to-face interviews with 12 registered nurses, nine of whom were observed during their work day. The participants were interviewed a second time, as a method of member checking, and during this interview they reviewed their transcripts, the emerging themes and categories. Directors of nursing from both the research sites and rural hospitals not involved in the study, experienced researchers, and nurse educators facilitated triangulation of the findings. 'Sociocentric rationalizing' emerged as the central phenomenon and referred to the sense of belonging and agency which impacted the decision-making in this small group of novice nurses in rural critical access hospitals. The observed consequences, which were conceptualized during the axial coding process and were derived from observations and interviews of the 12 novice nurses in this study include: (1) gathering information before making a decision included assessment of: the credibility of co-workers, patients' subjective and objective data, and one's own past and current experiences; (2) conferring with co-workers as a direct method of confirming/denying decisions being made was considered more realistic and expedient than policy books and decision trees; (3) rural practicum clinical experiences, along with support after orientation, provide for transition to the rural nurse role; (4) involved directors of nursing served as both models and protectors of novice nurses placed in high accountability positions early in their careers. These novice nurses were often working with a limited staff, while managing an ever-changing census and acuity of patients. The significance of interdependence and welcoming relationships with their co-workers and directors of nursing was pivotal in the clinical decision-making process. Despite access to a number of resources at their disposal (including policy books, decision trees, standing orders, textbooks, and in some cases internet resources), the 12 nurses in this study indicated collaboration with co-workers was a major means of facilitating their decision-making. Rural novice nurses require facilitation of social skills as much as critical thinking skills both within their programs of nursing and during their new employee orientation; however, decision-making must be guided by more experienced nurses who are willing to mentor novice nurses and advise them to to reflect upon their decisions as they care for patients using evidenced based practice. In a rural setting, this is especially important because novice nurses are tasked early in their career with decision-making, which often involves ill-structured problems set in dynamic and changing environments, in high-stakes situations where patient safety is a concern.

Concept mapping in a critical care orientation program: a pilot study to develop critical thinking and decision-making skills in novice nurses.

PubMed

Wahl, Stacy E; Thompson, Anita M

2013-10-01

Newly graduated registered nurses who were hired into a critical care intensive care unit showed a lack of critical thinking skills to inform their clinical decision-making abilities. This study evaluated the effectiveness of concept mapping as a teaching tool to improve critical thinking and clinical decision-making skills in novice nurses. A self-evaluation tool was administered before and after the learning intervention. The 25-item tool measured five key indicators of the development of critical thinking skills: problem recognition, clinical decision-making, prioritization, clinical implementation, and reflection. Statistically significant improvements were seen in 10 items encompassing all five indicators. Concept maps are an effective tool for educators to use in assisting novice nurses to develop their critical thinking and clinical decision-making skills. Copyright 2013, SLACK Incorporated.

Instruments to assess the perception of physicians in the decision-making process of specific clinical encounters: a systematic review

PubMed Central

Légaré, France; Moher, David; Elwyn, Glyn; LeBlanc, Annie; Gravel, Karine

2007-01-01

Background The measurement of processes and outcomes that reflect the complexity of the decision-making process within specific clinical encounters is an important area of research to pursue. A systematic review was conducted to identify instruments that assess the perception physicians have of the decision-making process within specific clinical encounters. Methods For every year available up until April 2007, PubMed, PsycINFO, Current Contents, Dissertation Abstracts and Sociological Abstracts were searched for original studies in English or French. Reference lists from retrieved studies were also consulted. Studies were included if they reported a self-administered instrument evaluating physicians' perceptions of the decision-making process within specific clinical encounters, contained sufficient description to permit critical appraisal and presented quantitative results based on administering the instrument. Two individuals independently assessed the eligibility of the instruments and abstracted information on their conceptual underpinnings, main evaluation domain, development, format, reliability, validity and responsiveness. They also assessed the quality of the studies that reported on the development of the instruments with a modified version of STARD. Results Out of 3431 records identified and screened for evaluation, 26 potentially relevant instruments were assessed; 11 met the inclusion criteria. Five instruments were published before 1995. Among those published after 1995, five offered a corresponding patient version. Overall, the main evaluation domains were: satisfaction with the clinical encounter (n = 2), mutual understanding between health professional and patient (n = 2), mental workload (n = 1), frustration with the clinical encounter (n = 1), nurse-physician collaboration (n = 1), perceptions of communication competence (n = 2), degree of comfort with a decision (n = 1) and information on medication (n = 1). For most instruments (n = 10), some reliability and validity criteria were reported in French or English. Overall, the mean number of items on the modified version of STARD was 12.4 (range: 2 to 18). Conclusion This systematic review provides a critical appraisal and repository of instruments that assess the perception physicians have of the decision-making process within specific clinical encounters. More research is needed to pursue the validation of the existing instruments and the development of patient versions. This will help researchers capture the complexity of the decision-making process within specific clinical encounters. PMID:17937801

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

PubMed

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

2015-01-01

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

Cognitive continuum theory in interprofessional healthcare: A critical analysis.

PubMed

Parker-Tomlin, Michelle; Boschen, Mark; Morrissey, Shirley; Glendon, Ian

2017-07-01

Effective clinical decision making is among the most important skills required by healthcare practitioners. Making sound decisions while working collaboratively in interprofessional healthcare teams is essential for modern healthcare planning, successful interventions, and patient care. The cognitive continuum theory (CCT) is a model of human judgement and decision making aimed at orienting decision-making processes. CCT has the potential to improve both individual health practitioner, and interprofessional team understanding about, and communication of, clinical decision-making processes. Examination of the current application of CCT indicates that this theory could strengthen interprofessional team clinical decision making (CDM). However, further research is needed before extending the use of this theoretical framework to a wider range of interprofessional healthcare team processes. Implications for research, education, practice, and policy are addressed.

The use of economic evaluation in CAM: an introductory framework.

PubMed

Ford, Emily; Solomon, Daniela; Adams, Jon; Graves, Nicholas

2010-11-11

For CAM to feature prominently in health care decision-making there is a need to expand the evidence-base and to further incorporate economic evaluation into research priorities.In a world of scarce health care resources and an emphasis on efficiency and clinical efficacy, CAM, as indeed do all other treatments, requires rigorous evaluation to be considered in budget decision-making. Economic evaluation provides the tools to measure the costs and health consequences of CAM interventions and thereby inform decision making. This article offers CAM researchers an introductory framework for understanding, undertaking and disseminating economic evaluation. The types of economic evaluation available for the study of CAM are discussed, and decision modelling is introduced as a method for economic evaluation with much potential for use in CAM. Two types of decision models are introduced, decision trees and Markov models, along with a worked example of how each method is used to examine costs and health consequences. This is followed by a discussion of how this information is used by decision makers. Undoubtedly, economic evaluation methods form an important part of health care decision making. Without formal training it can seem a daunting task to consider economic evaluation, however, multidisciplinary teams provide an opportunity for health economists, CAM practitioners and other interested researchers, to work together to further develop the economic evaluation of CAM.

How shrinks think: decision making in psychiatry.

PubMed

Bhugra, Dinesh; Malliaris, Yanni; Gupta, Susham

2010-10-01

Psychiatrists use biopsychosocial models in identifying aetiological factors in assessing their patients and similar approaches in planning management. Models in decision making will be influenced by previous experience, training, age and gender, among other factors. Critical thinking and evidence base are both important components in the process of reaching clinical decisions. Expected outcome of treatment may be another factor. The way we think influences our decision making, clinical or otherwise. With patients expecting and taking larger roles in their own management, there needs to be a shift towards patient-centred care in decision making. Further exploration in how clinical decisions are made by psychiatrists is necessary. An understanding of the manner in which therapeutic alliances are formed between the clinician and the patient is necessary to understand decision making.

Biomedical Informatics for Computer-Aided Decision Support Systems: A Survey

PubMed Central

Belle, Ashwin; Kon, Mark A.; Najarian, Kayvan

2013-01-01

The volumes of current patient data as well as their complexity make clinical decision making more challenging than ever for physicians and other care givers. This situation calls for the use of biomedical informatics methods to process data and form recommendations and/or predictions to assist such decision makers. The design, implementation, and use of biomedical informatics systems in the form of computer-aided decision support have become essential and widely used over the last two decades. This paper provides a brief review of such systems, their application protocols and methodologies, and the future challenges and directions they suggest. PMID:23431259

Patient-reported outcomes in randomised controlled trials of gynaecological cancers: investigating methodological quality and impact on clinical decision-making.

PubMed

Efficace, Fabio; Jacobs, Marc; Pusic, Andrea; Greimel, Elfriede; Piciocchi, Alfonso; Kieffer, Jacobien M; Gilbert, Alexandra; Fayers, Peter; Blazeby, Jane

2014-07-01

The aim for this study is to investigate the methodological quality and potential impact on clinical decision making of patient reported outcome (PRO) assessment in randomised controlled trials (RCTs) in the gynaecological cancer sites. A systematic review identified RCTs published between January 2004 and June 2012. Relevant studies were evaluated using a pre-determined extraction form which included: (1) Trial demographics and clinical and PRO characteristics; (2) level of PRO reporting and (3) bias, assessed using the Cochrane Risk of Bias tool. All studies were additionally analysed in relation to their relevance in supporting clinical decision making. Fifty RCTs enrolling 24,991 patients were identified. In eight RCTs (16%) a PRO was the primary end-point. Twenty-one studies (42%) were carried out in a multi-national context. Where statistically significant PRO differences between treatments were found, it related in most cases to both symptoms and domains other than symptoms (n=17, 57%). The majority of studies (n=42, 84%) did not mention the mode of administration nor the methods of collecting PRO data. Statistical approaches for dealing with missing data were only explicitly mentioned in nine RCTs (18%). Sixteen RCTs (32%) were considered to be of high-quality and thus able to inform clinical decision making. Higher-quality PRO studies were generally associated with RCTs that were at a low risk of bias. This study showed that RCTs with PROs were generally well designed and conducted. In a third the information was very informative to fully understand the pros and cons of PROs treatment decision-making. Copyright © 2014 Elsevier Ltd. All rights reserved.

Patients' Values in Clinical Decision-Making.

PubMed

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

2017-09-01

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

Group Health's participation in a shared decision-making demonstration yielded lessons, such as role of culture change.

PubMed

King, Jaime; Moulton, Benjamin

2013-02-01

In 2007 Washington State became the first state to enact legislation encouraging the use of shared decision making and decision aids to address deficiencies in the informed-consent process. Group Health volunteered to fulfill a legislated mandate to study the costs and benefits of integrating these shared decision-making processes into clinical practice across a range of conditions for which multiple treatment options are available. The Group Health Demonstration Project, conducted during 2009-11, yielded five key lessons for successful implementation, including the synergy between efforts to reduce practice variation and increase shared decision making; the need to support modifications in practice with changes in physician training and culture; and the value of identifying best implementation methods through constant evaluation and iterative improvement. These lessons, and the legislated provisions that supported successful implementation, can guide other states and health care institutions moving toward informed patient choice as the standard of care for medical decision making.

Improving Medical Students' Application of Knowledge and Clinical Decision-Making Through a Porcine-Based Integrated Cardiac Basic Science Program.

PubMed

Stott, Martyn Charles; Gooseman, Michael Richard; Briffa, Norman Paul

2016-01-01

Despite the concerted effort of modern undergraduate curriculum designers, the ability to integrate basic sciences in clinical rotations is an ongoing problem in medical education. Students and newly qualified doctors themselves report worry about the effect this has on their clinical performance. There are examples in the literature to support development of attempts at integrating such aspects, but this "vertical integration" has proven to be difficult. We designed an expert-led integrated program using dissection of porcine hearts to improve the use of cardiac basic sciences in clinical medical students' decision-making processes. To our knowledge, this is the first time in the United Kingdom that an animal model has been used to teach undergraduate clinical anatomy to medical students to direct wider application of knowledge. Action research methodology was used to evaluate the local curriculum and assess learners needs, and the agreed teaching outcomes, methods, and delivery outline were established. A total of 18 students in the clinical years of their degree program attended, completing precourse and postcourse multichoice questions examinations and questionnaires to assess learners' development. Student's knowledge scores improved by 17.5% (p = 0.01; students t-test). Students also felt more confident at applying underlying knowledge to decision-making and diagnosis in clinical medicine. An expert teacher (consultant surgeon) was seen as beneficial to students' understanding and appreciation. This study outlines how the development of a teaching intervention using porcine-based methods successfully improved both student's knowledge and application of cardiac basic sciences. We recommend that clinicians fully engage with integrating previously learnt underlying sciences to aid students in developing decision-making and diagnostic skills as well as a deeper approach to learning. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Classifying clinical decision making: a unifying approach.

PubMed

Buckingham, C D; Adams, A

2000-10-01

This is the first of two linked papers exploring decision making in nursing which integrate research evidence from different clinical and academic disciplines. Currently there are many decision-making theories, each with their own distinctive concepts and terminology, and there is a tendency for separate disciplines to view their own decision-making processes as unique. Identifying good nursing decisions and where improvements can be made is therefore problematic, and this can undermine clinical and organizational effectiveness, as well as nurses' professional status. Within the unifying framework of psychological classification, the overall aim of the two papers is to clarify and compare terms, concepts and processes identified in a diversity of decision-making theories, and to demonstrate their underlying similarities. It is argued that the range of explanations used across disciplines can usefully be re-conceptualized as classification behaviour. This paper explores problems arising from multiple theories of decision making being applied to separate clinical disciplines. Attention is given to detrimental effects on nursing practice within the context of multidisciplinary health-care organizations and the changing role of nurses. The different theories are outlined and difficulties in applying them to nursing decisions highlighted. An alternative approach based on a general model of classification is then presented in detail to introduce its terminology and the unifying framework for interpreting all types of decisions. The classification model is used to provide the context for relating alternative philosophical approaches and to define decision-making activities common to all clinical domains. This may benefit nurses by improving multidisciplinary collaboration and weakening clinical elitism.

The effect of high-fidelity patient simulation on the critical thinking and clinical decision-making skills of new graduate nurses.

PubMed

Maneval, Rhonda; Fowler, Kimberly A; Kays, John A; Boyd, Tiffany M; Shuey, Jennifer; Harne-Britner, Sarah; Mastrine, Cynthia

2012-03-01

This study was conducted to determine whether the addition of high-fidelity patient simulation to new nurse orientation enhanced critical thinking and clinical decision-making skills. A pretest-posttest design was used to assess critical thinking and clinical decision-making skills in two groups of graduate nurses. Compared with the control group, the high-fidelity patient simulation group did not show significant improvement in mean critical thinking or clinical decision-making scores. When mean scores were analyzed, both groups showed an increase in critical thinking scores from pretest to posttest, with the high-fidelity patient simulation group showing greater gains in overall scores. However, neither group showed a statistically significant increase in mean test scores. The effect of high-fidelity patient simulation on critical thinking and clinical decision-making skills remains unclear. Copyright 2012, SLACK Incorporated.

Stakeholder Assessment of the Evidence for Cancer Genomic Tests: Insights from Three Case Studies

PubMed Central

Deverka, Patricia A.; Schully, Sheri D.; Ishibe, Naoko; Carlson, Josh J.; Freedman, Andrew; Goddard, Katrina A.B.; Khoury, Muin J.; Ramsey, Scott D.

2015-01-01

Insufficient evidence on the net benefits and harms of genomic tests in real-world settings is a translational barrier for genomic medicine. Purpose Understanding stakeholders’ assessment of the current evidence base for clinical practice and coverage decisions should be a critical step to influence research, policy, and practice. Methods Twenty-two stakeholders participated in a workshop exploring the evidence of genomic tests for clinical and coverage decision-making. Stakeholders completed a survey prior to and during the meeting. They also discussed if they would recommend for or against current clinical use of each test. Results At baseline, the level of confidence on the clinical validity and clinical utility of each test varied, although the group expressed greater confidence for EGFR mutation and Lynch Syndrome (LS) testing than for Oncotype DX. Following the discussion, survey results reflected even less confidence for Oncotype DX and EGFR testing, but not LS. The majority of stakeholders would consider clinical use for all three tests, but under the conditions of additional research or a shared clinical decision-making approach. Conclusion Stakeholder engagement in unbiased settings is necessary to understand various perspectives about evidentiary thresholds in genomic medicine. Participants recommended the use of various methods for evidence generation and synthesis. PMID:22481130

Patchy ‘coherence’: using normalization process theory to evaluate a multi-faceted shared decision making implementation program (MAGIC)

PubMed Central

2013-01-01

Background Implementing shared decision making into routine practice is proving difficult, despite considerable interest from policy-makers, and is far more complex than merely making decision support interventions available to patients. Few have reported successful implementation beyond research studies. MAking Good Decisions In Collaboration (MAGIC) is a multi-faceted implementation program, commissioned by The Health Foundation (UK), to examine how best to put shared decision making into routine practice. In this paper, we investigate healthcare professionals’ perspectives on implementing shared decision making during the MAGIC program, to examine the work required to implement shared decision making and to inform future efforts. Methods The MAGIC program approached implementation of shared decision making by initiating a range of interventions including: providing workshops; facilitating development of brief decision support tools (Option Grids); initiating a patient activation campaign (‘Ask 3 Questions’); gathering feedback using Decision Quality Measures; providing clinical leads meetings, learning events, and feedback sessions; and obtaining executive board level support. At 9 and 15 months (May and November 2011), two rounds of semi-structured interviews were conducted with healthcare professionals in three secondary care teams to explore views on the impact of these interventions. Interview data were coded by two reviewers using a framework derived from the Normalization Process Theory. Results A total of 54 interviews were completed with 31 healthcare professionals. Partial implementation of shared decision making could be explained using the four components of the Normalization Process Theory: ‘coherence,’ ‘cognitive participation,’ ‘collective action,’ and ‘reflexive monitoring.’ Shared decision making was integrated into routine practice when clinical teams shared coherent views of role and purpose (‘coherence’). Shared decision making was facilitated when teams engaged in developing and delivering interventions (‘cognitive participation’), and when those interventions fit with existing skill sets and organizational priorities (‘collective action’) resulting in demonstrable improvements to practice (‘reflexive monitoring’). The implementation process uncovered diverse and conflicting attitudes toward shared decision making; ‘coherence’ was often missing. Conclusions The study showed that implementation of shared decision making is more complex than the delivery of patient decision support interventions to patients, a portrayal that often goes unquestioned. Normalizing shared decision making requires intensive work to ensure teams have a shared understanding of the purpose of involving patients in decisions, and undergo the attitudinal shifts that many health professionals feel are required when comprehension goes beyond initial interpretations. Divergent views on the value of engaging patients in decisions remain a significant barrier to implementation. PMID:24006959

A conceptual model for generating and validating in-session clinical judgments

PubMed Central

Jacinto, Sofia B.; Lewis, Cara C.; Braga, João N.; Scott, Kelli

2016-01-01

Objective Little attention has been paid to the nuanced and complex decisions made in the clinical session context and how these decisions influence therapy effectiveness. Despite decades of research on the dual-processing systems, it remains unclear when and how intuitive and analytical reasoning influence the direction of the clinical session. Method This paper puts forth a testable conceptual model, guided by an interdisciplinary integration of the literature, that posits that the clinical session context moderates the use of intuitive versus analytical reasoning. Results A synthesis of studies examining professional best practices in clinical decision-making, empirical evidence from clinical judgment research, and the application of decision science theories indicate that intuitive and analytical reasoning may have profoundly different impacts on clinical practice and outcomes. Conclusions The proposed model is discussed with respect to its implications for clinical practice and future research. PMID:27088962

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

PubMed

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

2018-05-19

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

Clinical decision-making described by Swedish prehospital emergency care nurse students - An exploratory study.

PubMed

Nilsson, Tomas; Lindström, Veronica

2016-07-01

The purpose of this study was to explore the PECN students' clinical decision-making during a seven-week clinical rotation in the ambulance services. Developing expertise in prehospital emergency care practices requires both theoretical and empirical learning. A prehospital emergency care nurse (PECN) is a Registered Nurse (RN) with one year of additional training in emergency care. There has been little investigation of how PECN students describe their decision-making during a clinical rotation. A qualitative study design was used, and 12 logbooks written by the Swedish PECN students were analysed using content analysis. The students wrote about 997 patient encounters - ambulance assignments during their clinical rotation. Four themes emerged as crucial for the students' decision-making: knowing the patient, the context-situation awareness in the ambulance service, collaboration, and evaluation. Based on the themes, students made decisions on how to respond to patients' illnesses. The PECN students used several variables in their decision-making. The decision- making was an on-going process during the whole ambulance assignment. The university has the responsibility to guide the students during their transition from an RN to a PECN. The findings of the study can support the educators and clinical supervisors in developing the programme of study for becoming a PECN. Copyright © 2015 Elsevier Ltd. All rights reserved.

Informed decision making before initiating screening mammography: does it occur and does it make a difference?

PubMed

Nekhlyudov, Larissa; Li, Rong; Fletcher, Suzanne W

2008-12-01

Informed decision making regarding screening mammography is recommended for women under age 50. To what extent it occurs in clinical settings is unclear. Using a mailed instrument, we surveyed women aged 40-44 prior to their first screening mammogram. All women were members of a large health maintenance organization and received care at a large medical practice in the Greater Boston area. The survey measured informed decision making, decisional conflict, satisfaction, and screening mammography knowledge and intentions to undergo screening. Ninety-six women responded to the survey (response rate 47%). Overall, women reported limited informed decision making regarding screening mammography, both with respect to information exchange and involvement in the decision process. Less than half (47%) reported discussing the benefits of screening; 23% the uncertainties; and only 7% the harms. About 30% reported discussing the nature of the decision or clinical issue; and 29% reported their provider elicited their preferred role in the decision; 38% their preferences; and 24% their understanding of the information. Women who were uninformed had higher decisional conflict (2.37 vs. 1.83, P=0.005) about screening mammography and were more likely to be dissatisfied with the information and involvement. Women's screening mammography knowledge was limited in most areas; however being presented with information did not diminish their intentions to undergo screening. Informed decision making before initiating screening mammography is limited in this setting. There appears to be little indication that information about the benefits and harms decreases women's intentions to undergo screening. Methods to communicate information to women before initiating screening mammography are needed.

An integrated review of the correlation between critical thinking ability and clinical decision-making in nursing.

PubMed

Lee, Daphne Sk; Abdullah, Khatijah Lim; Subramanian, Pathmawathi; Bachmann, Robert Thomas; Ong, Swee Leong

2017-12-01

To explore whether there is a correlation between critical thinking ability and clinical decision-making among nurses. Critical thinking is currently considered as an essential component of nurses' professional judgement and clinical decision-making. If confirmed, nursing curricula may be revised emphasising on critical thinking with the expectation to improve clinical decision-making and thus better health care. Integrated literature review. The integrative review was carried out after a comprehensive literature search using electronic databases Ovid, EBESCO MEDLINE, EBESCO CINAHL, PROQuest and Internet search engine Google Scholar. Two hundred and 22 articles from January 1980 to end of 2015 were retrieved. All studies evaluating the relationship between critical thinking and clinical decision-making, published in English language with nurses or nursing students as the study population, were included. No qualitative studies were found investigating the relationship between critical thinking and clinical decision-making, while 10 quantitative studies met the inclusion criteria and were further evaluated using the Quality Assessment and Validity Tool. As a result, one study was excluded due to a low-quality score, with the remaining nine accepted for this review. Four of nine studies established a positive relationship between critical thinking and clinical decision-making. Another five studies did not demonstrate a significant correlation. The lack of refinement in studies' design and instrumentation were arguably the main reasons for the inconsistent results. Research studies yielded contradictory results as regard to the relationship between critical thinking and clinical decision-making; therefore, the evidence is not convincing. Future quantitative studies should have representative sample size, use critical thinking measurement tools related to the healthcare sector and evaluate the predisposition of test takers towards their willingness and ability to think. There is also a need for qualitative studies to provide a fresh approach in exploring the relationship between these variables uncovering currently unknown contributing factors. This review confirmed that evidence to support the existence of relationships between critical thinking and clinical decision-making is still unsubstantiated. Therefore, it serves as a call for nurse leaders and nursing academics to produce quality studies in order to firmly support or reject the hypothesis that there is a statistically significant correlation between critical thinking and clinical decision-making. © 2017 John Wiley & Sons Ltd.

Shared decision-making in home-care from the nurse's perspective: sitting at the kitchen table--a qualitative descriptive study.

PubMed

Truglio-Londrigan, Marie

2013-10-01

To come to know, understand and describe the experience of shared decision-making in home-care from the nurse's perspective. The literature presents the concept of shared decision-making as a complex process characterised by a partnership between the healthcare provider and the patient, which is participatory and action oriented with education and negotiation leading to agreement. Few studies have been carried out to explore and describe the events that make up the experiences of shared decision-making in home-care from the nurse's perspective. A qualitative descriptive study was implemented. Semi structured interviews were performed with 10 home-care nurses who were asked to reflect on a time in their practice when they were involved in a shared decision-making process with their patient. All data were analysed using Colaizzi's method. The following Themes were uncovered: Begin where the patient is; Education for shared decision-making; The village and shared decision-making; and Whose decision is it? Each of the four Themes contained Subthemes. The findings of this study present shared decision-making as a complex, multidimensional and fluid process. A thorough understanding of shared decision-making is essential within the multiple contexts in which care is delivered. Nurses in clinical practice need to know and understand the events of the experience of shared decision-making. A more comprehensive understanding of these facts can assist home-care nurses in their practice with regard to the application of shared decision-making. © 2013 Blackwell Publishing Ltd.

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

Clinical Decision Making and Mental Health Service Use Among Persons With Severe Mental Illness Across Europe.

PubMed

Cosh, Suzanne; Zenter, Nadja; Ay, Esra-Sultan; Loos, Sabine; Slade, Mike; De Rosa, Corrado; Luciano, Mario; Berecz, Roland; Glaub, Theodora; Munk-Jørgensen, Povl; Krogsgaard Bording, Malene; Rössler, Wulf; Kawohl, Wolfram; Puschner, Bernd

2017-09-01

The study explored relationships between preferences for and experiences of clinical decision making (CDM) with service use among persons with severe mental illness. Data from a prospective observational study in six European countries were examined. Associations of baseline staff-rated (N=213) and patient-rated (N=588) preferred and experienced decision making with service use were examined at baseline by using binomial regressions and at 12-month follow-up by using multilevel models. A preference by patients and staff for active patient involvement in decision making, rather than shared or passive decision making, was associated with longer hospital admissions and higher costs at baseline and with increases in admissions over 12 months (p=.043). Low patient-rated satisfaction with an experienced clinical decision was also related to increased costs over the study period (p=.005). A preference for shared decision making may reduce health care costs by reducing inpatient admissions. Patient satisfaction with decisions was a predictor of costs, and clinicians should maximize patient satisfaction with CDM.

The cognitive processes underpinning clinical decision in triage assessment: a theoretical conundrum?

PubMed

Noon, Amy J

2014-01-01

High quality clinical decision-making (CDM) has been highlighted as a priority across the nursing profession. Triage nurses, in the Accident and Emergency (A&E) department, work in considerable levels of uncertainty and require essential skills including: critical thinking, evaluation and decision-making. The content of this paper aims to promote awareness of how triage nurses make judgements and decisions in emergency situations. By exploring relevant literature on clinical judgement and decision-making theory, this paper demonstrates the importance of high quality decision-making skills underpinning the triage nurse's role. Having an awareness of how judgements and decisions are made is argued as essential, in a time where traditional nurse boundaries and responsibilities are never more challenged. It is hoped that the paper not only raises this awareness in general but also, in particular, engages the triage nurse to look more critically at how they make their own decisions in their everyday practice. Copyright © 2013 Elsevier Ltd. All rights reserved.

[Clinical reasoning in nursing, concept analysis].

PubMed

Côté, Sarah; St-Cyr Tribble, Denise

2012-12-01

Nurses work in situations of complex care requiring great clinical reasoning abilities. In literature, clinical reasoning is often confused with other concepts and it has no consensual definition. To conduct a concept analysis of a nurse's clinical reasoning in order to clarify, define and distinguish it from the other concepts as well as to better understand clinical reasoning. Rodgers's method of concept analysis was used, after literature was retrieved with the use of clinical reasoning, concept analysis, nurse, intensive care and decision making as key-words. The use of cognition, cognitive strategies, a systematic approach of analysis and data interpretation, generating hypothesis and alternatives are attributes of clinical reasoning. The antecedents are experience, knowledge, memory, cues, intuition and data collection. The consequences are decision making, action, clues and problem resolution. This concept analysis helped to define clinical reasoning, to distinguish it from other concepts used synonymously and to guide future research.

[Clinical decision making and critical thinking in the nursing diagnostic process].

PubMed

Müller-Staub, Maria

2006-10-01

The daily routine requires complex thinking processes of nurses, but clinical decision making and critical thinking are underestimated in nursing. A great demand for educational measures in clinical judgement related with the diagnostic process was found in nurses. The German literature hardly describes nursing diagnoses as clinical judgements about human reactions on health problems / life processes. Critical thinking is described as an intellectual, disciplined process of active conceptualisation, application and synthesis of information. It is gained through observation, experience, reflection and communication and leads thinking and action. Critical thinking influences the aspects of clinical decision making a) diagnostic judgement, b) therapeutic reasoning and c) ethical decision making. Human reactions are complex processes and in their course, human behavior is interpreted in the focus of health. Therefore, more attention should be given to the nursing diagnostic process. This article presents the theoretical framework of the paper "Clinical decision making: Fostering critical thinking in the nursing diagnostic process through case studies".

Multimorbidity, clinical decision making and health care delivery in New Zealand Primary care: a qualitative study.

PubMed

Stokes, Tim; Tumilty, Emma; Doolan-Noble, Fiona; Gauld, Robin

2017-04-05

Multimorbidity is a major issue for primary care. We aimed to explore primary care professionals' accounts of managing multimorbidity and its impact on clinical decision making and regional health care delivery. Qualitative interviews with 12 General Practitioners and 4 Primary Care Nurses in New Zealand's Otago region. Thematic analysis was conducted using the constant comparative method. Primary care professionals encountered challenges in providing care to patients with multimorbidity with respect to both clinical decision making and health care delivery. Clinical decision making occurred in time-limited consultations where the challenges of complexity and inadequacy of single disease guidelines were managed through the use of "satisficing" (care deemed satisfactory and sufficient for a given patient) and sequential consultations utilising relational continuity of care. The New Zealand primary care co-payment funding model was seen as a barrier to the delivery of care as it discourages sequential consultations, a problem only partially addressed through the use of the additional capitation based funding stream of Care Plus. Fragmentation of care also occurred within general practice and across the primary/secondary care interface. These findings highlight specific New Zealand barriers to the delivery of primary care to patients living with multimorbidity. There is a need to develop, implement and nationally evaluate a revised version of Care Plus that takes account of these barriers.

Driving with roadmaps and dashboards: using information resources to structure the decision models in service organizations.

PubMed

Chorpita, Bruce F; Bernstein, Adam; Daleiden, Eric L

2008-03-01

This paper illustrates the application of design principles for tools that structure clinical decision-making. If the effort to implement evidence-based practices in community services organizations is to be effective, attention must be paid to the decision-making context in which such treatments are delivered. Clinical research trials commonly occur in an environment characterized by structured decision making and expert supports. Technology has great potential to serve mental health organizations by supporting these potentially important contextual features of the research environment, through organization and reporting of clinical data into interpretable information to support decisions and anchor decision-making procedures. This article describes one example of a behavioral health reporting system designed to facilitate clinical and administrative use of evidence-based practices. The design processes underlying this system-mapping of decision points and distillation of performance information at the individual, caseload, and organizational levels-can be implemented to support clinical practice in a wide variety of settings.

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

PubMed

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

2018-03-01

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

Classifying clinical decision making: interpreting nursing intuition, heuristics and medical diagnosis.

PubMed

Buckingham, C D; Adams, A

2000-10-01

This is the second of two linked papers exploring decision making in nursing. The first paper, 'Classifying clinical decision making: a unifying approach' investigated difficulties with applying a range of decision-making theories to nursing practice. This is due to the diversity of terminology and theoretical concepts used, which militate against nurses being able to compare the outcomes of decisions analysed within different frameworks. It is therefore problematic for nurses to assess how good their decisions are, and where improvements can be made. However, despite the range of nomenclature, it was argued that there are underlying similarities between all theories of decision processes and that these should be exposed through integration within a single explanatory framework. A proposed solution was to use a general model of psychological classification to clarify and compare terms, concepts and processes identified across the different theories. The unifying framework of classification was described and this paper operationalizes it to demonstrate how different approaches to clinical decision making can be re-interpreted as classification behaviour. Particular attention is focused on classification in nursing, and on re-evaluating heuristic reasoning, which has been particularly prone to theoretical and terminological confusion. Demonstrating similarities in how different disciplines make decisions should promote improved multidisciplinary collaboration and a weakening of clinical elitism, thereby enhancing organizational effectiveness in health care and nurses' professional status. This is particularly important as nurses' roles continue to expand to embrace elements of managerial, medical and therapeutic work. Analysing nurses' decisions as classification behaviour will also enhance clinical effectiveness, and assist in making nurses' expertise more visible. In addition, the classification framework explodes the myth that intuition, traditionally associated with nurses' decision making, is less rational and scientific than other approaches.

Midwives׳ clinical reasoning during second stage labour: Report on an interpretive study.

PubMed

Jefford, Elaine; Fahy, Kathleen

2015-05-01

clinical reasoning was once thought to be the exclusive domain of medicine - setting it apart from 'non-scientific' occupations like midwifery. Poor assessment, clinical reasoning and decision-making skills are well known contributors to adverse outcomes in maternity care. Midwifery decision-making models share a common deficit: they are insufficiently detailed to guide reasoning processes for midwives in practice. For these reasons we wanted to explore if midwives actively engaged in clinical reasoning processes within their clinical practice and if so to what extent. The study was conducted using post structural, feminist methodology. to what extent do midwives engage in clinical reasoning processes when making decisions in the second stage labour? twenty-six practising midwives were interviewed. Feminist interpretive analysis was conducted by two researchers guided by the steps of a model of clinical reasoning process. Six narratives were excluded from analysis because they did not sufficiently address the research question. The midwives narratives were prepared via data reduction. A theoretically informed analysis and interpretation was conducted. using a feminist, interpretive approach we created a model of midwifery clinical reasoning grounded in the literature and consistent with the data. Thirteen of the 20 participant narratives demonstrate analytical clinical reasoning abilities but only nine completed the process and implemented the decision. Seven midwives used non-analytical decision-making without adequately checking against assessment data. over half of the participants demonstrated the ability to use clinical reasoning skills. Less than half of the midwives demonstrated clinical reasoning as their way of making decisions. The new model of Midwifery Clinical Reasoning includes 'intuition' as a valued way of knowing. Using intuition, however, should not replace clinical reasoning which promotes through decision-making can be made transparent and be consensually validated. Copyright © 2015 Elsevier Ltd. All rights reserved.

Development of a model to guide decision making in amyotrophic lateral sclerosis multidisciplinary care.

PubMed

Hogden, Anne; Greenfield, David; Nugus, Peter; Kiernan, Matthew C

2015-10-01

Patients with amyotrophic lateral sclerosis (ALS) face numerous decisions for symptom management and quality of life. Models of decision making in chronic disease and cancer care are insufficient for the complex and changing needs of patients with ALS . The aim was to examine the question: how can decision making that is both effective and patient-centred be enacted in ALS multidisciplinary care? Fifty-four respondents (32 health professionals, 14 patients and eight carers) from two specialized ALS multidisciplinary clinics participated in semi-structured interviews. Interviews were transcribed, coded and analysed thematically. Comparison of stakeholder perspectives revealed six key themes of ALS decision making. These were the decision-making process; patient-centred focus; timing and planning; information sources; engagement with specialized ALS services; and access to non-specialized services. A model, embedded in the specialized ALS multidisciplinary clinic, was derived to guide patient decision making. The model is cyclic, with four stages: 'Participant Engagement'; 'Option Information'; 'Option Deliberation'; and 'Decision Implementation'. Effective and patient-centred decision making is enhanced by the structure of the specialized ALS clinic, which promotes patients' symptom management and quality of life goals. However, patient and carer engagement in ALS decision making is tested by the dynamic nature of ALS, and patient and family distress. Our model optimizes patient-centred decision making, by incorporating patients' cyclic decision-making patterns and facilitating carer inclusion in decision processes. The model captures the complexities of patient-centred decision making in ALS. The framework can assist patients and carers, health professionals, researchers and policymakers in this challenging disease environment. © 2013 John Wiley & Sons Ltd.

CorRECTreatment: A Web-based Decision Support Tool for Rectal Cancer Treatment that Uses the Analytic Hierarchy Process and Decision Tree

PubMed Central

Karakülah, G.; Dicle, O.; Sökmen, S.; Çelikoğlu, C.C.

2015-01-01

Summary Background The selection of appropriate rectal cancer treatment is a complex multi-criteria decision making process, in which clinical decision support systems might be used to assist and enrich physicians’ decision making. Objective The objective of the study was to develop a web-based clinical decision support tool for physicians in the selection of potentially beneficial treatment options for patients with rectal cancer. Methods The updated decision model contained 8 and 10 criteria in the first and second steps respectively. The decision support model, developed in our previous study by combining the Analytic Hierarchy Process (AHP) method which determines the priority of criteria and decision tree that formed using these priorities, was updated and applied to 388 patients data collected retrospectively. Later, a web-based decision support tool named corRECTreatment was developed. The compatibility of the treatment recommendations by the expert opinion and the decision support tool was examined for its consistency. Two surgeons were requested to recommend a treatment and an overall survival value for the treatment among 20 different cases that we selected and turned into a scenario among the most common and rare treatment options in the patient data set. Results In the AHP analyses of the criteria, it was found that the matrices, generated for both decision steps, were consistent (consistency ratio<0.1). Depending on the decisions of experts, the consistency value for the most frequent cases was found to be 80% for the first decision step and 100% for the second decision step. Similarly, for rare cases consistency was 50% for the first decision step and 80% for the second decision step. Conclusions The decision model and corRECTreatment, developed by applying these on real patient data, are expected to provide potential users with decision support in rectal cancer treatment processes and facilitate them in making projections about treatment options. PMID:25848413

Problems and Processes in Medical Encounters: The CASES method of dialogue analysis

PubMed Central

Laws, M. Barton; Taubin, Tatiana; Bezreh, Tanya; Lee, Yoojin; Beach, Mary Catherine; Wilson, Ira B.

2013-01-01

Objective To develop methods to reliably capture structural and dynamic temporal features of clinical interactions. Methods Observational study of 50 audio-recorded routine outpatient visits to HIV specialty clinics, using innovative analytic methods. The Comprehensive Analysis of the Structure of Encounters System (CASES) uses transcripts coded for speech acts, then imposes larger-scale structural elements: threads – the problems or issues addressed; and processes within threads –basic tasks of clinical care labeled Presentation, Information, Resolution (decision making) and Engagement (interpersonal exchange). Threads are also coded for the nature of resolution. Results 61% of utterances are in presentation processes. Provider verbal dominance is greatest in information and resolution processes, which also contain a high proportion of provider directives. About half of threads result in no action or decision. Information flows predominantly from patient to provider in presentation processes, and from provider to patient in information processes. Engagement is rare. Conclusions In this data, resolution is provider centered; more time for patient participation in resolution, or interpersonal engagement, would have to come from presentation. Practice Implications Awareness of the use of time in clinical encounters, and the interaction processes associated with various tasks, may help make clinical communication more efficient and effective. PMID:23391684

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

PubMed

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

2016-06-01

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

Influences on women's decision making about intrauterine device use in Madagascar.

PubMed

Gottert, Ann; Jacquin, Karin; Rahaivondrafahitra, Bakoly; Moracco, Kathryn; Maman, Suzanne

2015-04-01

We explored influences on decision making about intrauterine device (IUD) use among women in the Women's Health Project (WHP), managed by Population Services International in Madagascar. We conducted six small group photonarrative discussions (n=18 individuals) and 12 individual in-depth interviews with women who were IUD users and nonusers. All participants had had contact with WHP counselors in three sites in Madagascar. Data analysis involved creating summaries of each transcript, coding in Atlas.ti and then synthesizing findings in a conceptual model. We identified three stages of women's decision making about IUD use, and specific forms of social support that seemed helpful at each stage. During the first stage, receiving correct information from a trusted source such as a counselor conveys IUD benefits and corrects misinformation, but lingering fears about the method often appeared to delay method adoption among interested women. During the second stage, hearing testimony from satisfied users and receiving ongoing emotional support appeared to help alleviate these fears. During the third stage, accompaniment by a counselor or peer seemed to help some women gain confidence to go to the clinic to receive the IUD. Identifying and supplying the types of social support women find helpful at different stages of the decision-making process could help program managers better respond to women's staged decision-making process about IUD use. This qualitative study suggests that women in Madagascar perceive multiple IUD benefits but also fear the method even after misinformation is corrected, leading to a staged decision-making process about IUD use. Programs should identify and supply the types of social support that women find helpful at each stage of decision making. Copyright © 2015 Elsevier Inc. All rights reserved.

Connecting clinical and actuarial prediction with rule-based methods.

PubMed

Fokkema, Marjolein; Smits, Niels; Kelderman, Henk; Penninx, Brenda W J H

2015-06-01

Meta-analyses comparing the accuracy of clinical versus actuarial prediction have shown actuarial methods to outperform clinical methods, on average. However, actuarial methods are still not widely used in clinical practice, and there has been a call for the development of actuarial prediction methods for clinical practice. We argue that rule-based methods may be more useful than the linear main effect models usually employed in prediction studies, from a data and decision analytic as well as a practical perspective. In addition, decision rules derived with rule-based methods can be represented as fast and frugal trees, which, unlike main effects models, can be used in a sequential fashion, reducing the number of cues that have to be evaluated before making a prediction. We illustrate the usability of rule-based methods by applying RuleFit, an algorithm for deriving decision rules for classification and regression problems, to a dataset on prediction of the course of depressive and anxiety disorders from Penninx et al. (2011). The RuleFit algorithm provided a model consisting of 2 simple decision rules, requiring evaluation of only 2 to 4 cues. Predictive accuracy of the 2-rule model was very similar to that of a logistic regression model incorporating 20 predictor variables, originally applied to the dataset. In addition, the 2-rule model required, on average, evaluation of only 3 cues. Therefore, the RuleFit algorithm appears to be a promising method for creating decision tools that are less time consuming and easier to apply in psychological practice, and with accuracy comparable to traditional actuarial methods. (c) 2015 APA, all rights reserved).

Making reasonable decisions: a qualitative study of medical decision making in the care of patients with a clinically significant haemoglobin disorder.

PubMed

Crowther, Helen J; Kerridge, Ian

2015-10-01

Therapies utilized in patients with clinically significant haemoglobin disorders appear to vary between clinicians and units. This study aimed to investigate the processes of evidence implementation and medical decision making in the care of such patients in NSW, Australia. Using semi-structured interviews, 11 haematologists discussed their medical decision-making processes with particular attention paid to the use of published evidence. Transcripts were thematically analysed by a single investigator on a line-by-line basis. Decision making surrounding the care of patients with significant haemoglobin disorders varied and was deeply contextual. Three main determinants of clinical decision making were identified - factors relating to the patient and to their illness, factors specific to the clinician and the institution in which they were practising and factors related to the notion of evidence and to utility and role of evidence-based medicine in clinical practice. Clinicians pay considerable attention to medical decision making and evidence incorporation and attempt to tailor these to particular patient contexts. However, the patient context is often inferred and when discordant with the clinician's own contexture can lead to discomfort with decision recommendations. Clinicians strive to improve comfort through the use of experience and trustworthy evidence. © 2015 John Wiley & Sons, Ltd.

Applying strategies from libertarian paternalism to decision making for prostate specific antigen (PSA) screening

PubMed Central

2011-01-01

Background Despite the recent publication of results from two randomized clinical trials, prostate specific antigen (PSA) screening for prostate cancer remains a controversial issue. There is lack of agreement across studies that PSA screening significantly reduces prostate cancer mortality. In spite of these facts, the widespread use of PSA testing in the United States leads to overdetection and overtreatment of clinically indolent prostate cancer, and its associated harms of incontinence and impotence. Discussion Given the inconclusive results from clinical trials and incongruent PSA screening guidelines, the decision to screen for prostate cancer with PSA testing is an uncertain one for patients and health care providers. Screening guidelines from some health organizations recommend an informed decision making (IDM) or shared decision making (SDM) approach for deciding on PSA screening. These approaches aim to empower patients to choose among the available options by making them active participants in the decision making process. By increasing involvement of patients in the clinical decision-making process, IDM/SDM places more of the responsibility for a complex decision on the patient. Research suggests, however, that patients are not well-informed of the harms and benefits associated with prostate cancer screening and are also subject to an assortment of biases, emotion, fears, and irrational thought that interferes with making an informed decision. In response, the IDM/SDM approaches can be augmented with strategies from the philosophy of libertarian paternalism (LP) to improve decision making. LP uses the insights of behavioural economics to help people better make better choices. Some of the main strategies of LP applicable to PSA decision making are a default decision rule, framing of decision aids, and timing of the decision. In this paper, we propose that applying strategies from libertarian paternalism can help with PSA screening decision-making. Summary Our proposal to augment IDM and SDM approaches with libertarian paternalism strategies is intended to guide patients toward a better decision about testing while maintaining personal freedom of choice. While PSA screening remains controversial and evidence conflicting, a libertarian-paternalism influenced approach to decision making can help prevent the overdiagnosis and overtreatment of prostate cancer. PMID:21510865

Applying strategies from libertarian paternalism to decision making for prostate specific antigen (PSA) screening.

PubMed

Wheeler, David C; Szymanski, Konrad M; Black, Amanda; Nelson, David E

2011-04-21

Despite the recent publication of results from two randomized clinical trials, prostate specific antigen (PSA) screening for prostate cancer remains a controversial issue. There is lack of agreement across studies that PSA screening significantly reduces prostate cancer mortality. In spite of these facts, the widespread use of PSA testing in the United States leads to overdetection and overtreatment of clinically indolent prostate cancer, and its associated harms of incontinence and impotence. Given the inconclusive results from clinical trials and incongruent PSA screening guidelines, the decision to screen for prostate cancer with PSA testing is an uncertain one for patients and health care providers. Screening guidelines from some health organizations recommend an informed decision making (IDM) or shared decision making (SDM) approach for deciding on PSA screening. These approaches aim to empower patients to choose among the available options by making them active participants in the decision making process. By increasing involvement of patients in the clinical decision-making process, IDM/SDM places more of the responsibility for a complex decision on the patient. Research suggests, however, that patients are not well-informed of the harms and benefits associated with prostate cancer screening and are also subject to an assortment of biases, emotion, fears, and irrational thought that interferes with making an informed decision. In response, the IDM/SDM approaches can be augmented with strategies from the philosophy of libertarian paternalism (LP) to improve decision making. LP uses the insights of behavioural economics to help people better make better choices. Some of the main strategies of LP applicable to PSA decision making are a default decision rule, framing of decision aids, and timing of the decision. In this paper, we propose that applying strategies from libertarian paternalism can help with PSA screening decision-making. Our proposal to augment IDM and SDM approaches with libertarian paternalism strategies is intended to guide patients toward a better decision about testing while maintaining personal freedom of choice. While PSA screening remains controversial and evidence conflicting, a libertarian-paternalism influenced approach to decision making can help prevent the overdiagnosis and overtreatment of prostate cancer.

Legal Considerations in Clinical Decision Making.

ERIC Educational Resources Information Center

Ursu, Samuel C.

1992-01-01

Discussion of legal issues in dental clinical decision making looks at the nature and elements of applicable law, especially malpractice, locus of responsibility, and standards of care. Greater use of formal decision analysis in clinical dentistry and better research on diagnosis and treatment are recommended, particularly in light of increasing…

Does accountability for reasonableness work? A protocol for a mixed methods study using an audit tool to evaluate the decision-making of clinical commissioning groups in England.

PubMed

Kieslich, Katharina; Littlejohns, Peter

2015-07-10

Clinical commissioning groups (CCGs) in England are tasked with making difficult decisions on which healthcare services to provide against the background of limited budgets. The question is how to ensure that these decisions are fair and legitimate. Accounts of what constitutes fair and legitimate priority setting in healthcare include Daniels' and Sabin's accountability for reasonableness (A4R) and Clark's and Weale's framework for the identification of social values. This study combines these accounts and asks whether the decisions of those CCGs that adhere to elements of such accounts are perceived as fairer and more legitimate by key stakeholders. The study addresses the empirical gap arising from a lack of research on whether frameworks such as A4R hold what they promise. It aims to understand the criteria that feature in CCG decision-making. Finally, it examines the usefulness of a decision-making audit tool (DMAT) in identifying the process and content criteria that CCGs apply when making decisions. The adherence of a sample of CCGs to criteria emerging from theories of fair priority setting will be examined using the DMAT developed by PL. The results will be triangulated with data from semistructured interviews with key stakeholders in the CCG sample to ascertain whether there is a correlation between those CCGs that performed well in the DMAT exercise and those whose decisions are perceived positively by interviewees. Descriptive statistical methods will be used to analyse the DMAT data. A combination of quantitative and qualitative content analysis methods will be used to analyse the interview transcripts. Full ethics approval was received by the King's College London Biomedical Sciences, Dentistry, Medicine and Natural and Mathematical Sciences Research Ethics Subcommittee. The results of the study will be disseminated through publications in peer review journals. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Using the modified Delphi method to establish clinical consensus for the diagnosis and treatment of patients with rotator cuff pathology.

PubMed

Eubank, Breda H; Mohtadi, Nicholas G; Lafave, Mark R; Wiley, J Preston; Bois, Aaron J; Boorman, Richard S; Sheps, David M

2016-05-20

Patients presenting to the healthcare system with rotator cuff pathology do not always receive high quality care. High quality care occurs when a patient receives care that is accessible, appropriate, acceptable, effective, efficient, and safe. The aim of this study was twofold: 1) to develop a clinical pathway algorithm that sets forth a stepwise process for making decisions about the diagnosis and treatment of rotator cuff pathology presenting to primary, secondary, and tertiary healthcare settings; and 2) to establish clinical practice guidelines for the diagnosis and treatment of rotator cuff pathology to inform decision-making processes within the algorithm. A three-step modified Delphi method was used to establish consensus. Fourteen experts representing athletic therapy, physiotherapy, sport medicine, and orthopaedic surgery were invited to participate as the expert panel. In round 1, 123 best practice statements were distributed to the panel. Panel members were asked to mark "agree" or "disagree" beside each statement, and provide comments. The same voting method was again used for round 2. Round 3 consisted of a final face-to-face meeting. In round 1, statements were grouped and reduced to 44 statements that met consensus. In round 2, five statements reached consensus. In round 3, ten statements reached consensus. Consensus was reached for 59 statements representing five domains: screening, diagnosis, physical examination, investigations, and treatment. The final face-to-face meeting was also used to develop clinical pathway algorithms (i.e., clinical care pathways) for three types of rotator cuff pathology: acute, chronic, and acute-on-chronic. This consensus guideline will help to standardize care, provide guidance on the diagnosis and treatment of rotator cuff pathology, and assist in clinical decision-making for all healthcare professionals.

Barriers to and facilitators of implementing shared decision making and decision support in a paediatric hospital: A descriptive study.

PubMed

Boland, Laura; McIsaac, Daniel I; Lawson, Margaret L

2016-04-01

To explore multiple stakeholders' perceived barriers to and facilitators of implementing shared decision making and decision support in a tertiary paediatric hospital. An interpretive descriptive qualitative study was conducted using focus groups and interviews to examine senior hospital administrators', clinicians', parents' and youths' perceived barriers to and facilitators of shared decision making and decision support implementation. Data were analyzed using inductive thematic analysis. Fifty-seven stakeholders participated. Six barrier and facilitator themes emerged. The main barrier was gaps in stakeholders' knowledge of shared decision making and decision support. Facilitators included compatibility between shared decision making and the hospital's culture and ideal practices, perceptions of positive patient and family outcomes associated with shared decision making, and positive attitudes regarding shared decision making and decision support. However, youth attitudes regarding the necessity and usefulness of a decision support program were a barrier. Two themes were both a barrier and a facilitator. First, stakeholder groups were uncertain which clinical situations are suitable for shared decision making (eg, new diagnoses, chronic illnesses, complex decisions or urgent decisions). Second, the clinical process may be hindered if shared decision making and decision support decrease efficiency and workflow; however, shared decision making may reduce repeat visits and save time over the long term. Specific knowledge translation strategies that improve shared decision making knowledge and match specific barriers identified by each stakeholder group may be required to promote successful shared decision making and decision support implementation in the authors' paediatric hospital.

Deriving the expected utility of a predictive model when the utilities are uncertain.

PubMed

Cooper, Gregory F; Visweswaran, Shyam

2005-01-01

Predictive models are often constructed from clinical databases with the goal of eventually helping make better clinical decisions. Evaluating models using decision theory is therefore natural. When constructing a model using statistical and machine learning methods, however, we are often uncertain about precisely how the model will be used. Thus, decision-independent measures of classification performance, such as the area under an ROC curve, are popular. As a complementary method of evaluation, we investigate techniques for deriving the expected utility of a model under uncertainty about the model's utilities. We demonstrate an example of the application of this approach to the evaluation of two models that diagnose coronary artery disease.

Towards public health decision support: a systematic review of bidirectional communication approaches

PubMed Central

Dixon, Brian E; Gamache, Roland E; Grannis, Shaun J

2013-01-01

Objective To summarize the literature describing computer-based interventions aimed at improving bidirectional communication between clinical and public health. Materials and Methods A systematic review of English articles using MEDLINE and Google Scholar. Search terms included public health, epidemiology, electronic health records, decision support, expert systems, and decision-making. Only articles that described the communication of information regarding emerging health threats from public health agencies to clinicians or provider organizations were included. Each article was independently reviewed by two authors. Results Ten peer-reviewed articles highlight a nascent but promising area of research and practice related to alerting clinicians about emerging threats. Current literature suggests that additional research and development in bidirectional communication infrastructure should focus on defining a coherent architecture, improving interoperability, establishing clear governance, and creating usable systems that will effectively deliver targeted, specific information to clinicians in support of patient and population decision-making. Conclusions Increasingly available clinical information systems make it possible to deliver timely, relevant knowledge to frontline clinicians in support of population health. Future work should focus on developing a flexible, interoperable infrastructure for bidirectional communications capable of integrating public health knowledge into clinical systems and workflows. PMID:23467470

"In the physio we trust": A qualitative study on patients' preferences for physiotherapy.

PubMed

Bernhardsson, Susanne; Larsson, Maria E H; Johansson, Kajsa; Öberg, Birgitta

2017-07-01

Patients' preferences should be integrated in evidence-based practice. This study aimed to explore patients' preferences for physiotherapy treatment and participation in decision making. A qualitative study set in an urban physiotherapy clinic in Gothenburg, Sweden. Individual, semi-structured interviews were conducted with 20 individuals who sought physiotherapy for musculoskeletal disorders. The interviews were recorded, transcribed, and analyzed with qualitative content analysis. An overarching theme, embracing six categories, was conceptualized: Trust in the physiotherapist fosters active engagement in therapy. The participants preferred active treatment strategies such as exercise and advice for self-management, allowing them to actively engage in their therapy. Some preferred passive treatments. Key influencers on treatment preferences were previous experiences and media. All participants wanted to be involved in the clinical decision making, but to varying extents. Some expressed a preference for an active role and wanting to share decisions while others were content with a passive role. Expectations for a professional management were reflected in trust and confidence in physiotherapists' skills and competence, expectations for good outcomes, and believing that treatment methods should be evidence-based. Trust in the physiotherapist's competence, as well as a desire to participate in clinical decision making, fosters active engagement in physiotherapy.

Modelling emergency decisions: recognition-primed decision making. The literature in relation to an ophthalmic critical incident.

PubMed

Bond, Susan; Cooper, Simon

2006-08-01

To review and reflect on the literature on recognition-primed decision (RPD) making and influences on emergency decisions with particular reference to an ophthalmic critical incident involving the sub-arachnoid spread of local anaesthesia following the peribulbar injection. This paper critics the literature on recognition-primed decision making, with particular reference to emergency situations. It illustrates the findings by focussing on an ophthalmic critical incident. Systematic literature review with critical incident reflection. Medline, CINAHL and PsychINFO databases were searched for papers on recognition-primed decision making (1996-2004) followed by the 'snowball method'. Studies were selected in accordance with preset criteria. A total of 12 papers were included identifying the recognition-primed decision making as a good theoretical description of acute emergency decisions. In addition, cognitive resources, situational awareness, stress, team support and task complexity were identified as influences on the decision process. Recognition-primed decision-making theory describes the decision processes of experts in time-bound emergency situations and is the foundation for a model of emergency decision making (Fig. 2). Decision theory and models, in this case related to emergency situations, inform practice and enhance clinical effectiveness. The critical incident described highlights the need for nurses to have a comprehensive and in-depth understanding of anaesthetic techniques as well as an ability to manage and resuscitate patients autonomously. In addition, it illustrates how the critical incidents should influence the audit cycle with improvements in patient safety.

Surrogate biochemical markers: precise measurement for strategic drug and biologics development.

PubMed

Lee, J W; Hulse, J D; Colburn, W A

1995-05-01

More efficient drug and biologics development is necessary for future success of pharmaceutical and biotechnology companies. One way to achieve this objective is to use rationally selected surrogate markers to improve the early decision-making process. Using typical clinical chemistry methods to measure biochemical markers may not ensure adequate precision and reproducibility. In contrast, using analytical methods that meet good laboratory practices along with rational selection and validation of biochemical markers can give those who use them a competitive advantage over those who do not by providing meaningful data for earlier decision making.

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…

The value of arthrography in the decision-making process regarding surgery for internal derangement of the temporomandibular joint.

PubMed

Nitzan, D W; Dolwick, F M; Marmary, Y

1991-04-01

In this study, the clinical and arthrographic findings from 43 internally deranged temporomandibular joints (TMJs) were compared with the intra-surgical observations. In 40 of 43 joints, arthrography did not provide any additional information useful for diagnosis or treatment. In six joints, the problem was misdiagnosed. Only in three joints did arthrography demonstrate the existence of perforation in the posterior attachment that had not been suspected during the clinical examination. Because of the doubtful importance of arthrographic information for the decision-making process, it is suggested that the method be applied only in cases in which clinical examination and plain radiographs have failed to uncover the signs and symptoms indicative of a TMJ disorder.

Bayesian imperfect information analysis for clinical recurrent data

PubMed Central

Chang, Chih-Kuang; Chang, Chi-Chang

2015-01-01

In medical research, clinical practice must often be undertaken with imperfect information from limited resources. This study applied Bayesian imperfect information-value analysis to realistic situations to produce likelihood functions and posterior distributions, to a clinical decision-making problem for recurrent events. In this study, three kinds of failure models are considered, and our methods illustrated with an analysis of imperfect information from a trial of immunotherapy in the treatment of chronic granulomatous disease. In addition, we present evidence toward a better understanding of the differing behaviors along with concomitant variables. Based on the results of simulations, the imperfect information value of the concomitant variables was evaluated and different realistic situations were compared to see which could yield more accurate results for medical decision-making. PMID:25565853

The role of clinician emotion in clinical reasoning: Balancing the analytical process.

PubMed

Langridge, Neil; Roberts, Lisa; Pope, Catherine

2016-02-01

This review paper identifies and describes the role of clinicians' memory, emotions and physical responses in clinical reasoning processes. Clinical reasoning is complex and multi-factorial and key models of clinical reasoning within musculoskeletal physiotherapy are discussed, highlighting the omission of emotion and subsequent physical responses and how these can impact upon a clinician when making a decision. It is proposed that clinicians should consider the emotions associated with decision-making, especially when there is concern surrounding a presentation. Reflecting on practice in the clinical environment and subsequently applying this to a patient presentation should involve some acknowledgement of clinicians' physical responses, emotions and how they may play a part in any decision made. Presenting intuition and gut-feeling as separate reasoning methods and how these processes co-exist with other more accepted reasoning such as hypothetico-deductive is also discussed. Musculoskeletal physiotherapy should consider the elements of feelings, emotions and physical responses when applying reflective practice principles. Furthermore, clinicians dealing with difficult and challenging presentations should look at the emotional as well as the analytical experience when justifying decisions and learning from practice. Copyright © 2015 Elsevier Ltd. All rights reserved.

Assessment of Competence in Clinical Reasoning and Decision-Making under Uncertainty: The Script Concordance Test Method

ERIC Educational Resources Information Center

Ramaekers, Stephan; Kremer, Wim; Pilot, Albert; van Beukelen, Peter; van Keulen, Hanno

2010-01-01

Real-life, complex problems often require that decisions are made despite limited information or insufficient time to explore all relevant aspects. Incorporating authentic uncertainties into an assessment, however, poses problems in establishing results and analysing their methodological qualities. This study aims at developing a test on clinical…

Critical thinking: concept analysis from the perspective of Rodger's evolutionary method of concept analysis

PubMed Central

Carbogim, Fábio da Costa; de Oliveira, Larissa Bertacchini; Püschel, Vilanice Alves de Araújo

2016-01-01

ABSTRACT Objective: to analyze the concept of critical thinking (CT) in Rodger's evolutionary perspective. Method: documentary research undertaken in the Cinahl, Lilacs, Bdenf and Dedalus databases, using the keywords of 'critical thinking' and 'Nursing', without limitation based on year of publication. The data were analyzed in accordance with the stages of Rodger's conceptual model. The following were included: books and articles in full, published in Portuguese, English or Spanish, which addressed CT in the teaching and practice of Nursing; articles which did not address aspects related to the concept of CT were excluded. Results: the sample was made up of 42 works. As a substitute term, emphasis is placed on 'analytical thinking', and, as a related factor, decision-making. In order, the most frequent preceding and consequent attributes were: ability to analyze, training of the student nurse, and clinical decision-making. As the implications of CT, emphasis is placed on achieving effective results in care for the patient, family and community. Conclusion: CT is a cognitive skill which involves analysis, logical reasoning and clinical judgment, geared towards the resolution of problems, and standing out in the training and practice of the nurse with a view to accurate clinical decision-making and the achieving of effective results. PMID:27598376

Ethical case deliberation and decision making.

PubMed

Gracia, Diego

2003-01-01

During the last thirty years different methods have been proposed in order to manage and resolve ethical quandaries, specially in the clinical setting. Some of these methodologies are based on the principles of Decision-making theory. Others looked to other philosophical traditions, like Principlism, Hermeneutics, Narrativism, Casuistry, Pragmatism, etc. This paper defends the view that deliberation is the cornerstone of any adequate methodology. This is due to the fact that moral decisions must take into account not only principles and ideas, but also emotions, values and beliefs. Deliberation is the process in which everyone concerned by the decision is considered a valid moral agent, obliged to give reasons for their own points of view, and to listen to the reasons of others. The goal of this process is not the reaching of a consensus but the enrichment of one's own point of view with that of the others, increasing in this way the maturity of one's own decision, in order to make it more wise or prudent. In many cases the members of a group of deliberation will differ in the final solution of the case, but the confrontation of their reasons will modify the perception of the problem of everyone. This is the profit of the process. Our moral decisions cannot be completely rational, due to the fact that they are influenced by feelings, values, beliefs, etc., but they must be reasonable, that is, wise and prudent. Deliberation is the main procedure to reach this goal. It obliges us to take others into account, respecting their different beliefs and values and prompting them to give reasons for their own points of view. This method has been traditional in Western clinical medicine all over its history, and it should be also the main procedure for clinical ethics.

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

Vulnerable patients' perceptions of health care quality and quality data.

PubMed

Raven, Maria Catherine; Gillespie, Colleen C; DiBennardo, Rebecca; Van Busum, Kristin; Elbel, Brian

2012-01-01

Little is known about how patients served by safety-net hospitals utilize and respond to hospital quality data. To understand how vulnerable, lower income patients make health care decisions and define quality of care and whether hospital quality data factor into such decisions and definitions. Mixed quantitative and qualitative methods were used to gather primary data from patients at an urban, tertiary-care safety-net hospital. The study hospital is a member of the first public hospital system to voluntarily post hospital quality data online for public access. Patients were recruited from outpatient and inpatient clinics. Surveys were used to collect data on participants' sociodemographic characteristics, health literacy, health care experiences, and satisfaction variables. Focus groups were used to explore a representative sample of 24 patients' health care decision making and views of quality. Data from focus group transcripts were iteratively coded and analyzed by the authors. Focus group participants were similar to the broader diverse, low-income clinic. Participants reported exercising choice in making decisions about where to seek health care. Multiple sources influenced decision-making processes including participants' own beliefs and values, social influences, and prior experiences. Hospital quality data were notably absent as a source of influence in health care decision making for this population largely because participants were unaware of its existence. Participants' views of hospital quality were influenced by the quality and efficiency of services provided (with an emphasis on the doctor-patient relationship) and patient centeredness. When presented with it, patients appreciated the hospital quality data and, with guidance, were interested in incorporating it into health care decision making. Results suggest directions for optimizing the presentation, content, and availability of hospital quality data. Future research will explore how similar populations form and make choices based on presentation of hospital quality data.

Diagnostic decision-making and strategies to improve diagnosis.

PubMed

Thammasitboon, Satid; Cutrer, William B

2013-10-01

A significant portion of diagnostic errors arises through cognitive errors resulting from inadequate knowledge, faulty data gathering, and/or faulty verification. Experts estimate that 75% of diagnostic failures can be attributed to clinician diagnostic thinking failure. The cognitive processes that underlie diagnostic thinking of clinicians are complex and intriguing, and it is imperative that clinicians acquire explicit appreciation and application of different cognitive approaches to make decisions better. A dual-process model that unifies many theories of decision-making has emerged as a promising template for understanding how clinicians think and judge efficiently in a diagnostic reasoning process. The identification and implementation of strategies for decreasing or preventing such diagnostic errors has become a growing area of interest and research. Suggested strategies to decrease diagnostic error incidence include increasing clinician's clinical expertise and avoiding inherent cognitive errors to make decisions better. Implementing Interventions focused solely on avoiding errors may work effectively for patient safety issues such as medication errors. Addressing cognitive errors, however, requires equal effort on expanding the individual clinician's expertise. Providing cognitive support to clinicians for robust diagnostic decision-making serves as the final strategic target for decreasing diagnostic errors. Clinical guidelines and algorithms offer another method for streamlining decision-making and decreasing likelihood of cognitive diagnostic errors. Addressing cognitive processing errors is undeniably the most challenging task in reducing diagnostic errors. While many suggested approaches exist, they are mostly based on theories and sciences in cognitive psychology, decision-making, and education. The proposed interventions are primarily suggestions and very few of them have been tested in the actual practice settings. Collaborative research effort is required to effectively address cognitive processing errors. Researchers in various areas, including patient safety/quality improvement, decision-making, and problem solving, must work together to make medical diagnosis more reliable. © 2013 Mosby, Inc. All rights reserved.

A review of decision support, risk communication and patient information tools for thrombolytic treatment in acute stroke: lessons for tool developers

PubMed Central

2013-01-01

Background Tools to support clinical or patient decision-making in the treatment/management of a health condition are used in a range of clinical settings for numerous preference-sensitive healthcare decisions. Their impact in clinical practice is largely dependent on their quality across a range of domains. We critically analysed currently available tools to support decision making or patient understanding in the treatment of acute ischaemic stroke with intravenous thrombolysis, as an exemplar to provide clinicians/researchers with practical guidance on development, evaluation and implementation of such tools for other preference-sensitive treatment options/decisions in different clinical contexts. Methods Tools were identified from bibliographic databases, Internet searches and a survey of UK and North American stroke networks. Two reviewers critically analysed tools to establish: information on benefits/risks of thrombolysis included in tools, and the methods used to convey probabilistic information (verbal descriptors, numerical and graphical); adherence to guidance on presenting outcome probabilities (IPDASi probabilities items) and information content (Picker Institute Checklist); readability (Fog Index); and the extent that tools had comprehensive development processes. Results Nine tools of 26 identified included information on a full range of benefits/risks of thrombolysis. Verbal descriptors, frequencies and percentages were used to convey probabilistic information in 20, 19 and 18 tools respectively, whilst nine used graphical methods. Shortcomings in presentation of outcome probabilities (e.g. omitting outcomes without treatment) were identified. Patient information tools had an aggregate median Fog index score of 10. None of the tools had comprehensive development processes. Conclusions Tools to support decision making or patient understanding in the treatment of acute stroke with thrombolysis have been sub-optimally developed. Development of tools should utilise mixed methods and strategies to meaningfully involve clinicians, patients and their relatives in an iterative design process; include evidence-based methods to augment interpretability of textual and probabilistic information (e.g. graphical displays showing natural frequencies) on the full range of outcome states associated with available options; and address patients with different levels of health literacy. Implementation of tools will be enhanced when mechanisms are in place to periodically assess the relevance of tools and where necessary, update the mode of delivery, form and information content. PMID:23777368

Predictive and Prognostic Models: Implications for Healthcare Decision-Making in a Modern Recession

PubMed Central

Vogenberg, F. Randy

2009-01-01

Various modeling tools have been developed to address the lack of standardized processes that incorporate the perspectives of all healthcare stakeholders. Such models can assist in the decision-making process aimed at achieving specific clinical outcomes, as well as guide the allocation of healthcare resources and reduce costs. The current efforts in Congress to change the way healthcare is financed, reimbursed, and delivered have rendered the incorporation of modeling tools into the clinical decision-making all the more important. Prognostic and predictive models are particularly relevant to healthcare, particularly in the clinical decision-making, with implications for payers, patients, and providers. The use of these models is likely to increase, as providers and patients seek to improve their clinical decision process to achieve better outcomes, while reducing overall healthcare costs. PMID:25126292

A proposed approach for quantitative benefit-risk assessment in diagnostic radiology guideline development: the American College of Radiology Appropriateness Criteria Example.

PubMed

Agapova, Maria; Bresnahan, Brian B; Higashi, Mitchell; Kessler, Larry; Garrison, Louis P; Devine, Beth

2017-02-01

The American College of Radiology develops evidence-based practice guidelines to aid appropriate utilization of radiological procedures. Panel members use expert opinion to weight trade-offs and consensus methods to rate appropriateness of imaging tests. These ratings include an equivocal range, assigned when there is disagreement about a technology's appropriateness and the evidence base is weak or for special circumstances. It is not clear how expert consensus merges with the evidence base to arrive at an equivocal rating. Quantitative benefit-risk assessment (QBRA) methods may assist decision makers in this capacity. However, many methods exist and it is not clear which methods are best suited for this application. We perform a critical appraisal of QBRA methods and propose several steps that may aid in making transparent areas of weak evidence and barriers to consensus in guideline development. We identify QBRA methods with potential to facilitate decision making in guideline development and build a decision aid for selecting among these methods. This study identified 2 families of QBRA methods suited to guideline development when expert opinion is expected to contribute substantially to decision making. Key steps to deciding among QBRA methods involve identifying specific benefit-risk criteria and developing a state-of-evidence matrix. For equivocal ratings assigned for reasons other than disagreement or weak evidence base, QBRA may not be needed. In the presence of disagreement but the absence of a weak evidence base, multicriteria decision analysis approaches are recommended; and in the presence of weak evidence base and the absence of disagreement, incremental net health benefit alone or combined with multicriteria decision analysis is recommended. Our critical appraisal further extends investigation of the strengths and limitations of select QBRA methods in facilitating diagnostic radiology clinical guideline development. The process of using the decision aid exposes and makes transparent areas of weak evidence and barriers to consensus. © 2016 John Wiley & Sons, Ltd.

Shared Decision Making and Autonomy Among US Participants with Multiple Sclerosis in the NARCOMS Registry

PubMed Central

Thomas, Nina; Tyry, Tuula; Fox, Robert J.; Salter, Amber

2017-01-01

Background: Treatment decisions in multiple sclerosis (MS) are affected by many factors and are made by the patient, doctor, or both. With new disease-modifying therapies (DMTs) emerging, the complexity surrounding treatment decisions is increasing, further emphasizing the importance of understanding decision-making preferences. Methods: North American Research Committee on Multiple Sclerosis (NARCOMS) Registry participants completed the Fall 2014 Update survey, which included the Control Preferences Scale (CPS). The CPS consists of five images showing different patient/doctor roles in treatment decision making. The images were collapsed to three categories: patient-centered, shared, and physician-centered decision-making preferences. Associations between decision-making preferences and demographic and clinical factors were evaluated using multivariable logistic regression. Results: Of 7009 participants, 79.3% were women and 93.5% were white (mean [SD] age, 57.6 [10.3] years); 56.7% reported a history of relapses. Patient-centered decision making was most commonly preferred by participants (47.9%), followed by shared decision making (SDM; 42.8%). SDM preference was higher for women and those taking DMTs and increased with age and disease duration (all P < .05). Patient-centered decisions were most common for respondents not taking a DMT at the time of the survey and were preferred by those who had no DMT history compared with those who had previously taken a DMT (P < .0001). There was no difference in SDM preference by current MS disease course after adjusting for other disease-related factors. Conclusions: Responders reported most commonly considering their doctor's opinion before making a treatment decision and making decisions jointly with their doctor. DMT use, gender, and age were associated with decision-making preference. PMID:29270088

Decision-Making Capacity for Chemotherapy and Associated Factors in Newly Diagnosed Patients with Lung Cancer.

PubMed

Ogawa, Asao; Kondo, Kyoko; Takei, Hiroyuki; Fujisawa, Daisuke; Ohe, Yuichiro; Akechi, Tatsuo

2018-04-01

The objective of this study was to assess decision-making capacity in patients newly diagnosed with lung cancer, clinical factors associated with impaired capacity, and physicians' perceptions of patients' decision-making capacity. We recruited 122 patients newly diagnosed with lung cancer. One hundred fourteen completed the assessment. All patients were receiving a combination of treatments (e.g., chemotherapy, chemo-radiotherapy, or targeted therapy). Decision-making capacity was assessed using the MacArthur Competence Tool for Treatment. Cognitive impairment, depressive symptoms, and frailty were also evaluated. Physicians' perceptions were compared with the ascertainments. Twenty-seven (24%, 95% confidence interval [CI], 16-31) patients were judged to have incapacity. Clinical teams had difficulty in judging six (22.2%) patients for incapacity. Logistic regression identified frailty (odds ratio, 3.51; 95% CI, 1.13-10.8) and cognitive impairment (odds ratio, 5.45; 95% CI, 1.26-23.6) as the factors associated with decision-making incapacity. Brain metastasis, emphysema, and depression were not associated with decision-making incapacity. A substantial proportion of patients diagnosed with lung cancer show impairments in their capacity to make a medical decision. Assessment of cognitive impairment and frailty may provide appropriate decision-making frameworks to act in the best interest of patients. Decision-making capacity is the cornerstone of clinical practice. A substantial proportion of patients with cancer show impairments in their capacity to make a medical decision. Assessment of cognitive impairment and frailty may provide appropriate decision-making frameworks to act in the best interest of patients. © AlphaMed Press 2017.

Improving family satisfaction and participation in decision making in an intensive care unit.

PubMed

Huffines, Meredith; Johnson, Karen L; Smitz Naranjo, Linda L; Lissauer, Matthew E; Fishel, Marmie Ann-Michelle; D'Angelo Howes, Susan M; Pannullo, Diane; Ralls, Mindy; Smith, Ruth

2013-10-01

Background Survey data revealed that families of patients in a surgical intensive care unit were not satisfied with their participation in decision making or with how well the multidisciplinary team worked together. Objectives To develop and implement an evidence-based communication algorithm and evaluate its effect in improving satisfaction among patients' families. Methods A multidisciplinary team developed an algorithm that included bundles of communication interventions at 24, 72, and 96 hours after admission to the unit. The algorithm included clinical triggers, which if present escalated the algorithm. A pre-post design using process improvement methods was used to compare families' satisfaction scores before and after implementation of the algorithm. Results Satisfaction scores for participation in decision making (45% vs 68%; z = -2.62, P = .009) and how well the health care team worked together (64% vs 83%; z = -2.10, P = .04) improved significantly after implementation. Conclusions Use of an evidence-based structured communication algorithm may be a way to improve satisfaction of families of intensive care patients with their participation in decision making and their perception of how well the unit's team works together.

The normalization heuristic: an untested hypothesis that may misguide medical decisions.

PubMed

Aberegg, Scott K; O'Brien, James M

2009-06-01

Medical practice is increasingly informed by the evidence from randomized controlled trials. When such evidence is not available, clinical hypotheses based on pathophysiological reasoning and common sense guide clinical decision making. One commonly utilized general clinical hypothesis is the assumption that normalizing abnormal laboratory values and physiological parameters will lead to improved patient outcomes. We refer to the general use of this clinical hypothesis to guide medical therapeutics as the "normalization heuristic". In this paper, we operationally define this heuristic and discuss its limitations as a rule of thumb for clinical decision making. We review historical and contemporaneous examples of normalization practices as empirical evidence for the normalization heuristic and to highlight its frailty as a guide for clinical decision making.

Thinking in Pharmacy Practice: A Study of Community Pharmacists’ Clinical Reasoning in Medication Supply Using the Think-Aloud Method

PubMed Central

Croft, Hayley; Gilligan, Conor; Rasiah, Rohan; Levett-Jones, Tracy; Schneider, Jennifer

2017-01-01

Medication review and supply by pharmacists involves both cognitive and technical skills related to the safety and appropriateness of prescribed medicines. The cognitive ability of pharmacists to recall, synthesise and memorise information is a critical aspect of safe and optimal medicines use, yet few studies have investigated the clinical reasoning and decision-making processes pharmacists use when supplying prescribed medicines. The objective of this study was to examine the patterns and processes of pharmacists’ clinical reasoning and to identify the information sources used, when making decisions about the safety and appropriateness of prescribed medicines. Ten community pharmacists participated in a simulation in which they were required to review a prescription and make decisions about the safety and appropriateness of supplying the prescribed medicines to the patient, whilst at the same time thinking aloud about the tasks required. Following the simulation each pharmacist was asked a series of questions to prompt retrospective thinking aloud using video-stimulated recall. The simulated consultation and retrospective interview were recorded and transcribed for thematic analysis. All of the pharmacists made a safe and appropriate supply of two prescribed medicines to the simulated patient. Qualitative analysis identified seven core thinking processes used during the supply process: considering prescription in context, retrieving information, identifying medication-related issues, processing information, collaborative planning, decision making and reflection; and align closely with other health professionals. The insights from this study have implications for enhancing awareness of decision making processes in pharmacy practice and informing teaching and assessment approaches in medication supply. PMID:29301223

Thinking in Pharmacy Practice: A Study of Community Pharmacists' Clinical Reasoning in Medication Supply Using the Think-Aloud Method.

PubMed

Croft, Hayley; Gilligan, Conor; Rasiah, Rohan; Levett-Jones, Tracy; Schneider, Jennifer

2017-12-31

Medication review and supply by pharmacists involves both cognitive and technical skills related to the safety and appropriateness of prescribed medicines. The cognitive ability of pharmacists to recall, synthesise and memorise information is a critical aspect of safe and optimal medicines use, yet few studies have investigated the clinical reasoning and decision-making processes pharmacists use when supplying prescribed medicines. The objective of this study was to examine the patterns and processes of pharmacists' clinical reasoning and to identify the information sources used, when making decisions about the safety and appropriateness of prescribed medicines. Ten community pharmacists participated in a simulation in which they were required to review a prescription and make decisions about the safety and appropriateness of supplying the prescribed medicines to the patient, whilst at the same time thinking aloud about the tasks required. Following the simulation each pharmacist was asked a series of questions to prompt retrospective thinking aloud using video-stimulated recall. The simulated consultation and retrospective interview were recorded and transcribed for thematic analysis. All of the pharmacists made a safe and appropriate supply of two prescribed medicines to the simulated patient. Qualitative analysis identified seven core thinking processes used during the supply process: considering prescription in context, retrieving information, identifying medication-related issues, processing information, collaborative planning, decision making and reflection; and align closely with other health professionals. The insights from this study have implications for enhancing awareness of decision making processes in pharmacy practice and informing teaching and assessment approaches in medication supply.

Risk assessment and decision making about in-labour transfer from rural maternity care: a social judgment and signal detection analysis

PubMed Central

2012-01-01

Background The importance of respecting women’s wishes to give birth close to their local community is supported by policy in many developed countries. However, persistent concerns about the quality and safety of maternity care in rural communities have been expressed. Safe childbirth in rural communities depends on good risk assessment and decision making as to whether and when the transfer of a woman in labour to an obstetric led unit is required. This is a difficult decision. Wide variation in transfer rates between rural maternity units have been reported suggesting different decision making criteria may be involved; furthermore, rural midwives and family doctors report feeling isolated in making these decisions and that staff in urban centres do not understand the difficulties they face. In order to develop more evidence based decision making strategies greater understanding of the way in which maternity care providers currently make decisions is required. This study aimed to examine how midwives working in urban and rural settings and obstetricians make intrapartum transfer decisions, and describe sources of variation in decision making. Methods The study was conducted in three stages. 1. 20 midwives and four obstetricians described factors influencing transfer decisions. 2. Vignettes depicting an intrapartum scenario were developed based on stage one data. 3. Vignettes were presented to 122 midwives and 12 obstetricians who were asked to assess the level of risk in each case and decide whether to transfer or not. Social judgment analysis was used to identify the factors and factor weights used in assessment. Signal detection analysis was used to identify participants’ ability to distinguish high and low risk cases and personal decision thresholds. Results When reviewing the same case information in vignettes midwives in different settings and obstetricians made very similar risk assessments. Despite this, a wide range of transfer decisions were still made, suggesting that the main source of variation in decision making and transfer rates is not in the assessment but the personal decision thresholds of clinicians. Conclusions Currently health care practice focuses on supporting or improving decision making through skills training and clinical guidelines. However, these methods alone are unlikely to be effective in improving consistency of decision making. PMID:23114289

Guidelines, Algorithms, and Evidence-Based Psychopharmacology Training for Psychiatric Residents

ERIC Educational Resources Information Center

Osser, David N.; Patterson, Robert D.; Levitt, James J.

2005-01-01

Objective: The authors describe a course of instruction for psychiatry residents that attempts to provide the cognitive and informational tools necessary to make scientifically grounded decision making a routine part of clinical practice. Methods: In weekly meetings over two academic years, the course covers the psychopharmacology of various…

Shared decision-making in medical encounters regarding breast cancer treatment: the contribution of methodological triangulation.

PubMed

Durif-Bruckert, C; Roux, P; Morelle, M; Mignotte, H; Faure, C; Moumjid-Ferdjaoui, N

2015-07-01

The aim of this study on shared decision-making in the doctor-patient encounter about surgical treatment for early-stage breast cancer, conducted in a regional cancer centre in France, was to further the understanding of patient perceptions on shared decision-making. The study used methodological triangulation to collect data (both quantitative and qualitative) about patient preferences in the context of a clinical consultation in which surgeons followed a shared decision-making protocol. Data were analysed from a multi-disciplinary research perspective (social psychology and health economics). The triangulated data collection methods were questionnaires (n = 132), longitudinal interviews (n = 47) and observations of consultations (n = 26). Methodological triangulation revealed levels of divergence and complementarity between qualitative and quantitative results that suggest new perspectives on the three inter-related notions of decision-making, participation and information. Patients' responses revealed important differences between shared decision-making and participation per se. The authors note that subjecting patients to a normative behavioural model of shared decision-making in an era when paradigms of medical authority are shifting may undermine the patient's quest for what he or she believes is a more important right: a guarantee of the best care available. © 2014 John Wiley & Sons Ltd.

‘They leave at least believing they had a part in the discussion’: Understanding decision aid use and patient–clinician decision-making through qualitative research

PubMed Central

Tiedje, Kristina; Shippee, Nathan D.; Johnson, Anna M.; Flynn, Priscilla M.; Finnie, Dawn M.; Liesinger, Juliette T.; May, Carl R.; Olson, Marianne E.; Ridgeway, Jennifer L.; Shah, Nilay D.; Yawn, Barbara P.; Montori, Victor M.

2013-01-01

Objective This study explores how patient decision aids (DAs) for antihyperglycemic agents and statins, designed for use during clinical consultations, are embedded into practice, examining how patients and clinicians understand and experience DAs in primary care visits. Methods We conducted semistructured in-depth interviews with patients (n = 22) and primary care clinicians (n = 19), and videorecorded consultations (n = 44). Two researchers coded all transcripts. Inductive analyses guided by grounded theory led to the identification of themes. Video and interview data were compared and organized by themes. Results DAs used during consultations became flexible artifacts, incorporated into existing decision making roles for clinicians (experts, authority figures, persuaders, advisors) and patients (drivers of healthcare, learners, partners). DAs were applied to different decision making steps (deliberation, bargaining, convincing, case assessment), and introduced into an existing knowledge context (participants’ literacy regarding shared decision-making (SDM) and DAs). Conclusion DAs’ flexible use during consultations effectively provided space for discussion, even when SDM was not achieved. DAs can be used within any decision-making model. Practice implications Clinician training in DA use and SDM practice may be needed to facilitate DA implementation and promote more ideal-type forms of sharing in decision making. PMID:23598292

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.…

Disciplined Decision Making in an Interdisciplinary Environment: Some Implications for Clinical Applications of Statistical Process Control.

ERIC Educational Resources Information Center

Hantula, Donald A.

1995-01-01

Clinical applications of statistical process control (SPC) in human service organizations are considered. SPC is seen as providing a standard set of criteria that serves as a common interface for data-based decision making, which may bring decision making under the control of established contingencies rather than the immediate contingencies of…

Certainty, leaps of faith, and tradition: rethinking clinical interventions.

PubMed

Dzurec, L C

1998-12-01

Clinical decision making requires that clinicians think quickly and in ways that will foster optimal, safe client care. Tradition influences clinical decision making, enhancing efficiency of resulting nursing action; however, since many decisions must be based on data that are either uncertain, incomplete, or indirect, clinicians are readily ensnared in processes involving potentially faulty logic associated with tradition. The author addresses the tenacity of tradition and then focuses on three processes--consensus formation, the grounding of certainty in inductive reasoning, and affirming the consequent--that have affected clinical decision making. For some recipients of care, tradition has had a substantial and invalid influence on their ability to access care.

The role (or not) of economic evaluation at the micro level: can Bourdieu's theory provide a way forward for clinical decision-making?

PubMed

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

2010-06-01

Despite increasing interest in health economic evaluation, investigations have shown limited use by micro (clinical) level decision-makers. A considerable amount of health decisions take place daily at the point of the clinical encounter; especially in primary care. Since every decision has an opportunity cost, ignoring economic information in family physicians' (FPs) decision-making may have a broad impact on health care efficiency. Knowledge translation of economic evaluation is often based on taken-for-granted assumptions about actors' interests and interactions, neglecting much of the complexity of social reality. Health economics literature frequently assumes a rational and linear decision-making process. Clinical decision-making is in fact a complex social, dynamic, multifaceted process, involving relationships and contextual embeddedness. FPs are embedded in complex social networks that have a significant impact on skills, attitudes, knowledge, practices, and on the information being used. Because of their socially constructed nature, understanding preferences, professional culture, practices, and knowledge translation requires serious attention to social reality. There has been little exploration by health economists of whether the problem may be more fundamental and reside in a misunderstanding of the process of decision-making. There is a need to enhance our understanding of the role of economic evaluation in decision-making from a disciplinary perspective different than health economics. This paper argues for a different conceptualization of the role of economic evaluation in FPs' decision-making, and proposes Bourdieu's sociological theory as a research framework. Bourdieu's theory of practice illustrates how the context-sensitive nature of practice must be understood as a socially constituted practical knowledge. The proposed approach could substantially contribute to a more complex understanding of the role of economic evaluation in FPs' decision-making. Copyright 2010 Elsevier Ltd. All rights reserved.

Development of an evidence-based decision pathway for vestibular schwannoma treatment options.

PubMed

Linkov, Faina; Valappil, Benita; McAfee, Jacob; Goughnour, Sharon L; Hildrew, Douglas M; McCall, Andrew A; Linkov, Igor; Hirsch, Barry; Snyderman, Carl

To integrate multiple sources of clinical information with patient feedback to build evidence-based decision support model to facilitate treatment selection for patients suffering from vestibular schwannomas (VS). This was a mixed methods study utilizing focus group and survey methodology to solicit feedback on factors important for making treatment decisions among patients. Two 90-minute focus groups were conducted by an experienced facilitator. Previously diagnosed VS patients were recruited by clinical investigators at the University of Pittsburgh Medical Center (UPMC). Classical content analysis was used for focus group data analysis. Providers were recruited from practices within the UPMC system and were surveyed using Delphi methods. This information can provide a basis for multi-criteria decision analysis (MCDA) framework to develop a treatment decision support system for patients with VS. Eight themes were derived from these data (focus group + surveys): doctor/health care system, side effects, effectiveness of treatment, anxiety, mortality, family/other people, quality of life, and post-operative symptoms. These data, as well as feedback from physicians were utilized in building a multi-criteria decision model. The study illustrated steps involved in the development of a decision support model that integrates evidence-based data and patient values to select treatment alternatives. Studies focusing on the actual development of the decision support technology for this group of patients are needed, as decisions are highly multifactorial. Such tools have the potential to improve decision making for complex medical problems with alternate treatment pathways. Copyright © 2016 Elsevier Inc. All rights reserved.

Problems and processes in medical encounters: the cases method of dialogue analysis.

PubMed

Laws, M Barton; Taubin, Tatiana; Bezreh, Tanya; Lee, Yoojin; Beach, Mary Catherine; Wilson, Ira B

2013-05-01

To develop methods to reliably capture structural and dynamic temporal features of clinical interactions. Observational study of 50 audio-recorded routine outpatient visits to HIV specialty clinics, using innovative analytic methods. The comprehensive analysis of the structure of encounters system (CASES) uses transcripts coded for speech acts, then imposes larger-scale structural elements: threads--the problems or issues addressed; and processes within threads--basic tasks of clinical care labeled presentation, information, resolution (decision making) and Engagement (interpersonal exchange). Threads are also coded for the nature of resolution. 61% of utterances are in presentation processes. Provider verbal dominance is greatest in information and resolution processes, which also contain a high proportion of provider directives. About half of threads result in no action or decision. Information flows predominantly from patient to provider in presentation processes, and from provider to patient in information processes. Engagement is rare. In this data, resolution is provider centered; more time for patient participation in resolution, or interpersonal engagement, would have to come from presentation. Awareness of the use of time in clinical encounters, and the interaction processes associated with various tasks, may help make clinical communication more efficient and effective. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Automated Modular Magnetic Resonance Imaging Clinical Decision Support System (MIROR): An Application in Pediatric Cancer Diagnosis

PubMed Central

Zarinabad, Niloufar; Meeus, Emma M; Manias, Karen; Foster, Katharine

2018-01-01

Background Advances in magnetic resonance imaging and the introduction of clinical decision support systems has underlined the need for an analysis tool to extract and analyze relevant information from magnetic resonance imaging data to aid decision making, prevent errors, and enhance health care. Objective The aim of this study was to design and develop a modular medical image region of interest analysis tool and repository (MIROR) for automatic processing, classification, evaluation, and representation of advanced magnetic resonance imaging data. Methods The clinical decision support system was developed and evaluated for diffusion-weighted imaging of body tumors in children (cohort of 48 children, with 37 malignant and 11 benign tumors). Mevislab software and Python have been used for the development of MIROR. Regions of interests were drawn around benign and malignant body tumors on different diffusion parametric maps, and extracted information was used to discriminate the malignant tumors from benign tumors. Results Using MIROR, the various histogram parameters derived for each tumor case when compared with the information in the repository provided additional information for tumor characterization and facilitated the discrimination between benign and malignant tumors. Clinical decision support system cross-validation showed high sensitivity and specificity in discriminating between these tumor groups using histogram parameters. Conclusions MIROR, as a diagnostic tool and repository, allowed the interpretation and analysis of magnetic resonance imaging images to be more accessible and comprehensive for clinicians. It aims to increase clinicians’ skillset by introducing newer techniques and up-to-date findings to their repertoire and make information from previous cases available to aid decision making. The modular-based format of the tool allows integration of analyses that are not readily available clinically and streamlines the future developments. PMID:29720361

Patient Perspectives on Low-Dose Computed Tomography for Lung Cancer Screening, New Mexico, 2014

PubMed Central

Sussman, Andrew L.; Murrietta, Ambroshia M.; Getrich, Christina M.; Rhyne, Robert; Crowell, Richard E.; Taylor, Kathryn L.; Reifler, Ellen J.; Wescott, Pamela H.; Saeed, Ali I.; Hoffman, Richard M.

2016-01-01

Introduction National guidelines call for annual lung cancer screening for high-risk smokers using low-dose computed tomography (LDCT). The objective of our study was to characterize patient knowledge and attitudes about lung cancer screening, smoking cessation, and shared decision making by patient and health care provider. Methods We conducted semistructured qualitative interviews with patients with histories of heavy smoking who received care at a Federally Qualified Health Center (FQHC Clinic) and at a comprehensive cancer center-affiliated chest clinic (Chest Clinic) in Albuquerque, New Mexico. The interviews, conducted from February through September 2014, focused on perceptions about health screening, knowledge and attitudes about LDCT screening, and preferences regarding decision aids. We used a systematic iterative analytic process to identify preliminary and emergent themes and to create a coding structure. Results We reached thematic saturation after 22 interviews (10 at the FQHC Clinic, 12 at the Chest Clinic). Most patients were unaware of LDCT screening for lung cancer but were receptive to the test. Some smokers said they would consider quitting smoking if their screening result were positive. Concerns regarding screening were cost, radiation exposure, and transportation issues. To support decision making, most patients said they preferred one-on-one discussions with a provider. They also valued decision support tools (print materials, videos), but raised concerns about readability and Internet access. Conclusion Implementing lung cancer screening in sociodemographically diverse populations poses significant challenges. The value of tobacco cessation counseling cannot be overemphasized. Effective interventions for shared decision making to undergo lung cancer screening will need the active engagement of health care providers and will require the use of accessible decision aids designed for people with low health literacy. PMID:27536900

Informing men about prostate cancer screening: a randomized controlled trial of patient education materials.

PubMed

Ilic, Dragan; Egberts, Kristine; McKenzie, Joanne E; Risbridger, Gail; Green, Sally

2008-04-01

Patient education materials can assist patient decision making on prostate cancer screening. To explore the effectiveness of presenting health information on prostate cancer screening using video, internet, and written interventions on patient decision making, attitudes, knowledge, and screening interest. Randomized controlled trial. A total of 161 men aged over 45, who had never been screened for prostate cancer, were randomized to receive information on prostate cancer screening. Participants were assessed at baseline and 1-week postintervention for decisional conflict, screening interest, knowledge, anxiety, and decision-making preference. A total of 156 men were followed-up at 1-week postintervention. There was no statistical, or clinical, difference in mean change in decisional conflict scores between the 3 intervention groups (video vs internet -0.06 [95% CI -0.24 to 0.12]; video vs pamphlet 0.04 [95%CI -0.15 to 0.22]; internet vs pamphlet 0.10 [95%CI -0.09 to 0.28]). There was also no statistically significant difference in mean knowledge, anxiety, decision-making preference, and screening interest between the 3 intervention groups. Results from this study indicate that there are no clinically significant differences in decisional conflict when men are presented health information on prostate cancer screening via video, written materials, or the internet. Given the equivalence of the 3 methods, other factors need to be considered in deciding which method to use. Health professionals should provide patient health education materials via a method that is most convenient to the patient and their preferred learning style.

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

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

PubMed

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

2018-07-01

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

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.

Informed Decision Making About Prostate Cancer Testing in Predominantly Immigrant Black Men: A Randomized Controlled Trial

PubMed Central

Lepore, Stephen J.; Wolf, Randi L.; Basch, Charles E.; Godfrey, Melissa; McGinty, Emma; Shmukler, Celia; Ullman, Ralph; Thomas, Nigel; Weinrich, Sally

2012-01-01

Background Decision support interventions have been developed to help men clarify their values and make informed decisions about prostate cancer testing, but they seldom target high-risk black and immigrant men. Purpose This study evaluated the efficacy of a decision support intervention focused on prostate cancer testing in a sample of predominantly immigrant black men. Methods Black men (N = 490) were randomized to tailored telephone education about prostate cancer testing or a control condition. Results Post-intervention, the intervention group had significantly greater knowledge, lower decision conflict, and greater likelihood of talking with their physician about prostate cancer testing than the control group. There were no significant intervention effects on prostate specific antigen testing, congruence between testing intention and behavior, or anxiety. Conclusions A tailored telephone decision support intervention can promote informed decision making about prostate cancer testing in black and predominantly immigrant men without increasing testing or anxiety. Clinical trial Registered in clinicaltrials.gov (NCT01415375) PMID:22825933

Behavioral Economics: A New Lens for Understanding Genomic Decision Making.

PubMed

Moore, Scott Emory; Ulbrich, Holley H; Hepburn, Kenneth; Holaday, Bonnie; Mayo, Rachel; Sharp, Julia; Pruitt, Rosanne H

2018-05-01

This article seeks to take the next step in examining the insights that nurses and other healthcare providers can derive from applying behavioral economic concepts to support genomic decision making. As genomic science continues to permeate clinical practice, nurses must continue to adapt practice to meet new challenges. Decisions associated with genomics are often not simple and dichotomous in nature. They can be complex and challenging for all involved. This article offers an introduction to behavioral economics as a possible tool to help support patients', families', and caregivers' decision making related to genomics. Using current writings from nursing, ethics, behavioral economic, and other healthcare scholars, we review key concepts of behavioral economics and discuss their relevance to supporting genomic decision making. Behavioral economic concepts-particularly relativity, deliberation, and choice architecture-are specifically examined as new ways to view the complexities of genomic decision making. Each concept is explored through patient decision making and clinical practice examples. This article also discusses next steps and practice implications for further development of the behavioral economic lens in nursing. Behavioral economics provides valuable insight into the unique nature of genetic decision-making practices. Nurses are often a source of information and support for patients during clinical decision making. This article seeks to offer behavioral economic concepts as a framework for understanding and examining the unique nature of genomic decision making. As genetic and genomic testing become more common in practice, it will continue to grow in importance for nurses to be able to support the autonomous decision making of patients, their families, and caregivers. © 2018 Sigma Theta Tau International.

Using service data: tools for taking action.

PubMed

1992-01-01

Program performance can be improved through use of a simple information system. The focus of the discussion is on analysis of service data, decision making, and program improvement. Clinic managers must collect and analyze their own data and not wait for supervisors from central or district offices to conduct thorough examination. Local decision making has the advantage of providing monitoring and modification of services in a timely way and in a way responsive to client needs. Information can be shared throughout all levels of local and central administration. The model for decision making is based on data collection, data analysis, decision making, action, evaluation, information dissemination, and feedback. Data need to be collected on types of clients (new acceptor or continuing user), type of contraceptive method and quantity dispensed, and how the client learned about the clinic. Supply data also needs to be collected on methods of contraceptives on hand, number dispensed by method to clients, and projected supplies; requests for additional supplies can thus be made in a timely and appropriate way. The basic clinic forms are the family planning (FP), client record, the client referral card, an appointment card, a complication card, a daily FP activity register, a FP activities worksheet, a monthly summary of FP activities, and a commodities request/receipt form. A suggestion sheet from users addresses issues about performance targets, continuing users, dropouts, staff motivation, and setting up a system. Suggestions are also provided on the importance of staff training in data collection and analysis and in creating awareness of the program's objectives. Discussion is directed to how to interpret new acceptor data and to look for patterns. A sample chart is provided of a summary of FP activities, possible interpretations, and possible actions to take. Analysis is given for new acceptor trends, contraceptive method mix, and sources of information. A short example illustrates how client card data and bar graphs of method mix by desire for no more children or for more children revealed that couples childbearing desires did not affect method choice.

Forensic issues in medical evaluation: competency and end-of-life issues.

PubMed

Soliman, Sherif; Hall, Ryan C W

2015-01-01

Decision-making capacity is a common reason for psychiatric consultation that is likely to become more common as the population ages. Capacity assessments are frequently compromised by misconceptions, such as the belief that incapacity is permanent or that patients with dementia categorically lack capacity. This chapter will review the conceptual framework of decision-making capacity and discuss its application to medical decision-making. We will review selected developments in capacity assessment and recommend an approach to assessing decision-making capacity. We will discuss the unique challenges posed by end-of-life care, including determining capacity, identifying surrogate decision-makers, and working with surrogate decision-makers. We will discuss clinical and legal approaches to incapacity, including advance directives, surrogate decision-makers, and guardians. We will discuss the legal standards based on which surrogates make medical decisions and outline options for resolving disagreements between clinical staff and surrogate decision-makers. We will offer recommendations for approaching decision-making capacity assessments. © 2015 S. Karger AG, Basel.

An evidence-based shared decision making programme on the prevention of myocardial infarction in type 2 diabetes: protocol of a randomised-controlled trial.

PubMed

Buhse, Susanne; Heller, Tabitha; Kasper, Jürgen; Mühlhauser, Ingrid; Müller, Ulrich Alfons; Lehmann, Thomas; Lenz, Matthias

2013-10-19

Lack of patient involvement in decision making has been suggested as one reason for limited treatment success. Concepts such as shared decision making may contribute to high quality healthcare by supporting patients to make informed decisions together with their physicians.A multi-component shared decision making programme on the prevention of heart attack in type 2 diabetes has been developed. It aims at improving the quality of decision-making by providing evidence-based patient information, enhancing patients' knowledge, and supporting them to actively participate in decision-making. In this study the efficacy of the programme is evaluated in the setting of a diabetes clinic. A single blinded randomised-controlled trial is conducted to compare the shared decision making programme with a control-intervention. The intervention consists of an evidence-based patient decision aid on the prevention of myocardial infarction and a corresponding counselling module provided by diabetes educators. Similar in duration and structure, the control-intervention targets nutrition, sports, and stress coping. A total of 154 patients between 40 and 69 years of age with type 2 diabetes and no previous diagnosis of ischaemic heart disease or stroke are enrolled and allocated either to the intervention or the control-intervention. Primary outcome measure is the patients' knowledge on benefits and harms of heart attack prevention captured by a standardised knowledge test. Key secondary outcome measure is the achievement of treatment goals prioritised by the individual patient. Treatment goals refer to statin taking, HbA1c-, blood pressure levels and smoking status. Outcomes are assessed directly after the counselling and at 6 months follow-up. Analyses will be carried out on intention-to-treat basis. Concurrent qualitative methods are used to explore intervention fidelity and to gain insight into implementation processes. Interventions to facilitate evidence-based shared decision making represent an innovative approach in diabetes care. The results of this study will provide information on the efficacy of such a concept in the setting of a diabetes clinic in Germany. ISRCTN84636255.

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

PubMed Central

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

2012-01-01

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

Making Good Decisions in Healthcare with Multi-Criteria Decision Analysis: The Use, Current Research and Future Development of MCDA.

PubMed

Mühlbacher, Axel C; Kaczynski, Anika

2016-02-01

Healthcare decision making is usually characterized by a low degree of transparency. The demand for transparent decision processes can be fulfilled only when assessment, appraisal and decisions about health technologies are performed under a systematic construct of benefit assessment. The benefit of an intervention is often multidimensional and, thus, must be represented by several decision criteria. Complex decision problems require an assessment and appraisal of various criteria; therefore, a decision process that systematically identifies the best available alternative and enables an optimal and transparent decision is needed. For that reason, decision criteria must be weighted and goal achievement must be scored for all alternatives. Methods of multi-criteria decision analysis (MCDA) are available to analyse and appraise multiple clinical endpoints and structure complex decision problems in healthcare decision making. By means of MCDA, value judgments, priorities and preferences of patients, insurees and experts can be integrated systematically and transparently into the decision-making process. This article describes the MCDA framework and identifies potential areas where MCDA can be of use (e.g. approval, guidelines and reimbursement/pricing of health technologies). A literature search was performed to identify current research in healthcare. The results showed that healthcare decision making is addressing the problem of multiple decision criteria and is focusing on the future development and use of techniques to weight and score different decision criteria. This article emphasizes the use and future benefit of MCDA.

A method for studying decision-making by guideline development groups.

PubMed

Gardner, Benjamin; Davidson, Rosemary; McAteer, John; Michie, Susan

2009-08-05

Multidisciplinary guideline development groups (GDGs) have considerable influence on UK healthcare policy and practice, but previous research suggests that research evidence is a variable influence on GDG recommendations. The Evidence into Recommendations (EiR) study has been set up to document social-psychological influences on GDG decision-making. In this paper we aim to evaluate the relevance of existing qualitative methodologies to the EiR study, and to develop a method best-suited to capturing influences on GDG decision-making. A research team comprised of three postdoctoral research fellows and a multidisciplinary steering group assessed the utility of extant qualitative methodologies for coding verbatim GDG meeting transcripts and semi-structured interviews with GDG members. A unique configuration of techniques was developed to permit data reduction and analysis. Our method incorporates techniques from thematic analysis, grounded theory analysis, content analysis, and framework analysis. Thematic analysis of individual interviews conducted with group members at the start and end of the GDG process defines discrete problem areas to guide data extraction from GDG meeting transcripts. Data excerpts are coded both inductively and deductively, using concepts taken from theories of decision-making, social influence and group processes. These codes inform a framework analysis to describe and explain incidents within GDG meetings. We illustrate the application of the method by discussing some preliminary findings of a study of a National Institute for Health and Clinical Excellence (NICE) acute physical health GDG. This method is currently being applied to study the meetings of three of NICE GDGs. These cover topics in acute physical health, mental health and public health, and comprise a total of 45 full-day meetings. The method offers potential for application to other health care and decision-making groups.

Cancer patient decision making related to clinical trial participation: an integrative review with implications for patients' relational autonomy.

PubMed

Bell, Jennifer A H; Balneaves, Lynda G

2015-04-01

Oncology clinical trials are necessary for the improvement of patient care as they have the ability to confirm the efficacy and safety of novel cancer treatments and in so doing, contribute to a solid evidence base on which practitioners and patients can make informed treatment decisions. However, only 3-5 % of adult cancer patients enroll in clinical trials. Lack of participation compromises the success of clinical trials and squanders an opportunity for improving patient outcomes. This literature review summarizes the factors and contexts that influence cancer patient decision making related to clinical trial participation. An integrative review was undertaken within PubMed, CINAHL, and EMBASE databases for articles written between 1995 and 2012 and archived under relevant keywords. Articles selected were data-based, written in English, and limited to adult cancer patients. In the 51 articles reviewed, three main types of factors were identified that influence cancer patients' decision making about participation in clinical trials: personal, social, and system factors. Subthemes included patients' trust in their physician and the research process, undue influence within the patient-physician relationship, and systemic social inequalities. How these factors interact and influence patients' decision-making process and relational autonomy, however, is insufficiently understood. Future research is needed to further elucidate the sociopolitical barriers and facilitators of clinical trial participation and to enhance ethical practice within clinical trial enrolment. This research will inform targeted education and support interventions to foster patients' relational autonomy in the decision-making process and potentially improve clinical trial participation rates.

The Iowa Gambling Task in fMRI Images

PubMed Central

Li, Xiangrui; Lu, Zhong-Lin; D'Argembeau, Arnaud; Ng, Marie; Bechara, Antoine

2009-01-01

The Iowa Gambling Task (IGT) is a sensitive test for the detection of decision-making impairments in several neurologic and psychiatric populations. Very few studies have employed the IGT in fMRI investigations, in part, because the task is cognitively complex. Here we report a method for exploring brain activity using fMRI during performance of the IGT. Decision-making during the IGT was associated with activity in several brain regions in a group of healthy individuals. The activated regions were consistent with the neural circuitry hypothesized to underlie somatic marker activation and decision-making. Specifically, a neural circuitry involving the dorsolateral prefrontal cortex (for working memory), the insula and posterior cingulate cortex (for representations of emotional states), the mesial orbitofrontal and ventromedial prefrontal cortex (for coupling the two previous processes), the ventral striatum and anterior cingulate/SMA (supplementary motor area) for implementing behavioral decisions was engaged. These results have implications for using the IGT to study abnormal mechanisms of decision making in a variety of clinical populations. PMID:19777556

Systematic review: the effect on surrogates of making treatment decisions for others.

PubMed

Wendler, David; Rid, Annette

2011-03-01

Clinical practice relies on surrogates to make or help to make treatment decisions for incapacitated adults; however, the effect of this practice on surrogates has not been evaluated. To assess the effect on surrogates of making treatment decisions for adults who cannot make their own decisions. Empirical studies published in English and listed in MEDLINE, EMBASE, CINAHL, BIOETHICSLINE, PsycINFO, or Scopus before 1 July 2010. Eligible studies provided quantitative or qualitative empirical data, by evaluating surrogates, regarding the effect on surrogates of making treatment decisions for an incapacitated adult. Information on study location, number and type of surrogates, timing of data collection, type of decisions, patient setting, methods, main findings, and limitations. 40 studies, 29 using qualitative and 11 using quantitative methods, provided data on 2854 surrogates, more than one half of whom were family members of the patient. Most surrogates were surveyed several months to years after making treatment decisions, the majority of which were end-of-life decisions. The quantitative studies found that at least one third of surrogates experienced a negative emotional burden as the result of making treatment decisions. The qualitative studies reported that many or most surrogates experienced negative emotional burden. The negative effects on surrogates were often substantial and typically lasted months or, in some cases, years. The most common negative effects cited by surrogates were stress, guilt over the decisions they made, and doubt regarding whether they had made the right decisions. Nine of the 40 studies also reported beneficial effects on a few surrogates, the most common of which were supporting the patient and feeling a sense of satisfaction. Knowing which treatment is consistent with the patient's preferences was frequently cited as reducing the negative effect on surrogates. Thirty-two of the 40 articles reported data collected in the United States. Because the study populations were relatively homogenous, it is unclear whether the findings apply to other groups. In some cases, the effect of making treatment decisions could not be isolated from that of other stressors, such as grief or prognostic uncertainty. Nine of the studies had a response rate less than 50%, and 9 did not report a response rate. Many of the studies had a substantial interval between the treatment decisions and data collection. Making treatment decisions has a negative emotional effect on at least one third of surrogates, which is often substantial and typically lasts months (or sometimes years). Future research should evaluate ways to reduce this burden, including methods to identify which treatment options are consistent with the patient's preferences. National Institutes of Health.

Impact of computer-based treatment planning software on clinical judgment of dental students for planning prosthodontic rehabilitation

PubMed Central

Deshpande, Saee; Chahande, Jayashree

2014-01-01

Purpose Successful prosthodontic rehabilitation involves making many interrelated clinical decisions which have an impact on each other. Self-directed computer-based training has been shown to be a very useful tool to develop synthetic and analytical problem-solving skills among students. Thus, a computer-based case study and treatment planning (CSTP) software program was developed which would allow students to work through the process of comprehensive, multidisciplinary treatment planning for patients in a structured and logical manner. The present study was aimed at assessing the effect of this CSTP software on the clinical judgment of dental students while planning prosthodontic rehabilitation and to assess the students’ perceptions about using the program for its intended use. Methods A CSTP software program was developed and validated. The impact of this program on the clinical decision making skills of dental graduates was evaluated by real life patient encounters, using a modified and validated mini-CEX. Students’ perceptions about the program were obtained by a pre-validated feedback questionnaire. Results The faculty assessment scores of clinical judgment improved significantly after the use of this program. The majority of students felt it was an informative, useful, and innovative way of learning and they strongly felt that they had learnt the logical progression of planning, the insight into decision making, and the need for flexibility in treatment planning after using this program. Conclusion CSTP software was well received by the students. There was significant improvement in students’ clinical judgment after using this program. It should thus be envisaged fundamentally as an adjunct to conventional teaching techniques to improve students’ decision making skills and confidence. PMID:25170288

An evaluation of learning clinical decision-making for early rehabilitation in the ICU via interactive education with audience response system.

PubMed

Toonstra, Amy L; Nelliot, Archana; Aronson Friedman, Lisa; Zanni, Jennifer M; Hodgson, Carol; Needham, Dale M

2017-06-01

Knowledge-related barriers to safely implement early rehabilitation programs in intensive care units (ICUs) may be overcome via targeted education. The purpose of this study was to evaluate the effectiveness of an interactive educational session on short-term knowledge of clinical decision-making for safe rehabilitation of patients in ICUs. A case-based teaching approach, drawing from published safety recommendations for initiation of rehabilitation in ICUs, was used with a multidisciplinary audience. An audience response system was incorporated to promote interaction and evaluate knowledge before vs. after the educational session. Up to 175 audience members, of 271 in attendance (129 (48%) physical therapists, 51 (19%) occupational therapists, 31 (11%) nursing, 14 (5%) physician, 46 (17%) other), completed both the pre- and post-test questions for each of the six unique patient cases. In four of six patient cases, there was a significant (p< 0.001) increase in identifying the correct answer regarding initiation of rehabilitation activities. This learning effect was similar irrespective of participants' years of experience and clinical discipline. An interactive, case-based, educational session may be effective for increasing short-term knowledge, and identifying knowledge gaps, regarding clinical decision-making for safe rehabilitation of patients in ICUs. Implications for Rehabilitation Lack of knowledge regarding the safety considerations for early rehabilitation of ICU patients is a barrier to implementing early rehabilitation. Interactive educational formats, such as the use of audience response systems, offer a new method of teaching and instantly assessing learning of clinically important information. In a small study, we have shown that an interactive, case-based educational format may be used to effectively teach clinical decision-making for the safe rehabilitation of ICU patients to a diverse audience of clinicians.

Treatment decision-making in ductal carcinoma in situ: A mixed methods systematic review of women's experiences and information needs.

PubMed

Rutherford, Claudia; Mercieca-Bebber, Rebecca; Butow, Phyllis; Wu, Jenny Liang; King, Madeleine T

2017-09-01

Decision-making in ductal carcinoma in situ (DCIS) is complex due to the heterogeneity of the disease. This study aimed to understand women's experience of making treatment decisions for DCIS, their information and support needs, and factors that influenced decisions. We searched six electronic databases, conference proceedings, and key authors. Two reviewers independently applied inclusion and quality criteria, and extracted findings. Thematic analysis was used to combine and summarise findings. We identified six themes and 28 subthemes from 18 studies. Women with DCIS have knowledge deficits about DCIS, experience anxiety related to information given at diagnosis and the complexity of decision-making, and have misconceptions regarding risks and outcomes of treatment. Women's decisions are influenced by their understanding of risk, the clinical features of their DCIS, and the benefits and harms of treatment options. Women are dissatisfied with the decisional support available. Informed and shared decision-making in this complex decision setting requires clear communication of information specific to DCIS and individual's, as well as decision support for patients and clinicians. This approach would educate patients and clinicians, and assist clinicians in supporting patients to an evidence-based treatment plan that aligns with individual values and pReferences. Copyright © 2017 Elsevier B.V. All rights reserved.

Clinical reasoning in nursing, a think-aloud study using virtual patients - a base for an innovative assessment.

PubMed

Forsberg, Elenita; Ziegert, Kristina; Hult, Håkan; Fors, Uno

2014-04-01

In health-care education, it is important to assess the competencies that are essential for the professional role. To develop clinical reasoning skills is crucial for nursing practice and therefore an important learning outcome in nursing education programmes. Virtual patients (VPs) are interactive computer simulations of real-life clinical scenarios and have been suggested for use not only for learning, but also for assessment of clinical reasoning. The aim of this study was to investigate how experienced paediatric nurses reason regarding complex VP cases and how they make clinical decisions. The study was also aimed to give information about possible issues that should be assessed in clinical reasoning exams for post-graduate students in diploma specialist paediatric nursing education. The information from this study is believed to be of high value when developing scoring and grading models for a VP-based examination for the specialist diploma in paediatric nursing education. Using the think-aloud method, data were collected from 30 RNs working in Swedish paediatric departments, and child or school health-care centres. Content analysis was used to analyse the data. The results indicate that experienced nurses try to consolidate their hypotheses by seeing a pattern and judging the value of signs, symptoms, physical examinations, laboratory tests and radiology. They show high specific competence but earlier experience of similar cases was also of importance for the decision making. The nurses thought it was an innovative assessment focusing on clinical reasoning and clinical decision making. They thought it was an enjoyable way to be assessed and that all three main issues could be assessed using VPs. In conclusion, VPs seem to be a possible model for assessing the clinical reasoning process and clinical decision making, but how to score and grade such exams needs further research. © 2013.

Experiences of treatment decision making for young people diagnosed with depressive disorders: a qualitative study in primary care and specialist mental health settings

PubMed Central

2011-01-01

Background Clinical guidelines advocate for the inclusion of young people experiencing depression as well as their caregivers in making decisions about their treatment. Little is known, however, about the degree to which these groups are involved, and whether they want to be. This study sought to explore the experiences and desires of young people and their caregivers in relation to being involved in treatment decision making for depressive disorders. Methods Semi-structured interviews were carried out with ten young people and five caregivers from one primary care and one specialist mental health service about their experiences and beliefs about treatment decision making. Interviews were audio taped, transcribed verbatim and analysed using thematic analysis. Results Experiences of involvement for clients varied and were influenced by clients themselves, clinicians and service settings. For caregivers, experiences of involvement were more homogenous. Desire for involvement varied across clients, and within clients over time; however, most clients wanted to be involved at least some of the time. Both clients and caregivers identified barriers to involvement. Conclusions This study supports clinical guidelines that advocate for young people diagnosed with depressive disorders to be involved in treatment decision making. In order to maximise engagement, involvement in treatment decision making should be offered to all clients. Involvement should be negotiated explicitly and repeatedly, as desire for involvement may change over time. Caregiver involvement should be negotiated on an individual basis; however, all caregivers should be supported with information about mental disorders and treatment options. PMID:22151735

The ethics of sham surgery on research subjects with cognitive impairments that affect decision-making capacity.

PubMed

Resnik, David B; Miller, Frank

2010-09-01

Populations recruited to participate in sham surgery clinical trials sometimes include patients with cognitive impairments that affect decision-making capacity. In this commentary we examine arguments for and against including these patients in sham surgery clinical trials. We argue that patients with cognitive impairments that affect decision-making capacity should not be excluded from a sham surgery clinical trial if there are scientific reasons for including them in the study and basic ethical requirements for clinical research are met. Published by Elsevier Inc.

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

PubMed

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

2018-05-09

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

A description of nurses' decision-making in managing electrocardiographic monitor alarms.

PubMed

Gazarian, Priscilla K; Carrier, Natalie; Cohen, Rachel; Schram, Haley; Shiromani, Samara

2015-01-01

To describe the cues and factors that nurses use in their decision-making when responding to clinical alarms. Alarms are designed to be very sensitive, and as a result, they are not very specific. Lack of adherence to the practice standards for electrocardiographic monitoring in hospital settings has been observed, resulting in overuse of the electrocardiographic monitoring. Monitoring without consideration of clinical indicators uses scarce healthcare resources and may even produce untoward circumstances because of alarm fatigue. With so many false alarms, alarm fatigue represents a symptom of a larger problem. It cannot be fixed until all of the factors that contribute to its existence have been examined. This was a qualitative descriptive study. This study was conducted at an academic medical centre located in the Northeast United States. Eight participants were enrolled using purposive sampling. Nurses were observed for two three-hour periods. Following each observation, the nurse was interviewed using the critical decision method to describe the cognitive processes related to the alarm activities. Qualitative data from the conducted interviews were analysed via an a priori framework founded in the critical decision method. This study reveals information, experience, guidance and decision-making as the four prominent categories contributing to nurses' decision-making in relation to alarm management. Managing technology was a category not identified a priori that emerged in the data analysis. Nurses revealed a breadth of information needed to adequately identify and interpret monitor alarms, and how they used that information to put the alarms into the particular context of an individual patient's situations. Understanding the cues and factors nurses use when responding to cardiac alarms will guide the development of learning experiences and inform policies to guide practice. © 2014 John Wiley & Sons Ltd.

Meeting the nutritional needs of patients with severe dysphagia following a stroke: an interdisciplinary approach.

PubMed

Rodrigue, Nathalie; Côté, Robert; Kirsch, Connie; Germain, Chantal; Couturier, Céline; Fraser, Roxanne

2002-03-01

Dysphagia is a common problem with individuals who have experienced a stroke. The interdisciplinary stroke team noted delays in clinical decision-making, or in implementing plans for patients with severe dysphagia requiring an alternative method to oral feeding, such as enteral feeding via Dobhoff (naso-jejunum) or PEG (percutaneous endoscopic gastrostomy) tubes, occurred because protocols had not been established. This resulted in undernourishment, which in turn contributed to clinical problems, such as infections and confusion, which delayed rehabilitation and contributed to excess disability. The goal of the project was to improve quality of care and quality of life for stroke patients experiencing swallowing problems by creating a dysphagia management decision-making process. The project began with a retrospective chart review of 91 cases over a period of six months to describe the population characteristics, dysphagia frequency, stroke and dysphagia severity, and delays encountered with decision-making regarding dysphagia management. A literature search was conducted, and experts in the field were consulted to provide current knowledge prior to beginning the project. Using descriptive statistics, dysphagia was present in 44% of the stroke population and 69% had mild to moderate stroke severity deficit. Delays were found in the decision to insert a PEG (mean 10 days) and the time between decision and PEG insertion (mean 12 days). Critical periods were examined in order to speed up the process of decision-making and intervention. This resulted in the creation of a decision-making algorithm based on stroke and dysphagia severity that will be tested during winter 2002.

An introduction to behavioural decision-making theories for paediatricians.

PubMed

Haward, Marlyse F; Janvier, Annie

2015-04-01

Behavioural decision-making theories provide insights into how people make choices under conditions of uncertainty. However, few have been studied in paediatrics. This study introduces these theories, reviews current research and makes recommendations for their application within the context of shared decision-making. As parents are expected to share decision-making in paediatrics, it is critical that the fields of behavioural economics, communication and decision sciences merge with paediatric clinical ethics to optimise decision-making. ©2015 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.

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…

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. Copyright © 2013 Elsevier Ltd. All rights reserved.

Research on Bidding Decision-making of International Public-Private Partnership Projects

NASA Astrophysics Data System (ADS)

Hu, Zhen Yu; Zhang, Shui Bo; Liu, Xin Yan

2018-06-01

In order to select the optimal quasi-bidding project for an investment enterprise, a bidding decision-making model for international PPP projects was established in this paper. Firstly, the literature frequency statistics method was adopted to screen out the bidding decision-making indexes, and accordingly the bidding decision-making index system for international PPP projects was constructed. Then, the group decision-making characteristic root method, the entropy weight method, and the optimization model based on least square method were used to set the decision-making index weights. The optimal quasi-bidding project was thus determined by calculating the consistent effect measure of each decision-making index value and the comprehensive effect measure of each quasi-bidding project. Finally, the bidding decision-making model for international PPP projects was further illustrated by a hypothetical case. This model can effectively serve as a theoretical foundation and technical support for the bidding decision-making of international PPP projects.

Variation, certainty, evidence, and change in dental education: employing evidence-based dentistry in dental education.

PubMed

Marinho, V C; Richards, D; Niederman, R

2001-05-01

Variation in health care, and more particularly in dental care, was recently chronicled in a Readers Digest investigative report. The conclusions of this report are consistent with sound scientific studies conducted in various areas of health care, including dental care, which demonstrate substantial variation in the care provided to patients. This variation in care parallels the certainty with which clinicians and faculty members often articulate strongly held, but very different opinions. Using a case-based dental scenario, we present systematic evidence-based methods for accessing dental health care information, evaluating this information for validity and importance, and using this information to make informed curricular and clinical decisions. We also discuss barriers inhibiting these systematic approaches to evidence-based clinical decision making and methods for effectively promoting behavior change in health care professionals.

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. © 2016 Royal College of Physicians.

A scoping review of the potential for chart stimulated recall as a clinical research method.

PubMed

Sinnott, Carol; Kelly, Martina A; Bradley, Colin P

2017-08-22

Chart-stimulated recall (CSR) is a case-based interviewing technique, which is used in the assessment of clinical decision-making in medical education and professional certification. Increasingly, clinical decision-making is a concern for clinical research in primary care. In this study, we review the prior application and utility of CSR as a technique for research interviews in primary care. Following Arksey & O'Malley's method for scoping reviews, we searched seven databases, grey literature, reference lists, and contacted experts in the field. We excluded studies on medical education or competence assessment. Retrieved citations were screened by one reviewer and full texts were ordered for all potentially relevant abstracts. Two researchers independently reviewed full texts and performed data extraction and quality appraisal if inclusion criteria were met. Data were collated and summarised using a published framework on the reporting of qualitative interview techniques, which was chosen a priori. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines informed the review report. From an initial list of 789 citations, eight studies using CSR in research interviews were included in the review: six from North America, one from the Netherlands, and one from Ireland. The most common purpose of included studies was to examine the influence of guidelines on physicians' decisions. The number of interviewees ranged from seven to twenty nine, while the number of charts discussed per interview ranged from one to twelve. CSR gave insights into physicians' reasoning for actions taken or not taken; the unrecorded social and clinical influences on decisions; and discrepancies between physicians' real and perceived practice. Ethical concerns and the training and influence of the researcher were poorly discussed in most of the studies. Potential pitfalls included the risk of recall, selection and observation biases. Despite the proven validity, reliability and acceptability of CSR in assessment interviews in medical education, its use in clinical research is limited. Application of CSR in qualitative research brings interview data closer to the reality of practice. Although further development of the approach is required, we recommend a role for CSR in research interviews on decision-making in clinical practice.

Value of information and pricing new healthcare interventions.

PubMed

Willan, Andrew R; Eckermann, Simon

2012-06-01

Previous application of value-of-information methods to optimal clinical trial design have predominantly taken a societal decision-making perspective, implicitly assuming that healthcare costs are covered through public expenditure and trial research is funded by government or donation-based philanthropic agencies. In this paper, we consider the interaction between interrelated perspectives of a societal decision maker (e.g. the National Institute for Health and Clinical Excellence [NICE] in the UK) charged with the responsibility for approving new health interventions for reimbursement and the company that holds the patent for a new intervention. We establish optimal decision making from societal and company perspectives, allowing for trade-offs between the value and cost of research and the price of the new intervention. Given the current level of evidence, there exists a maximum (threshold) price acceptable to the decision maker. Submission for approval with prices above this threshold will be refused. Given the current level of evidence and the decision maker's threshold price, there exists a minimum (threshold) price acceptable to the company. If the decision maker's threshold price exceeds the company's, then current evidence is sufficient since any price between the thresholds is acceptable to both. On the other hand, if the decision maker's threshold price is lower than the company's, then no price is acceptable to both and the company's optimal strategy is to commission additional research. The methods are illustrated using a recent example from the literature.

Conceptual framework of knowledge management for ethical decision-making support in neonatal intensive care.

PubMed

Frize, Monique; Yang, Lan; Walker, Robin C; O'Connor, Annette M

2005-06-01

This research is built on the belief that artificial intelligence estimations need to be integrated into clinical social context to create value for health-care decisions. In sophisticated neonatal intensive care units (NICUs), decisions to continue or discontinue aggressive treatment are an integral part of clinical practice. High-quality evidence supports clinical decision-making, and a decision-aid tool based on specific outcome information for individual NICU patients will provide significant support for parents and caregivers in making difficult "ethical" treatment decisions. In our approach, information on a newborn patient's likely outcomes is integrated with the physician's interpretation and parents' perspectives into codified knowledge. Context-sensitive content adaptation delivers personalized and customized information to a variety of users, from physicians to parents. The system provides structuralized knowledge translation and exchange between all participants in the decision, facilitating collaborative decision-making that involves parents at every stage on whether to initiate, continue, limit, or terminate intensive care for their infant.

Investigating the Heart Pump Implant Decision Process: Opportunities for Decision Support Tools to Help

PubMed Central

Yang, Qian; Zimmerman, John; Steinfeld, Aaron; Carey, Lisa; Antaki, James F.

2016-01-01

Clinical decision support tools (DSTs) are computational systems that aid healthcare decision-making. While effective in labs, almost all these systems failed when they moved into clinical practice. Healthcare researchers speculated it is most likely due to a lack of user-centered HCI considerations in the design of these systems. This paper describes a field study investigating how clinicians make a heart pump implant decision with a focus on how to best integrate an intelligent DST into their work process. Our findings reveal a lack of perceived need for and trust of machine intelligence, as well as many barriers to computer use at the point of clinical decision-making. These findings suggest an alternative perspective to the traditional use models, in which clinicians engage with DSTs at the point of making a decision. We identify situations across patients’ healthcare trajectories when decision supports would help, and we discuss new forms it might take in these situations. PMID:27833397

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

PubMed

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

2017-03-01

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

Conceptual and Empirical Approaches to Financial Decision-making by Older Adults: Results from a Financial Decision-Making Rating Scale

PubMed Central

Lichtenberg, Peter A.; Ocepek-Welikson, Katja; Ficker, Lisa J.; Gross, Evan; Rahman-Filipiak, Analise; Teresi, Jeanne A.

2017-01-01

Objectives The objectives of this study were threefold: (1) to empirically test the conceptual model proposed by the Lichtenberg Financial Decision Rating Scale (LFDRS); (2) to examine the psychometric properties of the LFDRS contextual factors in financial decision-making by investigating both the reliability and convergent validity of the subscales and total scale, and (3) extending previous work on the scale through the collection of normative data on financial decision-making. Methods A convenience sample of 200 independent function and community dwelling older adults underwent cognitive and financial management testing and were interviewed using the LFDRS. Confirmatory factor analysis, internal consistency measures, and hierarchical regression were used in a sample of 200 community-dwelling older adults, all of whom were making or had recently made a significant financial decision. Results Results confirmed the scale’s reliability and supported the conceptual model. Convergent validity analyses indicate that as hypothesized, cognition is a significant predictor of risk scores. Financial management scores, however, were not predictive of decision-making risk scores. Conclusions The psychometric properties of the LFDRS support the scale’s use as it was proposed in Lichtenberg et al., 2015. Clinical Implications The LFDRS instructions and scale are provided for clinicians to use in financial capacity assessments. PMID:29077531

Decision-Making under Criteria Uncertainty

NASA Astrophysics Data System (ADS)

Kureychik, V. M.; Safronenkova, I. B.

2018-05-01

Uncertainty is an essential part of a decision-making procedure. The paper deals with the problem of decision-making under criteria uncertainty. In this context, decision-making under uncertainty, types and conditions of uncertainty were examined. The decision-making problem under uncertainty was formalized. A modification of the mathematical decision support method under uncertainty via ontologies was proposed. A critical distinction of the developed method is ontology usage as its base elements. The goal of this work is a development of a decision-making method under criteria uncertainty with the use of ontologies in the area of multilayer board designing. This method is oriented to improvement of technical-economic values of the examined domain.

Informed consent: clinical and legal issues in family practice.

PubMed

Searight, H R; Barbarash, R A

1994-04-01

While patient informed consent is an important clinical and legal dimension of specialty medical care, many important issues arise in primary care. Family physicians are in a unique position to implement informed consent discussions in the ethical spirit in which the doctrine was intended. Because of their long-term relationships with patients and sensitivity to psychosocial issues, family physicians can engage patients in collaborative health care decision making. Primary care physicians are optimally suited to assess patients' understanding of medical information and their competence. Instead of viewing the informed consent process simply as a necessary legal requirement, it should be a method for educating patients and allowing them to participate in their health care decision making.

Characteristics Associated With Preferences for Parent-Centered Decision Making in Neonatal Intensive Care.

PubMed

Weiss, Elliott Mark; Xie, Dawei; Cook, Noah; Coughlin, Katherine; Joffe, Steven

2018-05-01

Little is known about how characteristics of particular clinical decisions influence decision-making preferences by patients or their surrogates. A better understanding of the factors underlying preferences is essential to improve the quality of shared decision making. To identify the characteristics of particular decisions that are associated with parents' preferences for family- vs medical team-centered decision making across the spectrum of clinical decisions that arise in the neonatal intensive care unit (NICU). This cross-sectional survey assessed parents' preferences for parent- vs medical team-centered decision making across 16 clinical decisions, along with parents' assessments of 7 characteristics of those decisions. Respondents included 136 parents of infants in 1 of 3 academically affiliated hospital NICUs in Philadelphia, Pennsylvania, from January 7 to July 8, 2016. Respondents represented a wide range of educational levels, employment status, and household income but were predominantly female (109 [80.1%]), white (68 [50.0%]) or African American (53 [39.0%]), and married (81 of 132 responding [61.4%]). Preferences for parent-centered decision making. For each decision characteristic (eg, urgency), multivariable analyses tested whether middle and high levels of that characteristic (compared with low levels) were associated with a preference for parent-centered decision making, resulting in 2 odds ratios (ORs) per decision characteristic. Among the 136 respondents (109 women [80.1%] and 27 men [19.9%]; median age, 30 years [range, 18-43 years]), preferences for parent-centered decision making were positively associated with decisions that involved big-picture goals (middle OR, 2.01 [99% CI, 0.83-4.86]; high OR, 3.38 [99% CI, 1.48-7.75]) and that had the potential to harm the infant (middle OR, 1.32 [99% CI, 0.84-2.08]; high OR, 2.62 [99% CI, 1.67-4.11]). In contrast, preferences for parent-centered decision making were inversely associated with the following 4 decision characteristics: technical decisions (middle OR, 0.82 [99% CI, 0.45-1.52]; high OR, 0.48 [99% CI, 0.25-0.93]), the potential to benefit the infant (middle OR, 0.42 [99% CI, 0.16-1.05]; high OR, 0.21 [99% CI, 0.08-0.52]), requires medical expertise (middle OR, 0.48 [99% CI, 0.22-1.05]; high OR, 0.21 [99% CI, 0.10-0.48]), and a high level of urgency (middle OR, 0.47 [99% CI, 0.24-0.92]; high OR, 0.42 [99% CI, 0.22-0.83]). Preferences for parent-centered vs medical team-centered decision making among parents of infants in the NICU may vary systematically by the characteristics of particular clinical decisions. Incorporating this variation into shared decision making and endorsing models that allow parents to cede control to physicians in appropriate clinical circumstances might improve the quality and outcomes of medical decisions.

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.

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

PubMed

Demeter, Sandor J

2016-12-21

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.

Type-2 fuzzy set extension of DEMATEL method combined with perceptual computing for decision making

NASA Astrophysics Data System (ADS)

Hosseini, Mitra Bokaei; Tarokh, Mohammad Jafar

2013-05-01

Most decision making methods used to evaluate a system or demonstrate the weak and strength points are based on fuzzy sets and evaluate the criteria with words that are modeled with fuzzy sets. The ambiguity and vagueness of the words and different perceptions of a word are not considered in these methods. For this reason, the decision making methods that consider the perceptions of decision makers are desirable. Perceptual computing is a subjective judgment method that considers that words mean different things to different people. This method models words with interval type-2 fuzzy sets that consider the uncertainty of the words. Also, there are interrelations and dependency between the decision making criteria in the real world; therefore, using decision making methods that cannot consider these relations is not feasible in some situations. The Decision-Making Trail and Evaluation Laboratory (DEMATEL) method considers the interrelations between decision making criteria. The current study used the combination of DEMATEL and perceptual computing in order to improve the decision making methods. For this reason, the fuzzy DEMATEL method was extended into type-2 fuzzy sets in order to obtain the weights of dependent criteria based on the words. The application of the proposed method is presented for knowledge management evaluation criteria.

Decision curve analysis for assessing the usefulness of tests for making decisions to treat: an application to tests for prodromal psychosis.

PubMed

Pulleyblank, Ryan; Chuma, Jefter; Gilbody, Simon M; Thompson, Carl

2013-09-01

For a test to be considered useful for making treatment decisions, it is necessary that making treatment decisions based on the results of the test be a preferable strategy to making treatment decisions without the test. Decision curve analysis is a framework for assessing when a test would be expected to be useful, which integrates evidence of a test's performance characteristics (sensitivity and specificity), condition prevalence among at-risk patients, and patient preferences for treatment. We describe decision curve analysis generally and illustrate its potential through an application to tests for prodromal psychosis. Clinical psychosis is often preceded by a prodromal phase, but not all those with prodromal symptoms proceed to develop full psychosis. Patients identified as at risk for developing psychosis may be considered for proactive treatment to mitigate development of clinically defined psychosis. Tests exist to help identify those at-risk patients most likely to develop psychosis, but it is uncertain when these tests would be considered useful for making proactive treatment decisions. We apply decision curve analysis to results from a systematic review of studies investigating clinical tests for predicting the development of psychosis in at-risk populations, and present resulting decision curves that illustrate when the tests may be expected to be useful for making proactive treatment decisions.

[Shared decision-making in acute psychiatric medicine : Contraindication or a challenge?

PubMed

Heres, S; Hamann, J

2017-09-01

The concept of shared decision-making (SDM) has existed since the 1990s in multiple fields of somatic medicine but has only been poorly applied in psychiatric clinical routine despite broad acceptance and promising outcomes in clinical studies on its positive effects. The concept itself and its practicability in mental health are carefully assessed and strategies for its future implementation in psychiatric medicine are presented in this article. Ongoing clinical studies probing some of those strategies are further outlined. On top of the ubiquitous shortage of time in clinical routine, psychiatrists report their concern about patients' limited abilities in sharing decisions and their own fear of potentially harmful decisions resulting from a shared process. Misinterpretation of shared decision-making restricting the health care professional to rather an informed choice scenario and their own adhesion to the traditional paternalistic decision-making approach further add to SDM's underutilization. Those hurdles could be overcome by communication skill workshops for all mental health care professionals, including nursing personnels, psychologists, social workers and physicians, as well as the use of decision aids and training courses for patients to motivate and empower them in sharing decisions with the medical staff. By this, the patient-centered treatment approach demanded by guidelines, carers and users could be further facilitated in psychiatric clinical routine.

Clinical versus actuarial judgment.

PubMed

Dawes, R M; Faust, D; Meehl, P E

1989-03-31

Professionals are frequently consulted to diagnose and predict human behavior; optimal treatment and planning often hinge on the consultant's judgmental accuracy. The consultant may rely on one of two contrasting approaches to decision-making--the clinical and actuarial methods. Research comparing these two approaches shows the actuarial method to be superior. Factors underlying the greater accuracy of actuarial methods, sources of resistance to the scientific findings, and the benefits of increased reliance on actuarial approaches are discussed.

Grey situation group decision-making method based on prospect theory.

PubMed

Zhang, Na; Fang, Zhigeng; Liu, Xiaqing

2014-01-01

This paper puts forward a grey situation group decision-making method on the basis of prospect theory, in view of the grey situation group decision-making problems that decisions are often made by multiple decision experts and those experts have risk preferences. The method takes the positive and negative ideal situation distance as reference points, defines positive and negative prospect value function, and introduces decision experts' risk preference into grey situation decision-making to make the final decision be more in line with decision experts' psychological behavior. Based on TOPSIS method, this paper determines the weight of each decision expert, sets up comprehensive prospect value matrix for decision experts' evaluation, and finally determines the optimal situation. At last, this paper verifies the effectiveness and feasibility of the method by means of a specific example.

Grey Situation Group Decision-Making Method Based on Prospect Theory

PubMed Central

Zhang, Na; Fang, Zhigeng; Liu, Xiaqing

2014-01-01

This paper puts forward a grey situation group decision-making method on the basis of prospect theory, in view of the grey situation group decision-making problems that decisions are often made by multiple decision experts and those experts have risk preferences. The method takes the positive and negative ideal situation distance as reference points, defines positive and negative prospect value function, and introduces decision experts' risk preference into grey situation decision-making to make the final decision be more in line with decision experts' psychological behavior. Based on TOPSIS method, this paper determines the weight of each decision expert, sets up comprehensive prospect value matrix for decision experts' evaluation, and finally determines the optimal situation. At last, this paper verifies the effectiveness and feasibility of the method by means of a specific example. PMID:25197706

Poor Decision Making Is a Consequence of Cognitive Decline among Older Persons without Alzheimer’s Disease or Mild Cognitive Impairment

PubMed Central

Boyle, Patricia A.; Yu, Lei; Wilson, Robert S.; Gamble, Keith; Buchman, Aron S.; Bennett, David A.

2012-01-01

Objective Decision making is an important determinant of health and well-being across the lifespan but is critical in aging, when many influential decisions are made just as cognitive function declines. Increasing evidence suggests that older adults, even those without dementia, often make poor decisions and are selectively vulnerable to scams. To date, however, the factors associated with poor decision making in old age are unknown. The objective of this study was to test the hypothesis that poor decision making is a consequence of cognitive decline among older persons without Alzheimer’s disease or mild cognitive impairment. Methods Participants were 420 non-demented persons from the Memory and Aging Project, a longitudinal, clinical-pathologic cohort study of aging in the Chicago metropolitan area. All underwent repeated cognitive evaluations and subsequently completed assessments of decision making and susceptibility to scams. Decision making was measured using 12 items from a previously established performance-based measure and a self-report measure of susceptibility to scams. Results Cognitive function data were collected over an average of 5.5 years prior to the decision making assessment. Regression analyses were used to examine whether the prior rate of cognitive decline predicted the level of decision making and susceptibility to scams; analyses controlled for age, sex, education, and starting level of cognition. Among 420 persons without dementia, more rapid cognitive decline predicted poorer decision making and increased susceptibility to scams (p’s<0.001). Further, the relations between cognitive decline, decision making and scams persisted in analyses restricted to persons without any cognitive impairment (i.e., no dementia or even mild cognitive impairment). Conclusions Poor decision making is a consequence of cognitive decline among older persons without Alzheimer’s disease or mild cognitive impairment, those widely considered “cognitively healthy.” These findings suggest that even very subtle age-related changes in cognition have detrimental effects on judgment. PMID:22916287

Whose decision is it anyway? How clinicians support decision-making participation after acquired brain injury.

PubMed

Knox, Lucy; Douglas, Jacinta M; Bigby, Christine

2013-01-01

To raise professional awareness of factors that may influence the support offered by clinicians to people with acquired brain injury (ABI), and to consider the potential implications of these factors in terms of post-injury rehabilitation and living. A review of the literature was conducted to identify factors that determine how clinicians provide support and influence opportunities for individuals with ABI to participate in decision making across the rehabilitation continuum. Clinical case studies are used to highlight two specific issues: (1) hidden assumptions on the part of the practitioner, and (2) perceptions of risk operating in clinical practice. There are a range of factors which may influence the decision-making support provided by clinicians and, ultimately, shape lifetime outcomes for individuals with ABI. A multidimensional framework may assist clinicians to identify relevant factors and consider their potential implications including those that influence how clinicians involved in supporting decision making approach this task. Participation in decision making is an undisputed human right and central to the provision of person-centred care. Further research is required to understand how clinical practice can maximise both opportunities and support for increased decision-making participation by individuals with ABI. There is an increasing focus on the rights of all individuals to be supported to participate in decision making about their life. A number of changes associated with ABI mean that individuals with ABI will require support with decision making. Clinicians have a critical role in providing this support over the course of the rehabilitation continuum. Clinicians need to be aware of the range of factors that may influence the decision-making support they provide. A multidimensional framework may be used by clinicians to identify influences on the decision-making support they provide.

The capacity of people with a 'mental disability' to make a health care decision.

PubMed

Wong, J G; Clare, C H; Holland, A J; Watson, P C; Gunn, M

2000-03-01

Based on the developing clinical and legal literature, and using the framework adopted in draft legislation, capacity to make a valid decision about a clinically required blood test was investigated in three groups of people with a 'mental disability' (i.e. mental illness (chronic schizophrenia), 'learning disability' ('mental retardation', or intellectual or developmental disability), or, dementia) and a fourth, comparison group. The three 'mental disability' groups (N = 20 in the 'learning disability' group, N = 21 in each of the other two groups) were recruited through the relevant local clinical services; and through a phlebotomy clinic for the 'general population' comparison group (N = 20). The decision-making task was progressively simplified by presenting the relevant information as separate elements and modifying the assessment of capacity so that responding became gradually less dependent on expressive verbal ability. Compared with the 'general population' group, capacity to make the particular decision was significantly more impaired in the 'learning disability' and 'dementia' groups. Importantly, however, it was not more impaired among the 'mental illness' group. All the groups benefited as the decision-making task was simplified, but at different stages. In each of the 'mental disability' groups, one participant benefited only when responding did not require any expensive verbal ability. Consistent with current views, capacity reflected an interaction between the decision-maker and the demands of the decision-making task. The findings have implications for the way in which decisions about health care interventions are sought from people with a 'mental disability'. The methodology may be extended to assess capacity to make other legally-significant decisions.

Building the Evidence Base for Decision-making in Cancer Genomic Medicine Using Comparative Effectiveness Research

PubMed Central

Goddard, Katrina A.B.; Knaus, William A.; Whitlock, Evelyn; Lyman, Gary H.; Feigelson, Heather Spencer; Schully, Sheri D.; Ramsey, Scott; Tunis, Sean; Freedman, Andrew N.; Khoury, Muin J.; Veenstra, David L.

2013-01-01

Background The clinical utility is uncertain for many cancer genomic applications. Comparative effectiveness research (CER) can provide evidence to clarify this uncertainty. Objectives To identify approaches to help stakeholders make evidence-based decisions, and to describe potential challenges and opportunities using CER to produce evidence-based guidance. Methods We identified general CER approaches for genomic applications through literature review, the authors’ experiences, and lessons learned from a recent, seven-site CER initiative in cancer genomic medicine. Case studies illustrate the use of CER approaches. Results Evidence generation and synthesis approaches include comparative observational and randomized trials, patient reported outcomes, decision modeling, and economic analysis. We identified significant challenges to conducting CER in cancer genomics: the rapid pace of innovation, the lack of regulation, the limited evidence for clinical utility, and the beliefs that genomic tests could have personal utility without having clinical utility. Opportunities to capitalize on CER methods in cancer genomics include improvements in the conduct of evidence synthesis, stakeholder engagement, increasing the number of comparative studies, and developing approaches to inform clinical guidelines and research prioritization. Conclusions CER offers a variety of methodological approaches to address stakeholders’ needs. Innovative approaches are needed to ensure an effective translation of genomic discoveries. PMID:22516979

Interpreting “statistical hypothesis testing” results in clinical research

PubMed Central

Sarmukaddam, Sanjeev B.

2012-01-01

Difference between “Clinical Significance and Statistical Significance” should be kept in mind while interpreting “statistical hypothesis testing” results in clinical research. This fact is already known to many but again pointed out here as philosophy of “statistical hypothesis testing” is sometimes unnecessarily criticized mainly due to failure in considering such distinction. Randomized controlled trials are also wrongly criticized similarly. Some scientific method may not be applicable in some peculiar/particular situation does not mean that the method is useless. Also remember that “statistical hypothesis testing” is not for decision making and the field of “decision analysis” is very much an integral part of science of statistics. It is not correct to say that “confidence intervals have nothing to do with confidence” unless one understands meaning of the word “confidence” as used in context of confidence interval. Interpretation of the results of every study should always consider all possible alternative explanations like chance, bias, and confounding. Statistical tests in inferential statistics are, in general, designed to answer the question “How likely is the difference found in random sample(s) is due to chance” and therefore limitation of relying only on statistical significance in making clinical decisions should be avoided. PMID:22707861

[Treatment regulations and treatment limits: factors influencing clinical decision-making].

PubMed

Baberg, H T; Kielstein, R; de Zeeuw, J; Sass, H-M

2002-08-02

Providing or withholding of treatment is based on a variety of factors. We sought for criteria in clinical decision making and reviewed attitudes towards clinical intuition and the patient's will. 503 physicians (25.6 % females; mean age 36.3) in 49 departments at nine hospitals of the universities Bochum and Magdeburg filled in a validated questionnaire. The most important factors in the decision to carry out a therapy were "international standards" and "own experience". The decision to omit a therapy was mainly influenced by the "patient's wish". Physicians with a higher status judged their own experience higher than young physicians, who considered the experience of colleagues more important. "Severe accompanying illnesses" and "multimorbidity" were the most frequently named reasons to withdraw a therapy. Intuitive decision-making was rare, especially in young physicians, although these decisions were seldom risky and often successful. A patient's will plays a prominent role in clinical decision making, especially in decisions to withdraw or to withhold treatment. Cost containment and research interest have been called less important, a remarkable response from research-based university hospitals. Also remarkable is the recognition and importance of clinical intuition in situations of complex or missing information. This important aspect is rarely discussed in the literature or in medical education. The widely voiced concern that priorities in clinical care are guided by scientific interest, financial or technical possibilities could not be confirmed.

Attitudes of Oncologists, Oncology Nurses, and Patients from a Women's Clinic Regarding Medical Decision Making for Older and Younger Breast Cancer Patients.

ERIC Educational Resources Information Center

Beisecker, Analee E.; And Others

1994-01-01

Administered Beisecker Locus of Authority in Decision Making: Breast Cancer survey to 67 oncologists, 94 oncology nurses, and 288 patients from women's clinic. All groups believed that physicians should have dominant role in decision making. Nurses felt that patients should have more input than patients or physicians felt they should. Physicians…

When four principles are too many: bloodgate, integrity and an action-guiding model of ethical decision making in clinical practice.

PubMed

Muirhead, William

2012-04-01

Medical ethical analysis remains dominated by the principlist account first proposed by Beauchamp and Childress. This paper argues that the principlist model is unreflective of how ethical decisions are taken in clinical practice. Two kinds of medical ethical decisions are distinguished: biosocial ethics and clinical ethics. It is argued that principlism is an inappropriate model for clinical ethics as it is neither sufficiently action-guiding nor does it emphasise the professional integrity of the clinician. An alternative model is proposed for decision making in the realm of clinical ethics.

Shared decision making in mental health: the importance for current clinical practice.

PubMed

Alguera-Lara, Victoria; Dowsey, Michelle M; Ride, Jemimah; Kinder, Skye; Castle, David

2017-12-01

We reviewed the literature on shared decision making (regarding treatments in psychiatry), with a view to informing our understanding of the decision making process and the barriers that exist in clinical practice. Narrative review of published English-language articles. After culling, 18 relevant articles were included. Themes identified included models of psychiatric care, benefits for patients, and barriers. There is a paucity of published studies specifically related to antipsychotic medications. Shared decision making is a central part of the recovery paradigm and is of increasing importance in mental health service delivery. The field needs to better understand the basis on which decisions are reached regarding psychiatric treatments. Discrete choice experiments might be useful to inform the development of tools to assist shared decision making in psychiatry.

Use of handheld computers in clinical practice: a systematic review.

PubMed

Mickan, Sharon; Atherton, Helen; Roberts, Nia Wyn; Heneghan, Carl; Tilson, Julie K

2014-07-06

Many healthcare professionals use smartphones and tablets to inform patient care. Contemporary research suggests that handheld computers may support aspects of clinical diagnosis and management. This systematic review was designed to synthesise high quality evidence to answer the question; Does healthcare professionals' use of handheld computers improve their access to information and support clinical decision making at the point of care? A detailed search was conducted using Cochrane, MEDLINE, EMBASE, PsycINFO, Science and Social Science Citation Indices since 2001. Interventions promoting healthcare professionals seeking information or making clinical decisions using handheld computers were included. Classroom learning and the use of laptop computers were excluded. Two authors independently selected studies, assessed quality using the Cochrane Risk of Bias tool and extracted data. High levels of data heterogeneity negated statistical synthesis. Instead, evidence for effectiveness was summarised narratively, according to each study's aim for assessing the impact of handheld computer use. We included seven randomised trials investigating medical or nursing staffs' use of Personal Digital Assistants. Effectiveness was demonstrated across three distinct functions that emerged from the data: accessing information for clinical knowledge, adherence to guidelines and diagnostic decision making. When healthcare professionals used handheld computers to access clinical information, their knowledge improved significantly more than peers who used paper resources. When clinical guideline recommendations were presented on handheld computers, clinicians made significantly safer prescribing decisions and adhered more closely to recommendations than peers using paper resources. Finally, healthcare professionals made significantly more appropriate diagnostic decisions using clinical decision making tools on handheld computers compared to colleagues who did not have access to these tools. For these clinical decisions, the numbers need to test/screen were all less than 11. Healthcare professionals' use of handheld computers may improve their information seeking, adherence to guidelines and clinical decision making. Handheld computers can provide real time access to and analysis of clinical information. The integration of clinical decision support systems within handheld computers offers clinicians the highest level of synthesised evidence at the point of care. Future research is needed to replicate these early results and to identify beneficial clinical outcomes.

A qualitative study on community pharmacists' decision-making process when making a diagnosis.

PubMed

Sinopoulou, Vassiliki; Summerfield, Paul; Rutter, Paul

2017-12-01

Self-care policies are increasingly directing patients to seek advice from community pharmacists. This means pharmacists need to have sound diagnostic decision-making skills to enable them to recognise a variety of conditions. The aim of this study was to investigate the process by which pharmacists manage patient signs and symptoms and to explore their use of decision-making for diagnostic purposes. Data were collected through semi-structured, face-to-face interviews with community pharmacists working in England, between August 2013 and November 2014. Pharmacists were asked to share their experiences on how they performed patient consultations, and more specifically how they would approach a hypothetical headache scenario. As part of the interview, their sources of knowledge and experience were also explored. Framework analysis was used to identify themes and subthemes. Eight interviews were conducted with pharmacists who had a wide range of working practice, from 1 year through to 40 years of experience. The pharmacists' main motivations during consultations were product selection and risk minimisation. Their questioning approach and decision-making relied heavily on mnemonic methods. This led to poor quality information gathering-although pharmacists acknowledged they needed to "delve deeper" but were often unable to articulate how or why. Some pharmacists exhibited elements of clinical reasoning in their consultations, but this seemed, mostly, to be unconscious and subsequently applied inappropriately. Overall, pharmacists exhibited poor decision-making ability, and often decisions were based on personal belief and experiences rather than evidence. Community pharmacists relied heavily on mnemonic methods to manage patients' signs and symptoms with diagnosis-based decision-making being seldom employed. These findings suggest practicing pharmacists should receive more diagnostic training. © 2017 John Wiley & Sons, Ltd.

Doing what's right: A grounded theory of ethical decision-making in occupational therapy.

PubMed

VanderKaay, Sandra; Letts, Lori; Jung, Bonny; Moll, Sandra E

2018-04-20

Ethical decision-making is an important aspect of reasoning in occupational therapy practice. However, the process of ethical decision-making within the broader context of reasoning is yet to be clearly explicated. The purpose of this study was to advance a theoretical understanding of the process by which occupational therapists make ethical decisions in day-to-day practice. A constructivist grounded theory approach was adopted, incorporating in-depth semi-structured interviews with 18 occupational therapists from a range of practice settings and years of experience. Initially, participants nominated as key informants who were able to reflect on their decision-making processes were recruited. Theoretical sampling informed subsequent stages of data collection. Participants were asked to describe their process of ethical decision-making using scenarios from clinical practice. Interview transcripts were analyzed using a systematic process of initial then focused coding, and theoretical categorization to construct a theory regarding the process of ethical decision-making. An ethical decision-making prism was developed to capture three main processes: Considering the Fundamental Checklist, Consulting Others, and Doing What's Right. Ethical decision-making appeared to be an inductive and dialectical process with the occupational therapist at its core. Study findings advance our understanding of ethical decision-making in day-to-day clinical practice.

Identification of design features to enhance utilization and acceptance of systems for Internet-based decision support at the point of care.

PubMed

Gadd, C S; Baskaran, P; Lobach, D F

1998-01-01

Extensive utilization of point-of-care decision support systems will be largely dependent on the development of user interaction capabilities that make them effective clinical tools in patient care settings. This research identified critical design features of point-of-care decision support systems that are preferred by physicians, through a multi-method formative evaluation of an evolving prototype of an Internet-based clinical decision support system. Clinicians used four versions of the system--each highlighting a different functionality. Surveys and qualitative evaluation methodologies assessed clinicians' perceptions regarding system usability and usefulness. Our analyses identified features that improve perceived usability, such as telegraphic representations of guideline-related information, facile navigation, and a forgiving, flexible interface. Users also preferred features that enhance usefulness and motivate use, such as an encounter documentation tool and the availability of physician instruction and patient education materials. In addition to identifying design features that are relevant to efforts to develop clinical systems for point-of-care decision support, this study demonstrates the value of combining quantitative and qualitative methods of formative evaluation with an iterative system development strategy to implement new information technology in complex clinical settings.

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

PubMed

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

2017-10-01

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 to take social and technological mediation into account. © 2016 The Authors Journal of Evaluation in Clinical Practice Published by John Wiley & Sons Ltd.

A practical guide to assessing clinical decision-making skills using the key features approach.

PubMed

Farmer, Elizabeth A; Page, Gordon

2005-12-01

This paper in the series on professional assessment provides a practical guide to writing key features problems (KFPs). Key features problems test clinical decision-making skills in written or computer-based formats. They are based on the concept of critical steps or 'key features' in decision making and represent an advance on the older, less reliable patient management problem (PMP) formats. The practical steps in writing these problems are discussed and illustrated by examples. Steps include assembling problem-writing groups, selecting a suitable clinical scenario or problem and defining its key features, writing the questions, selecting question response formats, preparing scoring keys, reviewing item quality and item banking. The KFP format provides educators with a flexible approach to testing clinical decision-making skills with demonstrated validity and reliability when constructed according to the guidelines provided.

Firefighter willingness to participate in a stem cell clinical trial for burns: A mixed methods study.

PubMed

Horch, Jenny D; Carr, Eloise C J; Harasym, Patricia; Burnett, Lindsay; Biernaskie, Jeff; Gabriel, Vincent

2016-12-01

Adult stem cells represent a potentially renewable and autologous source of cells to regenerate skin and improve wound healing. Firefighters are at risk of sustaining a burn and potentially benefiting from a split thickness skin graft (STSG). This mixed methods study examined firefighter willingness to participate in a future stem cell clinical trial, outcome priorities and factors associated with this decision. A sequential explanatory mixed methods design was used. The quantitative phase (online questionnaire) was followed by the qualitative phase (semi-structured interviews). A sample of 149 firefighters completed the online survey, and a purposeful sample of 15 firefighters was interviewed. A majority (74%) reported they would participate in a future stem cell clinical trial if they experienced burn benefiting from STSG. Hypothetical concerns related to receiving a STSG were pain, itch, scarring/redness and skin durability. Participants indicated willingness to undergo stem cell therapy if the risk of no improvement was 43% or less. Risk tolerance was predicted by perceived social support and having children. Interviews revealed four main themes: a desire to help others, improving clinical outcomes, trusting relationships, and a belief in scientific investigation. Many participants admitted lacking sufficient knowledge to make an informed decision regarding stem cell therapies. Firefighters indicated they were largely willing to participate in a stem cell clinical trial but also indicated a lack of knowledge upon which to make a decision. Public education of the role of stem cells in STSG will be increasingly important as clinical trials are developed. Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.

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

PubMed

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

2017-05-11

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

How to use multi-criteria decision analysis methods for reimbursement decision-making in healthcare: a step-by-step guide.

PubMed

Diaby, Vakaramoko; Goeree, Ron

2014-02-01

In recent years, the quest for more comprehensiveness, structure and transparency in reimbursement decision-making in healthcare has prompted the research into alternative decision-making frameworks. In this environment, multi-criteria decision analysis (MCDA) is arising as a valuable tool to support healthcare decision-making. In this paper, we present the main MCDA decision support methods (elementary methods, value-based measurement models, goal programming models and outranking models) using a case study approach. For each family of methods, an example of how an MCDA model would operate in a real decision-making context is presented from a critical perspective, highlighting the parameters setting, the selection of the appropriate evaluation model as well as the role of sensitivity and robustness analyses. This study aims to provide a step-by-step guide on how to use MCDA methods for reimbursement decision-making in healthcare.

Decision-making in palliative care: a reflective case study.

PubMed

Birchall, Melissa

2005-01-01

Critical examination of the processes by which we as nurses judge and reach clinical decisions is important. It facilitates the maintenance and refinement of good standards of nursing care and the pinpointing of areas where improvement is needed. In turn this potentially could support broader validation of nurse expertise and contribute to emancipation of the nursing profession. As pure theory, clinical decision-making may appear abstract and alien to nurses struggling in 'the swampy lowlands' (Schon 1983) of the realities of practice. This paper explores some of the key concepts in decision-making theory by introducing, then integrating, them in a reflective case study. The case study, which examines a 'snapshot' of the patient and practitioner's journey, interwoven with theory surrounding clinical decision-making, may aid understanding and utility of concepts and theories in practice.

Understanding shared decision making in pediatric otolaryngology.

PubMed

Chorney, Jill; Haworth, Rebecca; Graham, M Elise; Ritchie, Krista; Curran, Janet A; Hong, Paul

2015-05-01

The aim of this study was to describe the level of decisional conflict experienced by parents considering surgery for their children and to determine if decisional conflict and perceptions of shared decision making are related. Prospective cohort study. Academic pediatric otolaryngology clinic. Sixty-five consecutive parents of children who underwent surgical consultation for elective otolaryngological procedures were prospectively enrolled. Participants completed the Shared Decision Making Questionnaire and the Decisional Conflict Scale. Surgeons completed the Shared Decision Making Questionnaire-Physician version. Eleven participants (16.9%) scored over 25 on the Decisional Conflict Scale, a previously defined clinical cutoff indicating significant decisional conflict. Parent years of education and parent ratings of shared decision making were significantly correlated with decisional conflict (positively and negatively correlated, respectively). A logistic regression indicated that shared decision making but not education predicted the presence of significant decisional conflict. Parent and physician ratings of shared decision making were not related, and there was no correlation between physician ratings of shared decision making and parental decisional conflict. Many parents experienced considerable decisional conflict when making decisions about their child's surgical treatment. Parents who perceived themselves as being more involved in the decision-making process reported less decisional conflict. Parents and physicians had different perceptions of shared decision making. Future research should develop and assess interventions to increase parents' involvement in decision making and explore the impact of significant decisional conflict on health outcomes. © American Academy of Otolaryngology-Head and Neck Surgery Foundation 2015.

How to Choose? Using the Delphi Method to Develop Consensus Triggers and Indicators for Disaster Response.

PubMed

Lis, Rebecca; Sakata, Vicki; Lien, Onora

2017-08-01

To identify key decisions along the continuum of care (conventional, contingency, and crisis) and the critical triggers and data elements used to inform those decisions concerning public health and health care response during an emergency. A classic Delphi method, a consensus-building survey technique, was used with clinicians around Washington State to identify regional triggers and indicators. Additionally, using a modified Delphi method, we combined a workshop and single-round survey with panelists from public health (state and local) and health care coalitions to identify consensus state-level triggers and indicators. In the clinical survey, 122 of 223 proposed triggers or indicators (43.7%) reached consensus and were deemed important in regional decision-making during a disaster. In the state-level survey, 110 of 140 proposed triggers or indicators (78.6%) reached consensus and were deemed important in state-level decision-making during a disaster. The identification of consensus triggers and indicators for health care emergency response is crucial in supporting a comprehensive health care situational awareness process. This can inform the creation of standardized questions to ask health care, public health, and other partners to support decision-making during a response. (Disaster Med Public Health Preparedness. 2017;11:467-472).

Emergency nurses' knowledge, attitude and clinical decision making skills about pain.

PubMed

Ucuzal, Meral; Doğan, Runida

2015-04-01

Pain is the most common reason that patients come to the emergency department. Emergency nurses have an indispensable role in the management of this pain. The aim of this study was to examine emergency nurses' knowledge, attitude and clinical decision-making skills about pain. This descriptive study was conducted in a state and a university hospital between September and October 2012 in Malatya, Turkey. Of 98 nurses working in the emergency departments of these two hospitals, 57 returned the questionnaires. The response rate was 58%. Data were collected using the Demographic Information Questionnaire, Knowledge and Attitude Questionnaire about Pain and Clinical Decision Making Survey. Frequency, percentage, mean and standard deviation were used to evaluate data. 75.4% of participant nurses knew that patients' own statement about their pain was the most reliable indicator during pain assessment. Almost half of the nurses believed that patients should be encouraged to endure the pain as much as possible before resorting to a pain relief method. The results also indicate that most of nurses think that a sleeping patient does not have any pain and pain relief should be postponed as it can influence the diagnosis negatively. It is determined that the pain scale was not used frequently. Only 35.1% of nurses reported keeping records of pain. Despite all the recommendations of substantial past research the results of this study indicate that emergency nurses continue to demonstrate inadequate knowledge, clinical decision-making skills and negative attitudes about pain. Copyright © 2014 Elsevier Ltd. All rights reserved.

Development of a real-time clinical decision support system upon the web mvc-based architecture for prostate cancer treatment

PubMed Central

2011-01-01

Background A real-time clinical decision support system (RTCDSS) with interactive diagrams enables clinicians to instantly and efficiently track patients' clinical records (PCRs) and improve their quality of clinical care. We propose a RTCDSS to process online clinical informatics from multiple databases for clinical decision making in the treatment of prostate cancer based on Web Model-View-Controller (MVC) architecture, by which the system can easily be adapted to different diseases and applications. Methods We designed a framework upon the Web MVC-based architecture in which the reusable and extractable models can be conveniently adapted to other hospital information systems and which allows for efficient database integration. Then, we determined the clinical variables of the prostate cancer treatment based on participating clinicians' opinions and developed a computational model to determine the pretreatment parameters. Furthermore, the components of the RTCDSS integrated PCRs and decision factors for real-time analysis to provide evidence-based diagrams upon the clinician-oriented interface for visualization of treatment guidance and health risk assessment. Results The resulting system can improve quality of clinical treatment by allowing clinicians to concurrently analyze and evaluate the clinical markers of prostate cancer patients with instantaneous clinical data and evidence-based diagrams which can automatically identify pretreatment parameters. Moreover, the proposed RTCDSS can aid interactions between patients and clinicians. Conclusions Our proposed framework supports online clinical informatics, evaluates treatment risks, offers interactive guidance, and provides real-time reference for decision making in the treatment of prostate cancer. The developed clinician-oriented interface can assist clinicians in conveniently presenting evidence-based information to patients and can be readily adapted to an existing hospital information system and be easily applied in other chronic diseases. PMID:21385459

Understanding clinical and non-clinical decisions under uncertainty: a scenario-based survey.

PubMed

Simianu, Vlad V; Grounds, Margaret A; Joslyn, Susan L; LeClerc, Jared E; Ehlers, Anne P; Agrawal, Nidhi; Alfonso-Cristancho, Rafael; Flaxman, Abraham D; Flum, David R

2016-12-01

Prospect theory suggests that when faced with an uncertain outcome, people display loss aversion by preferring to risk a greater loss rather than incurring certain, lesser cost. Providing probability information improves decision making towards the economically optimal choice in these situations. Clinicians frequently make decisions when the outcome is uncertain, and loss aversion may influence choices. This study explores the extent to which prospect theory, loss aversion, and probability information in a non-clinical domain explains clinical decision making under uncertainty. Four hundred sixty two participants (n = 117 non-medical undergraduates, n = 113 medical students, n = 117 resident trainees, and n = 115 medical/surgical faculty) completed a three-part online task. First, participants completed an iced-road salting task using temperature forecasts with or without explicit probability information. Second, participants chose between less or more risk-averse ("defensive medicine") decisions in standardized scenarios. Last, participants chose between recommending therapy with certain outcomes or risking additional years gained or lost. In the road salting task, the mean expected value for decisions made by clinicians was better than for non-clinicians(-$1,022 vs -$1,061; <0.001). Probability information improved decision making for all participants, but non-clinicians improved more (mean improvement of $64 versus $33; p = 0.027). Mean defensive decisions decreased across training level (medical students 2.1 ± 0.9, residents 1.6 ± 0.8, faculty1.6 ± 1.1; p-trend < 0.001) and prospect-theory-concordant decisions increased (25.4%, 33.9%, and 40.7%;p-trend = 0.016). There was no relationship identified between road salting choices with defensive medicine and prospect-theory-concordant decisions. All participants made more economically-rational decisions when provided explicit probability information in a non-clinical domain. However, choices in the non-clinical domain were not related to prospect-theory concordant decision making and risk aversion tendencies in the clinical domain. Recognizing this discordance may be important when applying prospect theory to interventions aimed at improving clinical care.

Shared Decision-Making as the Future of Emergency Cardiology.

PubMed

Probst, Marc A; Noseworthy, Peter A; Brito, Juan P; Hess, Erik P

2018-02-01

Shared decision-making is playing an increasingly large role in emergency cardiovascular care. Although there are many challenges to successfully performing shared decision-making in the emergency department, there are numerous clinical scenarios in which it should be used. In this article, we explore new research and emerging decision aids in the following emergency care scenarios: (1) low-risk chest pain; (2) new-onset atrial fibrillation; and (3) moderate-risk syncope. These decision aids are designed to engage patients and facilitate shared decision-making for specific treatment and disposition (admit vs discharge) decisions. We then offer a 3-step, practical approach to performing shared decision-making in the acute care setting, on the basis of broad stakeholder input and previous conceptual work. Step 1 involves simply acknowledging that a clinical decision needs to be made. Step 2 involves a shared discussion about the working diagnosis and the options for care in the context of the patient's values, preferences, and circumstances. The third and final step requires the patient and provider to agree on a plan of action regarding further medical care. The implementation of shared decision-making in emergency cardiology has the potential to shift the paradigm of clinical practice from paternalism toward mutualism and improve the quality and experience of care for our patients. Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Transforming clinical practice guidelines and clinical pathways into fast-and-frugal decision trees to improve clinical care strategies.

PubMed

Djulbegovic, Benjamin; Hozo, Iztok; Dale, William

2018-02-27

Contemporary delivery of health care is inappropriate in many ways, largely due to suboptimal Q5 decision-making. A typical approach to improve practitioners' decision-making is to develop evidence-based clinical practice guidelines (CPG) by guidelines panels, who are instructed to use their judgments to derive practice recommendations. However, mechanisms for the formulation of guideline judgments remains a "black-box" operation-a process with defined inputs and outputs but without sufficient knowledge of its internal workings. Increased explicitness and transparency in the process can be achieved by implementing CPG as clinical pathways (CPs) (also known as clinical algorithms or flow-charts). However, clinical recommendations thus derived are typically ad hoc and developed by experts in a theory-free environment. As any recommendation can be right (true positive or negative), or wrong (false positive or negative), the lack of theoretical structure precludes the quantitative assessment of the management strategies recommended by CPGs/CPs. To realize the full potential of CPGs/CPs, they need to be placed on more solid theoretical grounds. We believe this potential can be best realized by converting CPGs/CPs within the heuristic theory of decision-making, often implemented as fast-and-frugal (FFT) decision trees. This is possible because FFT heuristic strategy of decision-making can be linked to signal detection theory, evidence accumulation theory, and a threshold model of decision-making, which, in turn, allows quantitative analysis of the accuracy of clinical management strategies. Fast-and-frugal provides a simple and transparent, yet solid and robust, methodological framework connecting decision science to clinical care, a sorely needed missing link between CPGs/CPs and patient outcomes. We therefore advocate that all guidelines panels express their recommendations as CPs, which in turn should be converted into FFTs to guide clinical care. © 2018 John Wiley & Sons, Ltd.

Education in the Workplace for the Physician: Clinical Management States as an Organizing Framework.

ERIC Educational Resources Information Center

Greenes, Robert A.

2000-01-01

Trends in health information technology include (1) improved access to patient care information; (2) methods for patient-doctor interaction and decision making; (3) computerized practice guidelines; and (4) the concept of patients being in clinical management states (CMS). Problem-specific environments and CMS-related resources should be the focus…

Validation of the Quantitative Diagnostic Thinking Inventory for Athletic Training: A Pilot Study

ERIC Educational Resources Information Center

Kicklighter, Taz; Barnum, Mary; Geisler, Paul R.; Martin, Malissa

2016-01-01

Context: The cognitive process of making a clinical decision lies somewhere on a continuum between novices using hypothetico-deductive reasoning and experts relying more on case pattern recognition. Although several methods exist for measuring facets of clinical reasoning in specific situations, none have been experimentally applied, as of yet, to…

A fourth dimension in decision making in hepatology.

PubMed

Ilan, Yaron

2010-12-01

Today, the assessment of liver function in patients suffering from acute or chronic liver disease is based on liver biopsy and blood tests including synthetic function, liver enzymes and viral load, most of which provide only circumstantial evidence as to the degree of hepatic impairment. Most of these tests lack the degree of sensitivity to be useful for follow-up of these patients at the frequency that is needed for decision making in clinical hepatology. Accurate assessment of liver function is essential to determine both short- and long-term prognosis, and for making decisions about liver and non-liver surgery, TIPS, chemoembolization or radiofrequency ablation in patients with chronic liver disease. Liver function tests can serve as the basis for accurate decision-making regarding the need for liver transplantation in the setting of acute failure or in patients with chronic liver disease. The liver metabolic breath test relies on measuring exhaled (13) C tagged methacetin, which is metabolized only by the liver. Measuring this liver-specific substrate by means of molecular correlation spectroscopy is a rapid, non-invasive method for assessing liver function at the point-of-care. The (13) C methacetin breath test (MBT) is a powerful tool to aid clinical hepatologists in bedside decision-making. Our recent findings regarding the ability of point-of-care (13) C MBT to assess the hepatic functional reserve in patients with acute and chronic liver disease are reviewed along with suggested treatment algorithms for common liver disorders. © 2010 The Japan Society of Hepatology.

Shared decision-making, gender and new technologies.

PubMed

Zeiler, Kristin

2007-09-01

Much discussion of decision-making processes in medicine has been patient-centred. It has been assumed that there is, most often, one patient. Less attention has been given to shared decision-making processes where two or more patients are involved. This article aims to contribute to this special area. What conditions need to be met if decision-making can be said to be shared? What is a shared decision-making process and what is a shared autonomous decision-making process? Why make the distinction? Examples are drawn from the area of new reproductive medicine and clinical genetics. Possible gender-differences in shared decision-making are discussed.

Clinical errors that can occur in the treatment decision-making process in psychotherapy.

PubMed

Park, Jake; Goode, Jonathan; Tompkins, Kelley A; Swift, Joshua K

2016-09-01

Clinical errors occur in the psychotherapy decision-making process whenever a less-than-optimal treatment or approach is chosen when working with clients. A less-than-optimal approach may be one that a client is unwilling to try or fully invest in based on his/her expectations and preferences, or one that may have little chance of success based on contraindications and/or limited research support. The doctor knows best and the independent choice models are two decision-making models that are frequently used within psychology, but both are associated with an increased likelihood of errors in the treatment decision-making process. In particular, these models fail to integrate all three components of the definition of evidence-based practice in psychology (American Psychological Association, 2006). In this article we describe both models and provide examples of clinical errors that can occur in each. We then introduce the shared decision-making model as an alternative that is less prone to clinical errors. PsycINFO Database Record (c) 2016 APA, all rights reserved

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

PubMed Central

2012-01-01

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

Are patient decision aids the best way to improve clinical decision making? Report of the IPDAS Symposium.

PubMed

Holmes-Rovner, Margaret; Nelson, Wendy L; Pignone, Michael; Elwyn, Glyn; Rovner, David R; O'Connor, Annette M; Coulter, Angela; Correa-de-Araujo, Rosaly

2007-01-01

This article reports on the International Patient Decision Aid Standards Symposium held in 2006 at the annual meeting of the Society for Medical Decision Making in Cambridge, Massachusetts. The symposium featured a debate regarding the proposition that "decision aids are the best way to improve clinical decision making.'' The formal debate addressed the theoretical problem of the appropriate gold standard for an improved decision, efficacy of decision aids, and prospects for implementation. Audience comments and questions focused on both theory and practice: the often unacknowledged roots of decision aids in expected utility theory and the practical problems of limited patient decision aid implementation in health care. The participants' vote on the proposition was approximately half for and half against.

National Evidence on the Use of Shared Decision Making in Prostate-Specific Antigen Screening

PubMed Central

Han, Paul K. J.; Kobrin, Sarah; Breen, Nancy; Joseph, Djenaba A.; Li, Jun; Frosch, Dominick L.; Klabunde, Carrie N.

2013-01-01

PURPOSE Recent clinical practice guidelines on prostate cancer screening using the prostate-specific antigen (PSA) test (PSA screening) have recommended that clinicians practice shared decision making—a process involving clinician-patient discussion of the pros, cons, and uncertainties of screening. We undertook a study to determine the prevalence of shared decision making in both PSA screening and nonscreening, as well as patient characteristics associated with shared decision making. METHODS A nationally representative sample of 3,427 men aged 50 to 74 years participating in the 2010 National Health Interview Survey responded to questions on the extent of shared decision making (past physician-patient discussion of advantages, disadvantages, and scientific uncertainty associated with PSA screening), PSA screening intensity (tests in past 5 years), and sociodemographic and health-related characteristics. RESULTS Nearly two-thirds (64.3%) of men reported no past physician-patient discussion of advantages, disadvantages, or scientific uncertainty (no shared decision making); 27.8% reported discussion of 1 to 2 elements only (partial shared decision making); 8.0% reported discussion of all 3 elements (full shared decision making). Nearly one-half (44.2%) reported no PSA screening, 27.8% reported low-intensity (less-than-annual) screening, and 25.1% reported high-intensity (nearly annual) screening. Absence of shared decision making was more prevalent in men who were not screened; 88% (95% CI, 86.2%–90.1%) of nonscreened men reported no shared decision making compared with 39% (95% CI, 35.0%–43.3%) of men undergoing high-intensity screening. Extent of shared decision making was associated with black race, Hispanic ethnicity, higher education, health insurance, and physician recommendation. Screening intensity was associated with older age, higher education, usual source of medical care, and physician recommendation, as well as with partial vs no or full shared decision making. CONCLUSIONS Most US men report little shared decision making in PSA screening, and the lack of shared decision making is more prevalent in nonscreened than in screened men. Screening intensity is greatest with partial shared decision making, and different elements of shared decision making are associated with distinct patient characteristics. Shared decision making needs to be improved in decisions for and against PSA screening. PMID:23835816

Clinical decision making: how surgeons do it.

PubMed

Crebbin, Wendy; Beasley, Spencer W; Watters, David A K

2013-06-01

Clinical decision making is a core competency of surgical practice. It involves two distinct types of mental process best considered as the ends of a continuum, ranging from intuitive and subconscious to analytical and conscious. In practice, individual decisions are usually reached by a combination of each, according to the complexity of the situation and the experience/expertise of the surgeon. An expert moves effortlessly along this continuum, according to need, able to apply learned rules or algorithms to specific presentations, choosing these as a result of either pattern recognition or analytical thinking. The expert recognizes and responds quickly to any mismatch between what is observed and what was expected, coping with gaps in information and making decisions even where critical data may be uncertain or unknown. Even for experts, the cognitive processes involved are difficult to articulate as they tend to be very complex. However, if surgeons are to assist trainees in developing their decision-making skills, the processes need to be identified and defined, and the competency needs to be measurable. This paper examines the processes of clinical decision making in three contexts: making a decision about how to manage a patient; preparing for an operative procedure; and reviewing progress during an operative procedure. The models represented here are an exploration of the complexity of the processes, designed to assist surgeons understand how expert clinical decision making occurs and to highlight the challenge of teaching these skills to surgical trainees. © 2013 The Authors. ANZ Journal of Surgery © 2013 Royal Australasian College of Surgeons.

The pitfalls of premature closure: clinical decision-making in a case of aortic dissection

PubMed Central

Kumar, Bharat; Kanna, Balavenkatesh; Kumar, Suresh

2011-01-01

Premature closure is a type of cognitive error in which the physician fails to consider reasonable alternatives after an initial diagnosis is made. It is a common cause of delayed diagnosis and misdiagnosis borne out of a faulty clinical decision-making process. The authors present a case of aortic dissection in which premature closure was avoided by the aggressive pursuit of the appropriate differential diagnosis, and discuss the importance of disciplined clinical decision-making in the setting of chest pain. PMID:22679162

Long-Term Retention after Self-Instructional Methods.

ERIC Educational Resources Information Center

Puskas, Jane C.; And Others

1992-01-01

A study of the effectiveness of self-instructional booklets and computer software for teaching dental students endodontic diagnosis found that the self-teaching method may be as effective as traditional lectures in teaching concepts central to development of clinical decision-making skills. Sampling difficulties created problems in assessment of…

Shared decision making after severe stroke-How can we improve patient and family involvement in treatment decisions?

PubMed

Visvanathan, Akila; Dennis, Martin; Mead, Gillian; Whiteley, William N; Lawton, Julia; Doubal, Fergus Neil

2017-12-01

People who are well may regard survival with disability as being worse than death. However, this is often not the case when those surviving with disability (e.g. stroke survivors) are asked the same question. Many routine treatments provided after an acute stroke (e.g. feeding via a tube) increase survival, but with disability. Therefore, clinicians need to support patients and families in making informed decisions about the use of these treatments, in a process termed shared decision making. This is challenging after acute stroke: there is prognostic uncertainty, patients are often too unwell to participate in decision making, and proxies may not know the patients' expressed wishes (i.e. values). Patients' values also change over time and in different situations. There is limited evidence on successful methods to facilitate this process. Changes targeted at components of shared decision making (e.g. decision aids to provide information and discussing patient values) increase patient satisfaction. How this influences decision making is unclear. Presumably, a "shared decision-making tool" that introduces effective changes at various stages in this process might be helpful after acute stroke. For example, by complementing professional judgement with predictions from prognostic models, clinicians could provide information that is more accurate. Decision aids that are personalized may be helpful. Further qualitative research can provide clinicians with a better understanding of patient values and factors influencing this at different time points after a stroke. The evaluation of this tool in its success to achieve outcomes consistent with patients' values may require more than one clinical trial.

Clinical use of patient decision-making aids for stone patients.

PubMed

Lim, Amy H; Streeper, Necole M; Best, Sara L; Penniston, Kristina L; Nakada, Stephen Y

2017-08-01

Patient decision-making aids (PDMAs) help patients make informed healthcare decisions and improve patient satisfaction. The utility of PDMAs for patients considering treatments for urolithiasis has not yet been published. We report our experience using PDMAs developed at our institution in the outpatient clinical setting in patients considering a variety of treatment options for stones. Patients with radiographically confirmed urolithiasis were given PDMAs regarding treatment options for their stone(s) based on their clinical profile. We assessed patients' satisfaction, involvedness, and feeling of making a more informed decision with utilization of the PDMAs using a Likert Scale Questionnaire. Information was also collected regarding previous stone passage, history and type of surgical intervention for urolithiasis, and level of education. Patients (n = 43; 18 males, 23 females and two unknown) 53 +/- 14years old were included. Patients reported that they understood the advantages and disadvantages outlined in the PDMAs (97%), that the PDMAs helped them make a more informed decision (83%) and felt more involved in the decision making process (88%). Patients reported that the aids were presented in a balanced manner and used up-to-date scientific information (100%, 84% respectively). Finally, a majority of the patients prefer an expert's opinion when making a treatment decision (98%) with 73% of patients preferring to form their own opinion based on available information. Previous stone surgery was associated with patients feeling more involved with the decision making process (p = 0.0465). PDMAs have a promising role in shared decision-making in the setting of treatment options for nephrolithiasis.

Shared Decision Making at the Limit of Viability: A Blueprint for Physician Action

PubMed Central

2016-01-01

Objective To document interactions during the antenatal consultation between parents and neonatologist that parents linked to their satisfaction with their participation in shared decision making for their infant at risk of being born at the limit of viability. Methods This multiple-case ethnomethodological qualitative research study, included mothers admitted for a threatened premature delivery between 200/7 and 266/7 weeks gestation, the father, and the staff neonatologist conducting the clinical antenatal consultation. Content analysis of an audiotaped post-antenatal consultation interview with parents obtained their satisfaction scores as well as their comments on physician actions that facilitated their desired participation. Results Five cases, each called a “system—infant at risk”, included 10 parents and 6 neonatologists. From the interviews emerged a blueprint for action by physicians, including communication strategies that parents say facilitated their participation in decision making; such as building trustworthy physician-parent relationships, providing "balanced" information, offering choices, and allowing time to think. Conclusion Parent descriptions indicate that the opportunity to participate to their satisfaction in the clinical antenatal consultation depends on how the physician interacts with them. Practice implications The parent-identified communication strategies facilitate shared decision making regarding treatment in the best interest of the infant at risk to be born at the limit of viability. PMID:27893823

Beneficent Persuasion: Techniques and Ethical Guidelines to Improve Patients’ Decisions

PubMed Central

Swindell, J. S.; McGuire, Amy L.; Halpern, Scott D.

2010-01-01

Physicians frequently encounter patients who make decisions that contravene their long-term goals. Behavioral economists have shown that irrationalities and self-thwarting tendencies pervade human decision making, and they have identified a number of specific heuristics (rules of thumb) and biases that help explain why patients sometimes make such counterproductive decisions. In this essay, we use clinical examples to describe the many ways in which these heuristics and biases influence patients’ decisions. We argue that physicians should develop their understanding of these potentially counterproductive decisional biases and, in many cases, use this knowledge to rebias their patients in ways that promote patients’ health or other values. Using knowledge of decision-making psychology to persuade patients to engage in healthy behaviors or to make treatment decisions that foster their long-term goals is ethically justified by physicians’ duties to promote their patients’ interests and will often enhance, rather than limit, their patients’ autonomy. We describe techniques that physicians may use to frame health decisions to patients in ways that are more likely to motivate patients to make choices that are less biased and more conducive to their long-term goals. Marketers have been using these methods for decades to get patients to engage in unhealthy behaviors; employers and policy makers are beginning to consider the use of similar approaches to influence healthy choices. It is time for clinicians also to make use of behavioral psychology in their interactions with patients. PMID:20458111

[Physician perspectives on the impact of patient preferences and the role of next-of-kin of patients in evidence-based decision-making: A qualitative interview study from oncology].

PubMed

Salloch, Sabine; Otte, Ina C; Reinacher-Schick, Anke; Vollmann, Jochen

2018-04-01

The impact of patient preferences in evidence-based medicine is a complex issue which touches on theoretical questions as well as medical practice in the clinical context. The interaction between evidence-based recommendations and value-related patient preferences in clinical practice is, however, highly complex and requires not only medical knowledge but social, psychological and communicative competencies on the side of the physician. The multi-layered process of oncology physicians' clinical decision-making was explored in 14 semi-structured interviews with respect to a first diagnosis of a pancreatic adenocarcinoma. A case vignette was used and the Q method ("card sorting") was applied to analyze the influence of different factors (such as evidence, patient preferences and the role of relatives) on physicians' deliberations. Content analysis (Mayring) was performed. The results show that the participating oncologists consider patient preferences as an important guidance which, however, is limited on certain occasions where the physicians assume a leadership role in decision-making. From the interviewees' perspectives, the preferences of the patients' relatives are likewise of high importance because debilitating oncologic treatments can only be carried out if patients have both social and psychological support. There is a need for an ongoing reflection of the physicians' own values and due consideration of the patients' social role within the context of shared decision-making. Copyright © 2018. Published by Elsevier GmbH.

Contrasting RCC, RVU, and ABC for managed care decisions. A case study compares three widely used costing methods and finds one superior.

PubMed

West, T D; Balas, E A; West, D A

1996-08-01

To obtain cost data needed to improve managed care decisions and negotiate profitable capitation contracts, most healthcare provider organizations use one of three costing methods: the ratio-of-costs-to-charges method, the relative value unit method, or the activity-based costing method. Although the ratio-of-costs to charges is used by a majority of provider organizations, a case study that applied these three methods in a renal dialysis clinic found that the activity-based costing method provided the most accurate cost data. By using this costing method, healthcare financial managers can obtain the data needed to make optimal decisions regarding resource allocation and cost containment, thus assuring the longterm financial viability of their organizations.

Decision-Making Process Related to Participation in Phase I Clinical Trials: A Nonsystematic Review of the Existing Evidence.

PubMed

Gorini, Alessandra; Mazzocco, Ketti; Pravettoni, Gabriella

2015-01-01

Due to the lack of other treatment options, patient candidates for participation in phase I clinical trials are considered the most vulnerable, and many ethical concerns have emerged regarding the informed consent process used in the experimental design of such trials. Starting with these considerations, this nonsystematic review is aimed at analyzing the decision-making processes underlying patients' decision about whether to participate (or not) in phase I trials in order to clarify the cognitive and emotional aspects most strongly implicated in this decision. Considering that there is no uniform decision calculus and that many different variables other than the patient-physician relationship (including demographic, clinical, and personal characteristics) may influence patients' preferences for and processing of information, we conclude that patients' informed decision-making can be facilitated by creating a rigorously developed, calibrated, and validated computer tool modeled on each single patient's knowledge, values, and emotional and cognitive decisional skills. Such a tool will also help oncologists to provide tailored medical information that is useful to improve the shared decision-making process, thereby possibly increasing patient participation in clinical trials. © 2015 S. Karger AG, Basel.

[Quantitative and qualitative research methods, can they coexist yet?].

PubMed

Hunt, Elena; Lavoie, Anne-Marise

2011-06-01

Qualitative design is gaining ground in Nursing research. In spite of a relative progress however, the evidence based practice movement continues to dominate and to underline the exclusive value of quantitative design (particularly that of randomized clinical trials) for clinical decision making. In the actual context convenient to those in power making utilitarian decisions on one hand, and facing nursing criticism of the establishment in favor of qualitative research on the other hand, it is difficult to chose a practical and ethical path that values the nursing role within the health care system, keeping us committed to quality care and maintaining researcher's integrity. Both qualitative and quantitative methods have advantages and disadvantages, and clearly, none of them can, by itself, capture, describe and explain reality adequately. Therefore, a balance between the two methods is needed. Researchers bare responsibility to society and science, and they should opt for the appropriate design susceptible to answering the research question, not promote the design favored by the research funding distributors.

Deliberation before determination: the definition and evaluation of good decision making.

PubMed

Elwyn, Glyn; Miron-Shatz, Talya

2010-06-01

In this article, we examine definitions of suggested approaches to measure the concept of good decisions, highlight the ways in which they converge, and explain why we have concerns about their emphasis on post-hoc estimations and post-decisional outcomes, their prescriptive concept of knowledge, and their lack of distinction between the process of deliberation, and the act of decision determination. There has been a steady trend to involve patients in decision making tasks in clinical practice, part of a shift away from paternalism towards the concept of informed choice. An increased understanding of the uncertainties that exist in medicine, arising from a weak evidence base and, in addition, the stochastic nature of outcomes at the individual level, have contributed to shifting the responsibility for decision making from physicians to patients. This led to increasing use of decision support and communication methods, with the ultimate aim of improving decision making by patients. Interest has therefore developed in attempting to define good decision making and in the development of measurement approaches. We pose and reflect whether decisions can be judged good or not, and, if so, how this goodness might be evaluated. We hypothesize that decisions cannot be measured by reference to their outcomes and offer an alternative means of assessment, which emphasizes the deliberation process rather than the decision's end results. We propose decision making comprises a pre-decisional process and an act of decision determination and consider how this model of decision making serves to develop a new approach to evaluating what constitutes a good decision making process. We proceed to offer an alternative, which parses decisions into the pre-decisional deliberation process, the act of determination and post-decisional outcomes. Evaluating the deliberation process, we propose, should comprise of a subjective sufficiency of knowledge, as well as emotional processing and affective forecasting of the alternatives. This should form the basis for a good act of determination.

A problem solving and decision making toolbox for approaching clinical problems and decisions.

PubMed

Margolis, C; Jotkowitz, A; Sitter, H

2004-08-01

In this paper, we begin by presenting three real patients and then review all the practical conceptual tools that have been suggested for systematically analyzing clinical problems. Each of these conceptual tools (e.g. Evidence-Based Medicine, Clinical Practice Guidelines, Decision Analysis) deals mainly with a different type or aspect of clinical problems. We suggest that all of these conceptual tools can be thought of as belonging in the clinician's toolbox for solving clinical problems and making clinical decisions. A heuristic for guiding the clinician in using the tools is proposed. The heuristic is then used to analyze management of the three patients presented at the outset. Copyright 2004 Birkhäuser Verlag, Basel

The Effect of Multimedia Replacing Text in Resident Clinical Decision-Making Assessment

ERIC Educational Resources Information Center

Chang, Todd P.; Schrager, Sheree M.; Rake, Alyssa J.; Chan, Michael W.; Pham, Phung K.; Christman, Grant

2017-01-01

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…

Exploring the use of Option Grid™ patient decision aids in a sample of clinics in Poland.

PubMed

Scalia, Peter; Elwyn, Glyn; Barr, Paul; Song, Julia; Zisman-Ilani, Yaara; Lesniak, Monika; Mullin, Sarah; Kurek, Krzysztof; Bushell, Matt; Durand, Marie-Anne

2018-05-29

Research on the implementation of patient decision aids to facilitate shared decision making in clinical settings has steadily increased across Western countries. A study which implements decision aids and measures their impact on shared decision making has yet to be conducted in the Eastern part of Europe. To study the use of Option Grid TM patient decision aids in a sample of Grupa LUX MED clinics in Warsaw, Poland, and measure their impact on shared decision making. We conducted a pre-post interventional study. Following a three-month period of usual care, clinicians from three Grupa LUX MED clinics received a one-hour training session on how to use three Option Grid TM decision aids and were provided with copies for use for four months. Throughout the study, all eligible patients were asked to complete the three-item CollaboRATE patient-reported measure of shared decision making after their clinical encounter. CollaboRATE enables patients to assess the efforts clinicians make to: (i) inform them about their health issues; (ii) listen to 'what matters most'; (iii) integrate their treatment preference in future plans. A Hierarchical Logistic Regression model was performed to understand which variables had an effect on CollaboRATE. 2,048 patients participated in the baseline phase; 1,889 patients participated in the intervention phase. Five of the thirteen study clinicians had a statistically significant increase in their CollaboRATE scores (p<.05) when comparing baseline phase to intervention phase. All five clinicians were located at the same clinic, the only clinic where an overall increase (non-significant) in the mean CollaboRATE top score percentage occurred from baseline phase (M=60 %, SD=0.49; 95 % CI [57-63 %]) to intervention phase (M=62 %, SD=0.49; 95% CI [59-65%]). Only three of those five clinicians who had a statistically significant increase had a clinically significant difference. The implementation of Option Grid TM helped some clinicians practice shared decision making as reflected in CollaboRATE scores, but most clinicians did not have a significant increase in their scores. Our study indicates that the effect of these interventions may be dependent on clinic contexts and clinician engagement. Copyright © 2018. Published by Elsevier GmbH.

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…

Clinical decision-making by midwives: managing case complexity.

PubMed

Cioffi, J; Markham, R

1997-02-01

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

The patient's role in clinical decision-making.

PubMed

Brody, D S

1980-11-01

Practicing physicians must frequently make decisions about how much they wish to encourage patient participation in clinical decision-making and how to respond to rational patient demands that do not coincide with their own decisions. These are difficult ethical dilemmas with no indisputable or universal solutions. The traditional concept of the doctor-patient relationship places the patient in a passive, compliant role. The patient's only obligation is to seek competent help and cooperate with the physician. A number of factors have contributed to the continued dominance of the traditional doctor-patient imbalance of power. Despite these factors, there seems to be a great deal of public dissatisfaction with health care delivery in the United States; demands for more patient autonomy are increasing. This paper discusses the concept of mutual participation, presents an approach to encouraging patient participation in clinical decision-making, and considers its theoretical advantages.

Emergency medical service provider decision-making in out of hospital cardiac arrest: an exploratory study.

PubMed

Brandling, J; Kirby, K; Black, S; Voss, S; Benger, J

2017-07-25

There are approximately 60,000 out-of-hospital cardiac arrests (OHCA) in the United Kingdom (UK) each year. Within the UK there are well-established clinical practice guidelines that define when resuscitation should be commenced in OHCA, and when resuscitation should cease. Background literature indicates that decision-making in the commencement and cessation of resuscitation efforts in OHCA is complex, and not comprehensively understood. No relevant research from the UK has been published to date and this research study seeks to explore the influences on UK Emergency Medical Service (EMS) provider decision-making when commencing and ceasing resuscitation attempts in OHCA. The aim of this research to explore the influences on UK Emergency Medical Services provider decision-making when commencing and ceasing resuscitation attempts in OHCA. Four focus groups were convened with 16 clinically active EMS providers. Four case vignettes were discussed to explore decision-making within the focus groups. Thematic analysis was used to analyse transcripts. This research found that there are three stages in the decision-making process when EMS providers consider whether to commence or cease resuscitation attempts in OHCA. These stages are: the call; arrival on scene; the protocol. Influential factors present at each of the three stages can lead to different decisions and variability in practice. These influences are: factual information available to the EMS provider; structural factors such as protocol, guidance and research; cultural beliefs and values; interpersonal factors; risk factors; personal values and beliefs. An improved understanding of the circumstantial, individual and interpersonal factors that mediate the decision-making process in clinical practice could inform the development of more effective clinical guidelines, education and clinical decision support in OHCA. These changes have the potential to lead to greater consistency. and EMS provider confidence, with the potential for improved patient outcome from OHCA.

Medicine Based Evidence for Individualized Decision Making: Case Study of Systemic Lupus Erythematosus.

PubMed

Wivel, Ashley E; Lapane, Kate; Kleoudis, Christi; Singer, Burton H; Horwitz, Ralph I

2017-11-01

To guide management decisions for an index patient, evidence is required from comparisons between approximate matches to the profile of the index case, where some matches contain responses to treatment and others act as controls. We describe a method for constructing clinically relevant histories/profiles using data collected but unreported from 2 recent phase 3 randomized controlled trials assessing belimumab in subjects with clinically active and serologically positive systemic lupus erythematosus. Outcome was the Systemic lupus erythematosus Responder Index (SRI) measured at 52 weeks. Among 1175 subjects, we constructed an algorithm utilizing 11 trajectory variables including 4 biological, 2 clinical, and 5 social/behavioral. Across all biological and social/behavioral variables, the proportion of responders based on the SRI whose value indicated clinical worsening or no improvement ranged from 27.5% to 42.3%. Kappa values suggested poor agreement, indicating that each biological and patient-reported outcome provides different information than gleaned from the SRI. The richly detailed patient profiles needed to guide decision-making in clinical practice are sharply at odds with the limited information utilized in conventional randomized controlled trial analyses. Copyright © 2017 Elsevier Inc. All rights reserved.

Postnatal Psychosocial Assessment and Clinical Decision-Making, a Descriptive Study.

PubMed

Sims, Deborah; Fowler, Cathrine

2018-05-18

The aim of this study is to describe experienced child and family health nurses' clinical decision-making during a postnatal psychosocial assessment. Maternal emotional wellbeing in the postnatal year optimises parenting and promotes infant development. Psychosocial assessment potentially enables early intervention and reduces the risk of a mental disorder occurring during this time of change. Assessment accuracy, and the interventions used are determined by the standard of nursing decision-making. A qualitative methodology was employed to explore decision-making behaviour when conducting a postnatal psychosocial assessment. This study was conducted in an Australian early parenting organisation. Twelve experienced child and family health nurses were interviewed. A detailed description of a postnatal psychosocial assessment process was obtained using a critical incident technique. Template analysis was used to determine the information domains the nurses accessed, and content analysis was used to determine the nurses' thinking strategies, to make clinical decisions from this assessment. The nurses described 24 domains of information and used 17 thinking strategies, in a variety of combinations. The four information domains most commonly used were parenting, assessment tools, women-determined issues and sleep. The seven thinking strategies most commonly used were searching for information, forming relationships between the information, recognising a pattern, drawing a conclusion, setting priorities, providing explanations for the information and judging the value of the information. The variety and complexity of the clinical decision-making involved in postnatal psychosocial assessment confirms that the nurses use information appropriately and within their scope of nursing practice. The standard of clinical decision-making determines the results of the assessment and the optimal access to care. Knowledge of the information domains and the decision-making strategies that experienced nurses use for psychosocial assessment potentially improves practice by providing a framework for education and mentoring. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

MDCT quantification is the dominant parameter in decision-making regarding chest tube drainage for stable patients with traumatic pneumothorax.

PubMed

Cai, Wenli; Lee, June-Goo; Fikry, Karim; Yoshida, Hiroyuki; Novelline, Robert; de Moya, Marc

2012-07-01

It is commonly believed that the size of a pneumothorax is an important determinant of treatment decision, in particular regarding whether chest tube drainage (CTD) is required. However, the volumetric quantification of pneumothoraces has not routinely been performed in clinics. In this paper, we introduced an automated computer-aided volumetry (CAV) scheme for quantification of volume of pneumothoraces in chest multi-detect CT (MDCT) images. Moreover, we investigated the impact of accurate volume of pneumothoraces in the improvement of the performance in decision-making regarding CTD in the management of traumatic pneumothoraces. For this purpose, an occurrence frequency map was calculated for quantitative analysis of the importance of each clinical parameter in the decision-making regarding CTD by a computer simulation of decision-making using a genetic algorithm (GA) and a support vector machine (SVM). A total of 14 clinical parameters, including volume of pneumothorax calculated by our CAV scheme, was collected as parameters available for decision-making. The results showed that volume was the dominant parameter in decision-making regarding CTD, with an occurrence frequency value of 1.00. The results also indicated that the inclusion of volume provided the best performance that was statistically significant compared to the other tests in which volume was excluded from the clinical parameters. This study provides the scientific evidence for the application of CAV scheme in MDCT volumetric quantification of pneumothoraces in the management of clinically stable chest trauma patients with traumatic pneumothorax. Copyright © 2012 Elsevier Ltd. All rights reserved.

Decision making for breast cancer prevention among women at elevated risk.

PubMed

Padamsee, Tasleem J; Wills, Celia E; Yee, Lisa D; Paskett, Electra D

2017-03-24

Several medical management approaches have been shown to be effective in preventing breast cancer and detecting it early among women at elevated risk: 1) prophylactic mastectomy; 2) prophylactic oophorectomy; 3) chemoprevention; and 4) enhanced screening routines. To varying extents, however, these approaches are substantially underused relative to clinical practice recommendations. This article reviews the existing research on the uptake of these prevention approaches, the characteristics of women who are likely to use various methods, and the decision-making processes that underlie the differing choices of women. It also highlights important areas for future research, detailing the types of studies that are particularly needed in four key areas: documenting women's perspectives on their own perceptions of risk and prevention decisions; explicit comparisons of available prevention pathways and their likely health effects; the psychological, interpersonal, and social processes of prevention decision making; and the dynamics of subgroup variation. Ultimately, this research could support the development of interventions that more fully empower women to make informed and values-consistent decisions, and to move towards favorable health outcomes.

Colorectal cancer patients' attitudes towards involvement in decision making.

PubMed

Beaver, Kinta; Campbell, Malcolm; Craven, Olive; Jones, David; Luker, Karen A; Susnerwala, Shabbir S

2009-03-01

To design and administer an attitude rating scale, exploring colorectal cancer patients' views of involvement in decision making. To examine the impact of socio-demographic and/or treatment-related factors on decision making. To conduct principal components analysis to determine if the scale could be simplified into a number of factors for future clinical utility. An attitude rating scale was constructed based on previous qualitative work and administered to colorectal cancer patients using a cross-sectional survey approach. 375 questionnaires were returned (81.7% response). For patients it was important to be informed and involved in the decision-making process. Information was not always used to make decisions as patients placed their trust in medical expertise. Women had more positive opinions on decision making and were more likely to want to make decisions. Written information was understood to a greater degree than verbal information. The scale could be simplified to a number of factors, indicating clinical utility. Few studies have explored the attitudes of colorectal cancer patients towards involvement in decision making. This study presents new insights into how patients view the concept of participation; important when considering current policy imperatives in the UK of involving service users in all aspects of care and treatment.

Validation workflow for a clinical Bayesian network model in multidisciplinary decision making in head and neck oncology treatment.

PubMed

Cypko, Mario A; Stoehr, Matthaeus; Kozniewski, Marcin; Druzdzel, Marek J; Dietz, Andreas; Berliner, Leonard; Lemke, Heinz U

2017-11-01

Oncological treatment is being increasingly complex, and therefore, decision making in multidisciplinary teams is becoming the key activity in the clinical pathways. The increased complexity is related to the number and variability of possible treatment decisions that may be relevant to a patient. In this paper, we describe validation of a multidisciplinary cancer treatment decision in the clinical domain of head and neck oncology. Probabilistic graphical models and corresponding inference algorithms, in the form of Bayesian networks, can support complex decision-making processes by providing a mathematically reproducible and transparent advice. The quality of BN-based advice depends on the quality of the model. Therefore, it is vital to validate the model before it is applied in practice. For an example BN subnetwork of laryngeal cancer with 303 variables, we evaluated 66 patient records. To validate the model on this dataset, a validation workflow was applied in combination with quantitative and qualitative analyses. In the subsequent analyses, we observed four sources of imprecise predictions: incorrect data, incomplete patient data, outvoting relevant observations, and incorrect model. Finally, the four problems were solved by modifying the data and the model. The presented validation effort is related to the model complexity. For simpler models, the validation workflow is the same, although it may require fewer validation methods. The validation success is related to the model's well-founded knowledge base. The remaining laryngeal cancer model may disclose additional sources of imprecise predictions.

Comprehensible knowledge model creation for cancer treatment decision making.

PubMed

Afzal, Muhammad; Hussain, Maqbool; Ali Khan, Wajahat; Ali, Taqdir; Lee, Sungyoung; Huh, Eui-Nam; Farooq Ahmad, Hafiz; Jamshed, Arif; Iqbal, Hassan; Irfan, Muhammad; Abbas Hydari, Manzar

2017-03-01

A wealth of clinical data exists in clinical documents in the form of electronic health records (EHRs). This data can be used for developing knowledge-based recommendation systems that can assist clinicians in clinical decision making and education. One of the big hurdles in developing such systems is the lack of automated mechanisms for knowledge acquisition to enable and educate clinicians in informed decision making. An automated knowledge acquisition methodology with a comprehensible knowledge model for cancer treatment (CKM-CT) is proposed. With the CKM-CT, clinical data are acquired automatically from documents. Quality of data is ensured by correcting errors and transforming various formats into a standard data format. Data preprocessing involves dimensionality reduction and missing value imputation. Predictive algorithm selection is performed on the basis of the ranking score of the weighted sum model. The knowledge builder prepares knowledge for knowledge-based services: clinical decisions and education support. Data is acquired from 13,788 head and neck cancer (HNC) documents for 3447 patients, including 1526 patients of the oral cavity site. In the data quality task, 160 staging values are corrected. In the preprocessing task, 20 attributes and 106 records are eliminated from the dataset. The Classification and Regression Trees (CRT) algorithm is selected and provides 69.0% classification accuracy in predicting HNC treatment plans, consisting of 11 decision paths that yield 11 decision rules. Our proposed methodology, CKM-CT, is helpful to find hidden knowledge in clinical documents. In CKM-CT, the prediction models are developed to assist and educate clinicians for informed decision making. The proposed methodology is generalizable to apply to data of other domains such as breast cancer with a similar objective to assist clinicians in decision making and education. Copyright © 2017 Elsevier Ltd. All rights reserved.

MDCT quantification is the dominant parameter in decision–making regarding chest tube drainage for stable patients with traumatic pneumothorax

PubMed Central

Cai, Wenli; Lee, June-Goo; Fikry, Karim; Yoshida, Hiroyuki; Novelline, Robert; de Moya, Marc

2013-01-01

It is commonly believed that the size of a pneumothorax is an important determinant of treatment decision, in particular regarding whether chest tube drainage (CTD) is required. However, the volumetric quantification of pneumothoraces has not routinely been performed in clinics. In this paper, we introduced an automated computer-aided volumetry (CAV) scheme for quantification of volume of pneumothoraces in chest multi-detect CT (MDCT) images. Moreover, we investigated the impact of accurate volume of pneumothoraces in the improvement of the performance in decision-making regarding CTD in the management of traumatic pneumothoraces. For this purpose, an occurrence frequency map was calculated for quantitative analysis of the importance of each clinical parameter in the decision-making regarding CTD by a computer simulation of decision-making using a genetic algorithm (GA) and a support vector machine (SVM). A total of 14 clinical parameters, including volume of pneumothorax calculated by our CAV scheme, was collected as parameters available for decision-making. The results showed that volume was the dominant parameter in decision-making regarding CTD, with an occurrence frequency value of 1.00. The results also indicated that the inclusion of volume provided the best performance that was statistically significant compared to the other tests in which volume was excluded from the clinical parameters. This study provides the scientific evidence for the application of CAV scheme in MDCT volumetric quantification of pneumothoraces in the management of clinically stable chest trauma patients with traumatic pneumothorax. PMID:22560899

An intelligent, knowledge-based multiple criteria decision making advisor for systems design

NASA Astrophysics Data System (ADS)

Li, Yongchang

In systems engineering, design and operation of systems are two main problems which always attract researcher's attentions. The accomplishment of activities in these problems often requires proper decisions to be made so that the desired goal can be achieved, thus, decision making needs to be carefully fulfilled in the design and operation of systems. Design is a decision making process which permeates through out the design process, and is at the core of all design activities. In modern aircraft design, more and more attention is paid to the conceptual and preliminary design phases so as to increase the odds of choosing a design that will ultimately be successful at the completion of the design process, therefore, decisions made during these early design stages play a critical role in determining the success of a design. Since aerospace systems are complex systems with interacting disciplines and technologies, the Decision Makers (DMs) dealing with such design problems are involved in balancing the multiple, potentially conflicting attributes/criteria, transforming a large amount of customer supplied guidelines into a solidly defined set of requirement definitions. Thus, one could state with confidence that modern aerospace system design is a Multiple Criteria Decision Making (MCDM) process. A variety of existing decision making methods are available to deal with this type of decision problems. The selection of the most appropriate decision making method is of particular importance since inappropriate decision methods are likely causes of misleading engineering design decisions. With no sufficient knowledge about each of the methods, it is usually difficult for the DMs to find an appropriate analytical model capable of solving their problems. In addition, with the complexity of the decision problem and the demand for more capable methods increasing, new decision making methods are emerging with time. These various methods exacerbate the difficulty of the selection of an appropriate decision making method. Furthermore, some DMs may be exclusively using one or two specific methods which they are familiar with or trust and not realizing that they may be inappropriate to handle certain classes of the problems, thus yielding erroneous results. These issues reveal that in order to ensure a good decision a suitable decision method should be chosen before the decision making process proceeds. The first part of this dissertation proposes an MCDM process supported by an intelligent, knowledge-based advisor system referred to as Multi-Criteria Interactive Decision-Making Advisor and Synthesis process (MIDAS), which is able to facilitate the selection of the most appropriate decision making method and which provides insight to the user for fulfilling different preferences. The second part of this dissertation presents an autonomous decision making advisor which is capable of dealing with ever-evolving real time information and making autonomous decisions under uncertain conditions. The advisor encompasses a Markov Decision Process (MDP) formulation which takes uncertainty into account when determines the best action for each system state. (Abstract shortened by UMI.)

Gatekeepers for Pragmatic Clinical Trials

PubMed Central

Whicher, Danielle M.; Miller, Jennifer E.; Dunham, Kelly M.; Joffe, Steven

2015-01-01

To successfully implement a pragmatic clinical trial, investigators need access to numerous resources, including financial support, institutional infrastructure (e.g., clinics, facilities, staff), eligible patients, and patient data. Gatekeepers are people or entities who have the ability to allow or deny access to the resources required to support the conduct of clinical research. Based on this definition, gatekeepers relevant to the United States clinical research enterprise include research sponsors, regulatory agencies, payers, health system and other organizational leadership, research team leadership, human research protections programs, advocacy and community groups, and clinicians. This manuscript provides a framework to help guide gatekeepers’ decision-making related to the use of resources for pragmatic clinical trials. These include (1) concern for the interests of individuals, groups, and communities affected by the gatekeepers’ decisions, including protection from harm and maximization of benefits, (2) advancement of organizational mission and values, and (3) stewardship of financial, human, and other organizational resources. Separate from these ethical considerations, gatekeepers’ actions will be guided by relevant federal, state, and local regulations. This framework also suggests that to further enhance the legitimacy of their decision-making, gatekeepers should adopt transparent processes that engage relevant stakeholders when feasible and appropriate. We apply this framework to the set of gatekeepers responsible for making decisions about resources necessary for pragmatic clinical trials in the United States, describing the relevance of the criteria in different situations and pointing out where conflicts among the criteria and relevant regulations may affect decision-making. Recognition of the complex set of considerations that should inform decision-making will guide gatekeepers in making justifiable choices regarding the use of limited and valuable resources. PMID:26374683

Dual processing model of medical decision-making

PubMed Central

2012-01-01

Background Dual processing theory of human cognition postulates that reasoning and decision-making can be described as a function of both an intuitive, experiential, affective system (system I) and/or an analytical, deliberative (system II) processing system. To date no formal descriptive model of medical decision-making based on dual processing theory has been developed. Here we postulate such a model and apply it to a common clinical situation: whether treatment should be administered to the patient who may or may not have a disease. Methods We developed a mathematical model in which we linked a recently proposed descriptive psychological model of cognition with the threshold model of medical decision-making and show how this approach can be used to better understand decision-making at the bedside and explain the widespread variation in treatments observed in clinical practice. Results We show that physician’s beliefs about whether to treat at higher (lower) probability levels compared to the prescriptive therapeutic thresholds obtained via system II processing is moderated by system I and the ratio of benefit and harms as evaluated by both system I and II. Under some conditions, the system I decision maker’s threshold may dramatically drop below the expected utility threshold derived by system II. This can explain the overtreatment often seen in the contemporary practice. The opposite can also occur as in the situations where empirical evidence is considered unreliable, or when cognitive processes of decision-makers are biased through recent experience: the threshold will increase relative to the normative threshold value derived via system II using expected utility threshold. This inclination for the higher diagnostic certainty may, in turn, explain undertreatment that is also documented in the current medical practice. Conclusions We have developed the first dual processing model of medical decision-making that has potential to enrich the current medical decision-making field, which is still to the large extent dominated by expected utility theory. The model also provides a platform for reconciling two groups of competing dual processing theories (parallel competitive with default-interventionalist theories). PMID:22943520

Value-based decision making under uncertainty in hoarding and obsessive-compulsive disorders

PubMed Central

Pushkarskaya, Helen; Tolin, David; Ruderman, Lital; Henick, Daniel; Kelly, J. MacLaren; Pittenger, Christopher; Levy, Ifat

2017-01-01

Difficulties in decision making are a core impairment in a range of disease states. For instance, both obsessive-compulsive disorder (OCD) and hoarding disorder (HD) are associated with indecisiveness, inefficient planning, and enhanced uncertainty intolerance, even in contexts unrelated to their core symptomology. We examined decision-making patterns in 19 individuals with OCD, 19 individuals with HD, 19 individuals with comorbid OCD and HD, and 57 individuals from the general population, using a well-validated choice task grounded in behavioral economic theory. Our results suggest that difficulties in decision making in individuals with OCD (with or without comorbid HD) are linked to reduced fidelity of value-based decision making (i.e. increase in inconsistent choices). In contrast, we find that performance of individuals with HD on our laboratory task is largely intact. Overall, these results support our hypothesis that decision-making impairments in OCD and HD, which can appear quite similar clinically, have importantly different underpinnings. Systematic investigation of different aspects of decision making, under varying conditions, may shed new light on commonalities between and distinctions among clinical syndromes. PMID:28864119

Confidence and Information Access in Clinical Decision-Making: An Examination of the Cognitive Processes that affect the Information-seeking Behavior of Physicians.

PubMed

Uy, Raymonde Charles; Sarmiento, Raymond Francis; Gavino, Alex; Fontelo, Paul

2014-01-01

Clinical decision-making involves the interplay between cognitive processes and physicians' perceptions of confidence in the context of their information-seeking behavior. The objectives of the study are: to examine how these concepts interact, to determine whether physician confidence, defined in relation to information need, affects clinical decision-making, and if information access improves decision accuracy. We analyzed previously collected data about resident physicians' perceptions of information need from a study comparing abstracts and full-text articles in clinical decision accuracy. We found that there is a significant relation between confidence and accuracy (φ=0.164, p<0.01). We also found various differences in the alignment of confidence and accuracy, demonstrating the concepts of underconfidence and overconfidence across years of clinical experience. Access to online literature also has a significant effect on accuracy (p<0.001). These results highlight possible CDSS strategies to reduce medical errors.

How do persons with dementia participate in decision making related to health and daily care? A multi-case study

PubMed Central

2012-01-01

Background Many countries have passed laws giving patients the right to participate in decisions about health care. People with dementia cannot be assumed to be incapable of making decisions on their diagnosis alone as they may have retained cognitive abilities. The purpose of this study was to gain a better understanding of how persons with dementia participated in making decisions about health care and how their family carers and professional caregivers influenced decision making. Methods This Norwegian study had a qualitative multi-case design. The triad in each of the ten cases consisted of the person with dementia, the family carer and the professional caregiver, in all 30 participants. Inclusion criteria for the persons with dementia were: (1) 67 years or older (2) diagnosed with dementia (3) Clinical Dementia Rating score 2, moderate dementia; (3) able to communicate verbally. The family carers and professional caregivers were then asked to participate. A semi-structured interview guide was used in interviews with family carers and professional caregivers. Field notes were written after participant observation of interactions between persons with dementia and professional caregivers during morning care or activities at a day centre. How the professional caregivers facilitated decision making was the focus of the observations that varied in length from 30 to 90 minutes. The data were analyzed using framework analysis combined with a hermeneutical interpretive approach. Results Professional caregivers based their assessment of mental competence on experience and not on standardized tests. Persons with dementia demonstrated variability in how they participated in decision making. Pseudo-autonomous decision making and delegating decision making were new categories that emerged. Autonomous decision making did occur but shared decision making was the most typical pattern. Reduced mental capacity, lack of available choices or not being given the opportunity to participate led to non-involvement. Not all decisions were based on logic; personal values and relationships were also considered. Conclusions Persons with moderate dementia demonstrated variability in how they participated in decision making. Optimal involvement was facilitated by positioning them as capable of influencing decisions, assessing decision-specific competence, clarifying values and understanding the significance of relationships and context. PMID:22870952

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

PubMed

Landry, M D; Sibbald, W J

2001-11-01

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

Deepening the quality of clinical reasoning and decision-making in rural hospital nursing practice.

PubMed

Sedgwick, M G; Grigg, L; Dersch, S

2014-01-01

Rural acute care nursing requires an extensive breadth and depth of knowledge as well as the ability to quickly reason through problems in order to make sound clinical decisions. This reasoning often occurs within an environment that has minimal medical or ancillary support. Registered nurses (RN) new to rural nursing, and employers, have raised concerns about patient safety while new nurses make the transition into rural practice. In addition, feeling unprepared for the rigors of rural hospital nursing practice is a central issue influencing RN recruitment and retention. Understanding how rural RNs reason is a key element for identifying professional development needs and may support recruitment and retention of skilled rural nurses. The purpose of this study was to explore how rural RNs reason through clinical problems as well as to assess the quality of such reasoning. This study used a non-traditional approach for data collection. Fifteen rural acute care nurses with varying years of experience working in southern Alberta, Canada, were observed while they provided care to patients of varying acuity within a simulated rural setting. Following the simulation, semi-structured interviews were conducted using a substantive approach to critical thinking. Findings revealed that the ability to engage in deep clinical reasoning varied considerably among participants despite being given the same information under the same circumstances. Furthermore, the number of years of experience did not seem to be directly linked to the ability to engage in sound clinical reasoning. Novice nurses, however, did rely heavily on others in their decision making in order to ensure they were making the right decision. Hence, their relationships with other staff members influenced their ability to engage in clinical reasoning and decision making. In situations where the patient's condition was deteriorating quickly, regardless of years of experience, all of the participants depended on their colleagues when making decisions and reasoning throughout the simulation. Deep clinical reasoning and decision making is a function of reflection and self-correction that requires a critical self-awareness and is more about how nurses think than what they think. The degree of sophistication in reasoning of experts and novices is at times equivalent in that the reasoning of experts and novices can be somewhat limited and focused primarily on human physicality and less on conceptual knowledge. To become proficient in clinical reasoning, practice is necessary. The study supports the accumulating evidence that using clinical simulation and reflective interviewing that emphasize how clinical decisions are made enhances reasoning skills and confidence.

Insights from a conference on implementing comparative effectiveness research through shared decision-making

PubMed Central

Politi, Mary C; Clayman, Marla L; Fagerlin, Angela; Studts, Jamie L; Montori, Victor

2013-01-01

For decades, investigators have conducted innovative research on shared decision-making (SDM), helping patients and clinicians to discuss health decisions and balance evidence with patients' preferences for possible outcomes of options. In addition, investigators have developed and used rigorous methods for conducting comparative effectiveness research (CER), comparing the benefits and risks of different interventions in real-world settings with outcomes that matter to patients and other stakeholders. However, incorporating CER findings into clinical practice presents numerous challenges. In March 2012, we organized a conference at Washington University in St Louis (MO, USA) aimed at developing a network of researchers to collaborate in developing, conducting and disseminating research about the implementation of CER through SDM. Meeting attendees discussed conceptual similarities and differences between CER and SDM, challenges in implementing CER and SDM in practice, specific challenges when engaging SDM with unique populations and examples of ways to overcome these challenges. CER and SDM are related processes that emphasize examining the best clinical evidence and how it applies to real patients in real practice settings. SDM can provide one opportunity for clinicians to discuss CER findings with patients and engage in a dialog about how to manage uncertainty about evidence in order to make decisions on an individual patient level. This meeting highlighted key challenges and suggested avenues to pursue such that CER and SDM can be implemented into routine clinical practice. PMID:23430243

Integrating Decision Making and Mental Health Interventions Research: Research Directions

PubMed Central

Wills, Celia E.; Holmes-Rovner, Margaret

2006-01-01

The importance of incorporating patient and provider decision-making processes is in the forefront of the National Institute of Mental Health (NIMH) agenda for improving mental health interventions and services. Key concepts in patient decision making are highlighted within a simplified model of patient decision making that links patient-level/“micro” variables to services-level/“macro” variables via the decision-making process that is a target for interventions. The prospective agenda for incorporating decision-making concepts in mental health research includes (a) improved measures for characterizing decision-making processes that are matched to study populations, complexity, and types of decision making; (b) testing decision aids in effectiveness research for diverse populations and clinical settings; and (c) improving the understanding and incorporation of preference concepts in enhanced intervention designs. PMID:16724158

Parents and end-of-life decision-making for their child: roles and responsibilities.

PubMed

Sullivan, Jane; Gillam, Lynn; Monagle, Paul

2015-09-01

Whether parents want to be and should be the decision-maker for their child in end-of-life matters are contested clinical and ethical questions. Previous research outcomes are equivocal. A qualitative interview method was used to examine the views and experiences of 25 bereaved parents in end-of-life decision-making for their child. Data were analysed thematically. Three types of decision-making roles were identified: self-determined, guided (both involving active decision-making) and acquiescent (passive).The majority of parents had been active in the decision-making process for their child. They perceived themselves as the ultimate end-of-life decision-maker. This was perceived as part of their parental responsibility. A minority of parents did not consider that they had been an active, ultimate decision-maker. Generally, parents in the self-determined and guided groups reported no negative consequences from their decision-making involvement. Importantly, parents in the acquiescent group described their experience as difficult at the time and subsequently, although not all difficulties related directly to decision-making. Parents considered that in principle parents should be the end-of-life decision-maker for their child, but understood personal characteristics and preference could prevent some parents from taking this role. This study unequivocally supports parents' desire to fulfil the end-of-life decision-making role. It provides a nuanced understanding of parents' roles and contributes evidence for the ethical position that parents should be the end-of-life decision-makers for their child, unless not in the child's best interests. On the whole, parents want this role and can manage its consequences. Indeed, not being the end-of-life decision-maker could be detrimental to parents' well-being. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Decision-Making in Audiology: Balancing Evidence-Based Practice and Patient-Centered Care.

PubMed

Boisvert, Isabelle; Clemesha, Jennifer; Lundmark, Erik; Crome, Erica; Barr, Caitlin; McMahon, Catherine M

2017-01-01

Health-care service delivery models have evolved from a practitioner-centered approach toward a patient-centered ideal. Concurrently, increasing emphasis has been placed on the use of empirical evidence in decision-making to increase clinical accountability. The way in which clinicians use empirical evidence and client preferences to inform decision-making provides an insight into health-care delivery models utilized in clinical practice. The present study aimed to investigate the sources of information audiologists use when discussing rehabilitation choices with clients, and discuss the findings within the context of evidence-based practice and patient-centered care. To assess the changes that may have occurred over time, this study uses a questionnaire based on one of the few studies of decision-making behavior in audiologists, published in 1989. The present questionnaire was completed by 96 audiologists who attended the World Congress of Audiology in 2014. The responses were analyzed using qualitative and quantitative approaches. Results suggest that audiologists rank clinical test results and client preferences as the most important factors for decision-making. Discussion with colleagues or experts was also frequently reported as an important source influencing decision-making. Approximately 20% of audiologists mentioned utilizing research evidence to inform decision-making when no clear solution was available. Information shared at conferences was ranked low in terms of importance and reliability. This study highlights an increase in awareness of concepts associated with evidence-based practice and patient-centered care within audiology settings, consistent with current research-to-practice dissemination pathways. It also highlights that these pathways may not be sufficient for an effective clinical implementation of these practices.

Clinical Decision Support Tools for Osteoporosis Disease Management: A Systematic Review of Randomized Controlled Trials

PubMed Central

Straus, Sharon E.

2008-01-01

BACKGROUND Studies indicate a gap between evidence and clinical practice in osteoporosis management. Tools that facilitate clinical decision making at the point of care are promising strategies for closing these practice gaps. OBJECTIVE To systematically review the literature to identify and describe the effectiveness of tools that support clinical decision making in osteoporosis disease management. DATA SOURCES Medline, EMBASE, CINAHL, and EBM Reviews (CDSR, DARE, CCTR, and ACP J Club), and contact with experts in the field. REVIEW METHODS Randomized controlled trials (RCTs) in any language from 1966 to July 2006 investigating disease management interventions in patients at risk for osteoporosis. Outcomes included fractures and bone mineral density (BMD) testing. Two investigators independently assessed articles for relevance and study quality, and extracted data using standardized forms. RESULTS Of 1,246 citations that were screened for relevance, 13 RCTs met the inclusion criteria. Reported study quality was generally poor. Meta-analysis was not done because of methodological and clinical heterogeneity; 77% of studies included a reminder or education as a component of their intervention. Three studies of reminders plus education targeted to physicians and patients showed increased BMD testing (RR range 1.43 to 8.67) and osteoporosis medication use (RR range 1.60 to 8.67). A physician reminder plus a patient risk assessment strategy found reduced fractures [RR 0.58, 95% confidence interval (CI) 0.37 to 0.90] and increased osteoporosis therapy (RR 2.44, CI 1.43 to 4.17). CONCLUSION Multi-component tools that are targeted to physicians and patients may be effective for supporting clinical decision making in osteoporosis disease management. Electronic supplementary material The online version of this article (doi:10.1007/s11606-008-0812-9) contains supplementary material, which is available to authorized users. PMID:18836782

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.

Making a decision about trial participation: the feasibility of measuring deliberation during the informed consent process for clinical trials.

PubMed

Gillies, Katie; Elwyn, Glyn; Cook, Jonathan

2014-07-30

Informed consent of trial participants is both an ethical and a legal requirement. When facing a decision about trial participation, potential participants are provided with information about the trial and have the opportunity to have any questions answered before their degree of 'informed-ness' is assessed, usually subjectively, and before they are asked to sign a consent form. Currently, standardised methods for assessing informed consent have tended to be focused on aspects of understanding and associated outcomes, rather than on the process of consent and the steps associated with decision-making. Potential trial participants who were approached regarding participation in one of three randomised controlled trials were asked to complete a short questionnaire to measure their deliberation about trial participation. A total of 136 participants completed the 10-item questionnaire (DelibeRATE) before they made an explicit decision about trial participation (defined as signing the clinical trial consent form). Overall DelibeRATE scores were compared and investigated for differences between trial consenters and refusers. No differences in overall DelibeRATE scores were identified. In addition, there was no significant difference between overall score and the decision to participate, or not, in the parent trial. To our knowledge, this is the first study to prospectively measure the deliberation stage of the informed consent decision-making process of potential trial participants across different conditions and clinical areas. Although there were no differences detected in overall scores or scores of trial consenters and refusers, we did identify some interesting findings. These findings should be taken into consideration by those designing trials and others interested in developing and implementing measures of potential trial participants decision making during the informed consent process for research. International Standard Randomised Controlled Trial Number (ISRCTN) Register ISRCTN60695184 (date of registration: 13 May 2009), ISRCTN80061723 (date of registration: 8 March 2010), ISRCTN69423238 (date of registration: 18 November 2010).

Variation in clinical decision-making for induction of labour: a qualitative study.

PubMed

Nippita, Tanya A; Porter, Maree; Seeho, Sean K; Morris, Jonathan M; Roberts, Christine L

2017-09-22

Unexplained variation in induction of labour (IOL) rates exist between hospitals, even after accounting for casemix and hospital differences. We aimed to explore factors that influence clinical decision-making for IOL that may be contributing to the variation in IOL rates between hospitals. We undertook a qualitative study involving semi-structured, audio-recorded interviews with obstetricians and midwives. Using purposive sampling, participants known to have diverse opinions on IOL were selected from ten Australian maternity hospitals (based on differences in hospital IOL rate, size, location and case-mix complexities). Transcripts were indexed, coded, and analysed using the Framework Approach to identify main themes and subthemes. Forty-five participants were interviewed (21 midwives, 24 obstetric medical staff). Variations in decision-making for IOL were based on the obstetrician's perception of medical risk in the pregnancy (influenced by the obstetrician's personality and knowledge), their care relationship with the woman, how they involved the woman in decision-making, and resource availability. The role of a 'gatekeeper' in the procedural aspects of arranging an IOL also influenced decision-making. There was wide variation in the clinical decision-making practices of obstetricians and less accountability for decision-making in hospitals with a high IOL rate, with the converse occurring in hospitals with low IOL rates. Improved communication, standardised risk assessment and accountability for IOL offer potential for reducing variation in hospital IOL rates.

Clinical decision-making and secondary findings in systems medicine.

PubMed

Fischer, T; Brothers, K B; Erdmann, P; Langanke, M

2016-05-21

Systems medicine is the name for an assemblage of scientific strategies and practices that include bioinformatics approaches to human biology (especially systems biology); "big data" statistical analysis; and medical informatics tools. Whereas personalized and precision medicine involve similar analytical methods applied to genomic and medical record data, systems medicine draws on these as well as other sources of data. Given this distinction, the clinical translation of systems medicine poses a number of important ethical and epistemological challenges for researchers working to generate systems medicine knowledge and clinicians working to apply it. This article focuses on three key challenges: First, we will discuss the conflicts in decision-making that can arise when healthcare providers committed to principles of experimental medicine or evidence-based medicine encounter individualized recommendations derived from computer algorithms. We will explore in particular whether controlled experiments, such as comparative effectiveness trials, should mediate the translation of systems medicine, or if instead individualized findings generated through "big data" approaches can be applied directly in clinical decision-making. Second, we will examine the case of the Riyadh Intensive Care Program Mortality Prediction Algorithm, pejoratively referred to as the "death computer," to demonstrate the ethical challenges that can arise when big-data-driven scoring systems are applied in clinical contexts. We argue that the uncritical use of predictive clinical algorithms, including those envisioned for systems medicine, challenge basic understandings of the doctor-patient relationship. Third, we will build on the recent discourse on secondary findings in genomics and imaging to draw attention to the important implications of secondary findings derived from the joint analysis of data from diverse sources, including data recorded by patients in an attempt to realize their "quantified self." This paper examines possible ethical challenges that are likely to be raised as systems medicine to be translated into clinical medicine. These include the epistemological challenges for clinical decision-making, the use of scoring systems optimized by big data techniques and the risk that incidental and secondary findings will significantly increase. While some ethical implications remain still hypothetical we should use the opportunity to prospectively identify challenges to avoid making foreseeable mistakes when systems medicine inevitably arrives in routine care.

[Which research is needed to support clinical decision-making on integrative medicine? Can comparative effectiveness research close the gap?].

PubMed

Witt, Claudia M; Huang, Wen-jing; Lao, Lixing; Berman, Brian M

2013-08-01

In clinical research on complementary and integrative medicine, experts and scientists have often pursued a research agenda in spite of an incomplete understanding of the needs of end users. Consequently, the majority of previous clinical trials have mainly assessed the efficacy of interventions. Scant data is available on their effectiveness. Comparative effectiveness research (CER) promises to support decision makers by generating evidence that compares the benefits and harms of best care options. This evidence, more generalizable than evidence generated by traditional randomized clinical trials (RCTs), is better suited to inform real-world care decisions. An emphasis on CER supports the development of the evidence base for clinical and policy decision-making. Whereas in most areas of complementary and integrative medicine data on CER is scarce, available acupuncture research already contributes to CER evidence. This paper will introduce CER and make suggestions for future research.

Bioethics and the whole: pluralism, consensus, and the transmutation of bioethical methods into gold.

PubMed

Martin, P A

1999-01-01

Arguing that a consensus-based method of bioethical decision making can transform ethical pluralism into an ethical whole, author examines the theory of three consensus-based models--clinical pragmatism, ethics facilitation, and mediation--and develops a practical guide to ethics facilitation that includes a hypothetical case.

CorRECTreatment: a web-based decision support tool for rectal cancer treatment that uses the analytic hierarchy process and decision tree.

PubMed

Suner, A; Karakülah, G; Dicle, O; Sökmen, S; Çelikoğlu, C C

2015-01-01

The selection of appropriate rectal cancer treatment is a complex multi-criteria decision making process, in which clinical decision support systems might be used to assist and enrich physicians' decision making. The objective of the study was to develop a web-based clinical decision support tool for physicians in the selection of potentially beneficial treatment options for patients with rectal cancer. The updated decision model contained 8 and 10 criteria in the first and second steps respectively. The decision support model, developed in our previous study by combining the Analytic Hierarchy Process (AHP) method which determines the priority of criteria and decision tree that formed using these priorities, was updated and applied to 388 patients data collected retrospectively. Later, a web-based decision support tool named corRECTreatment was developed. The compatibility of the treatment recommendations by the expert opinion and the decision support tool was examined for its consistency. Two surgeons were requested to recommend a treatment and an overall survival value for the treatment among 20 different cases that we selected and turned into a scenario among the most common and rare treatment options in the patient data set. In the AHP analyses of the criteria, it was found that the matrices, generated for both decision steps, were consistent (consistency ratio<0.1). Depending on the decisions of experts, the consistency value for the most frequent cases was found to be 80% for the first decision step and 100% for the second decision step. Similarly, for rare cases consistency was 50% for the first decision step and 80% for the second decision step. The decision model and corRECTreatment, developed by applying these on real patient data, are expected to provide potential users with decision support in rectal cancer treatment processes and facilitate them in making projections about treatment options.

A web-based personalized risk communication and decision-making tool for women with dense breasts: Design and methods of a randomized controlled trial within an integrated health care system.

PubMed

Knerr, Sarah; Wernli, Karen J; Leppig, Kathleen; Ehrlich, Kelly; Graham, Amanda L; Farrell, David; Evans, Chalanda; Luta, George; Schwartz, Marc D; O'Neill, Suzanne C

2017-05-01

Mammographic breast density is one of the strongest risk factors for breast cancer after age and family history. Mandatory breast density disclosure policies are increasing nationally without clear guidance on how to communicate density status to women. Coupling density disclosure with personalized risk counseling and decision support through a web-based tool may be an effective way to allow women to make informed, values-consistent risk management decisions without increasing distress. This paper describes the design and methods of Engaged, a prospective, randomized controlled trial examining the effect of online personalized risk counseling and decision support on risk management decisions in women with dense breasts and increased breast cancer risk. The trial is embedded in a large integrated health care system in the Pacific Northwest. A total of 1250 female health plan members aged 40-69 with a recent negative screening mammogram who are at increased risk for interval cancer based on their 5-year breast cancer risk and BI-RADS® breast density will be randomly assigned to access either a personalized web-based counseling and decision support tool or standard educational content. Primary outcomes will be assessed using electronic health record data (i.e., chemoprevention and breast MRI utilization) and telephone surveys (i.e., distress) at baseline, six weeks, and twelve months. Engaged will provide evidence about whether a web-based personalized risk counseling and decision support tool is an effective method for communicating with women about breast density and risk management. An effective intervention could be disseminated with minimal clinical burden to align with density disclosure mandates. Clinical Trials Registration Number:NCT03029286. Copyright © 2017 Elsevier Inc. All rights reserved.

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

PubMed Central

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

2017-01-01

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

Grey Language Hesitant Fuzzy Group Decision Making Method Based on Kernel and Grey Scale

PubMed Central

Diao, Yuzhu; Hu, Aqin

2018-01-01

Based on grey language multi-attribute group decision making, a kernel and grey scale scoring function is put forward according to the definition of grey language and the meaning of the kernel and grey scale. The function introduces grey scale into the decision-making method to avoid information distortion. This method is applied to the grey language hesitant fuzzy group decision making, and the grey correlation degree is used to sort the schemes. The effectiveness and practicability of the decision-making method are further verified by the industry chain sustainable development ability evaluation example of a circular economy. Moreover, its simplicity and feasibility are verified by comparing it with the traditional grey language decision-making method and the grey language hesitant fuzzy weighted arithmetic averaging (GLHWAA) operator integration method after determining the index weight based on the grey correlation. PMID:29498699

Grey Language Hesitant Fuzzy Group Decision Making Method Based on Kernel and Grey Scale.

PubMed

Li, Qingsheng; Diao, Yuzhu; Gong, Zaiwu; Hu, Aqin

2018-03-02

Based on grey language multi-attribute group decision making, a kernel and grey scale scoring function is put forward according to the definition of grey language and the meaning of the kernel and grey scale. The function introduces grey scale into the decision-making method to avoid information distortion. This method is applied to the grey language hesitant fuzzy group decision making, and the grey correlation degree is used to sort the schemes. The effectiveness and practicability of the decision-making method are further verified by the industry chain sustainable development ability evaluation example of a circular economy. Moreover, its simplicity and feasibility are verified by comparing it with the traditional grey language decision-making method and the grey language hesitant fuzzy weighted arithmetic averaging (GLHWAA) operator integration method after determining the index weight based on the grey correlation.

Identification of design features to enhance utilization and acceptance of systems for Internet-based decision support at the point of care.

PubMed Central

Gadd, C. S.; Baskaran, P.; Lobach, D. F.

1998-01-01

Extensive utilization of point-of-care decision support systems will be largely dependent on the development of user interaction capabilities that make them effective clinical tools in patient care settings. This research identified critical design features of point-of-care decision support systems that are preferred by physicians, through a multi-method formative evaluation of an evolving prototype of an Internet-based clinical decision support system. Clinicians used four versions of the system--each highlighting a different functionality. Surveys and qualitative evaluation methodologies assessed clinicians' perceptions regarding system usability and usefulness. Our analyses identified features that improve perceived usability, such as telegraphic representations of guideline-related information, facile navigation, and a forgiving, flexible interface. Users also preferred features that enhance usefulness and motivate use, such as an encounter documentation tool and the availability of physician instruction and patient education materials. In addition to identifying design features that are relevant to efforts to develop clinical systems for point-of-care decision support, this study demonstrates the value of combining quantitative and qualitative methods of formative evaluation with an iterative system development strategy to implement new information technology in complex clinical settings. Images Figure 1 PMID:9929188

[Value-based cancer care. From traditional evidence-based decision making to balanced decision making within frameworks of shared values].

PubMed

Palazzo, Salvatore; Filice, Aldo; Mastroianni, Candida; Biamonte, Rosalbino; Conforti, Serafino; Liguori, Virginia; Turano, Salvatore; De Simone, Rosanna; Rovito, Antonio; Manfredi, Caterina; Minardi, Stefano; Vilardo, Emmanuelle; Loizzo, Monica; Oriolo, Carmela

2016-04-01

Clinical decision making in oncology is based so far on the evidence of efficacy from high-quality clinical research. Data collection and analysis from experimental studies provide valuable insight into response rates and progression-free or overall survival. Data processing generates valuable information for medical professionals involved in cancer patient care, enabling them to make objective and unbiased choices. The increased attention of many scientific associations toward a more rational resource consumption in clinical decision making is mirrored in the Choosing Wisely campaign against the overuse or misuse of exams and procedures of little or no benefit for the patient. This cultural movement has been actively promoting care solutions based on the concept of "value". As a result, the value-based decision-making process for cancer care should not be dissociated from economic sustainability and from ethics of the affordability, also given the growing average cost of the most recent cancer drugs. In support of this orientation, the National Comprehensive Cancer Network (NCCN) has developed innovative and "complex" guidelines based on values, defined as "evidence blocks", with the aim of assisting the medical community in making overall sustainable choices.

Clinical decision making in dermatology: observation of consultations and the patients' perspectives.

PubMed

Hajjaj, F M; Salek, M S; Basra, M K A; Finlay, A Y

2010-01-01

Clinical decision making is a complex process and might be influenced by a wide range of clinical and non-clinical factors. Little is known about this process in dermatology. The aim of this study was to explore the different types of management decisions made in dermatology and to identify factors influencing those decisions from observation of consultations and interviews with the patients. 61 patient consultations were observed by a physician with experience in dermatology. The patients were interviewed immediately after each consultation. Consultations and interviews were audio recorded, transcribed and their content analysed using thematic content analysis. The most common management decisions made during the consultations included: follow-up, carrying out laboratory investigation, starting new topical treatment, renewal of systemic treatment, renewal of topical treatment, discharging patients and starting new systemic treatment. Common influences on those decisions included: clinical factors such as ineffectiveness of previous therapy, adherence to prescribing guidelines, side-effects of medications, previous experience with the treatment, deterioration or improvement in the skin condition, and chronicity of skin condition. Non-clinical factors included: patient's quality of life, patient's friends or relatives, patient's time commitment, travel or transportation difficulties, treatment-related costs, availability of consultant, and availability of treatment. The study has shown that patients are aware that management decisions in dermatology are influenced by a wide range of clinical and non-clinical factors. Education programmes should be developed to improve the quality of decision making. Copyright © 2010 S. Karger AG, Basel.

Informed decision-making among students analyzing their personal genomes on a whole genome sequencing course: a longitudinal cohort study

PubMed Central

2013-01-01

Background Multiple laboratories now offer clinical whole genome sequencing (WGS). We anticipate WGS becoming routinely used in research and clinical practice. Many institutions are exploring how best to educate geneticists and other professionals about WGS. Providing students in WGS courses with the option to analyze their own genome sequence is one strategy that might enhance students’ engagement and motivation to learn about personal genomics. However, if this option is presented to students, it is vital they make informed decisions, do not feel pressured into analyzing their own genomes by their course directors or peers, and feel free to analyze a third-party genome if they prefer. We therefore developed a 26-hour introductory genomics course in part to help students make informed decisions about whether to receive personal WGS data in a subsequent advanced genomics course. In the advanced course, they had the option to receive their own personal genome data, or an anonymous genome, at no financial cost to them. Our primary aims were to examine whether students made informed decisions regarding analyzing their personal genomes, and whether there was evidence that the introductory course enabled the students to make a more informed decision. Methods This was a longitudinal cohort study in which students (N = 19) completed questionnaires assessing their intentions, informed decision-making, attitudes and knowledge before (T1) and after (T2) the introductory course, and before the advanced course (T3). Informed decision-making was assessed using the Decisional Conflict Scale. Results At the start of the introductory course (T1), most (17/19) students intended to receive their personal WGS data in the subsequent course, but many expressed conflict around this decision. Decisional conflict decreased after the introductory course (T2) indicating there was an increase in informed decision-making, and did not change before the advanced course (T3). This suggests that it was the introductory course content rather than simply time passing that had the effect. In the advanced course, all (19/19) students opted to receive their personal WGS data. No changes in technical knowledge of genomics were observed. Overall attitudes towards WGS were broadly positive. Conclusions Providing students with intensive introductory education about WGS may help them make informed decisions about whether or not to work with their personal WGS data in an educational setting. PMID:24373383

Financial Concerns About Participation in Clinical Trials Among Patients With Cancer.

PubMed

Wong, Yu-Ning; Schluchter, Mark D; Albrecht, Terrance L; Benson, Al Bowen; Buzaglo, Joanne; Collins, Michael; Flamm, Anne Lederman; Fleisher, Linda; Katz, Michael; Kinzy, Tyler G; Liu, Tasnuva M; Manne, Sharon; Margevicius, Seunghee; Miller, Dawn M; Miller, Suzanne M; Poole, David; Raivitch, Stephanie; Roach, Nancy; Ross, Eric; Meropol, Neal J

2016-02-10

The decision to enroll in a clinical trial is complex given the uncertain risks and benefits of new approaches. Many patients also have financial concerns. We sought to characterize the association between financial concerns and the quality of decision making about clinical trials. We conducted a secondary data analysis of a randomized trial of a Web-based educational tool (Preparatory Education About Clinical Trials) designed to improve the preparation of patients with cancer for making decisions about clinical trial enrollment. Patients completed a baseline questionnaire that included three questions related to financial concerns (five-point Likert scales): "How much of a burden on you is the cost of your medical care?," "I'm afraid that my health insurance won't pay for a clinical trial," and "I'm worried that I wouldn't be able to afford the costs of treatment on a clinical trial." Results were summed, with higher scores indicating greater concerns. We used multiple linear regressions to measure the association between concerns and self-reported measures of self-efficacy, preparation for decision making, distress, and decisional conflict in separate models, controlling for sociodemographic characteristics. One thousand two hundred eleven patients completed at least one financial concern question. Of these, 27% were 65 years or older, 58% were female, and 24% had a high school education or less. Greater financial concern was associated with lower self-efficacy and preparation for decision making, as well as with greater decisional conflict and distress, even after adjustment for age, race, sex, education, employment, and hospital location (P < .001 for all models). Financial concerns are associated with several psychological constructs that may negatively influence decision quality regarding clinical trials. Greater attention to patients' financial needs and concerns may reduce distress and improve patient decision making. © 2015 by American Society of Clinical Oncology.

Physician decision-making in the management of work related upper extremity injuries.

PubMed

Szekeres, Mike; Macdermid, Joy C; Katchky, Adam; Grewal, Ruby

2018-05-22

Physicians working in a tertiary care injured worker clinic are faced with clinical decision-making that must balance the needs of patients and society in managing complex clinical problems that are complicated by the work-workplace context. The purpose of this study is to describe and characterize the decision-making process of upper extremity specialized surgeons when managing injured workers within a specialized worker's compensation clinic. Surgeons were interviewed in a semi-structured manner. Following each interview, the surgeon was also observed in a clinic visit during a new patient assessment, allowing observation of the interactional patterns between surgeon and patient, and comparison of the process described in the interview to what actually occurred during clinic visits. The primary central theme emerging from the surgeon interviews and the clinical observation was the focus on the importance of comprehensive assessment to make the first critical decision: an accurate diagnosis. Two subthemes were also found. The first of these involved the decision whether to proceed to management strategies or to continue with further investigation if the correct diagnosis is uncertain. Once the central theme of diagnosis was achieved, a second subtheme was highlighted; selecting appropriate management options, given the complexities of managing the injured worker, the workplace, and the compensation board. This study illustrates that upper extremity surgeons rely on their training and experience with upper extremity conditions to follow a sequential but iterative decision-making process to provide a more definitive diagnosis and treatment plan for workers with injuries that are often complex. The surgeons are challenged by the context which takes them out of their familiar zone of typical clinical practice to deal with the interactions between the injury, worker, work, workplace and insurer.

“Entering a Clinical Trial: Is it Right For You?"-- A Randomized Study of The Clinical Trials Video and Its Impact on the Informed Consent Process

PubMed Central

Hoffner, Brianna; Bauer-Wu, Susan; Hitchcock-Bryan, Suzanne; Powell, Mark; Wolanski, Andrew; Joffe, Steven

2011-01-01

PURPOSE This randomized study was designed to assess the utility of an educational video in preparing cancer patients for decisions about clinical trial participation. The study assessed the effect of the video on patients’ understanding and perceptions of clinical trials, its impact on decision making and patient-provider communication, and patients’ satisfaction with the video. METHODS Ninety adults considering cancer clinical trials were randomized to receive (n=45) or not receive (n=45) the video. Using the validated Quality of Informed Consent (QuIC), respondents’ knowledge about clinical trial participation was assessed. All subjects completed additional questions about satisfaction with the video, decision making, and patient-provider communication. Data were analyzed using the Wilcoxon rank-sum test, regression model and descriptive statistics. RESULTS Although intent-to-treat analysis found no significant group differences in objective understanding between those randomized to view or not view the video, the majority of participants reported favorable experiences with regard to watching the video: 85% found the video was an important source of information about clinical trials; 81% felt better prepared to discuss the trial with their physician; 89% of those who watched the video with family indicated that it helped family better understand clinical trials; and 73% indicated it helped family accept their decision about participation. CONCLUSIONS Although the video did not measurably improve patients’ knowledge about clinical trials, it was an important source of information, helped educate families, and enhanced patient communication with their oncology providers. PMID:22009665

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

Value judgements in the decision-making process for the elderly patient.

PubMed

Ubachs-Moust, J; Houtepen, R; Vos, R; ter Meulen, R

2008-12-01

The question of whether old age should or should not play a role in medical decision-making for the elderly patient is regularly debated in ethics and medicine. In this paper we investigate exactly how age influences the decision-making process. To explore the normative argumentation in the decisions regarding an elderly patient we make use of the argumentation model advanced by Toulmin. By expanding the model in order to identify normative components in the argumentation process it is possible to analyse the way that age-related value judgements influence the medical decision-making process. We apply the model to practice descriptions made by medical students after they had attended consultations and meetings in medical practice during their clinical training. Our results show the pervasive character of age-related value judgements. They influence the physician's decision in several ways and at several points in the decision-making process. Such explicit value judgements were not exclusively used for arguments against further diagnosis or treatment of older patients. We found no systematic "ageist" pattern in the clinical decisions by physicians. Since age plays such an important, yet hidden role in the medical decision-making process, we make a plea for revealing such normative argumentation in order to gain transparency and accountability in this process. An explicit deliberative approach will make the medical decision-making process more transparent and improve the physician-patient relationship, creating confidence and trust, which are at the heart of medical practice.

Clinical decision-making to facilitate appropriate patient management in chiropractic practice: 'the 3-questions model'.

PubMed

Amorin-Woods, Lyndon G; Parkin-Smith, Gregory F

2012-03-14

A definitive diagnosis in chiropractic clinical practice is frequently elusive, yet decisions around management are still necessary. Often, a clinical impression is made after the exclusion of serious illness or injury, and care provided within the context of diagnostic uncertainty. Rather than focussing on labelling the condition, the clinician may choose to develop a defendable management plan since the response to treatment often clarifies the diagnosis. This paper explores the concept and elements of defensive problem-solving practice, with a view to developing a model of agile, pragmatic decision-making amenable to real-world application. A theoretical framework that reflects the elements of this approach will be offered in order to validate the potential of a so called '3-Questions Model'; Clinical decision-making is considered to be a key characteristic of any modern healthcare practitioner. It is, thus, prudent for chiropractors to re-visit the concept of defensible practice with a view to facilitate capable clinical decision-making and competent patient examination skills. In turn, the perception of competence and trustworthiness of chiropractors within the wider healthcare community helps integration of chiropractic services into broader healthcare settings.

Nurses' decision making in heart failure management based on heart failure certification status.

PubMed

Albert, Nancy M; Bena, James F; Buxbaum, Denise; Martensen, Linda; Morrison, Shannon L; Prasun, Marilyn A; Stamp, Kelly D

Research findings on the value of nurse certification were based on subjective perceptions or biased by correlations of certification status and global clinical factors. In heart failure, the value of certification is unknown. Examine the value of certification based nurses' decision-making. Cross-sectional study of nurses who completed heart failure clinical vignettes that reflected decision-making in clinical heart failure scenarios. Statistical tests included multivariable linear, logistic and proportional odds logistic regression models. Of nurses (N = 605), 29.1% were heart failure certified, 35.0% were certified in another specialty/job role and 35.9% were not certified. In multivariable modeling, nurses certified in heart failure (versus not heart failure certified) had higher clinical vignette scores (p = 0.002), reflecting higher evidence-based decision making; nurses with another specialty/role certification (versus no certification) did not (p = 0.62). Heart failure certification, but not in other specialty/job roles was associated with decisions that reflected delivery of high-quality care. Copyright © 2018 Elsevier Inc. All rights reserved.

Risk assessment and clinical decision making for colorectal cancer screening.

PubMed

Schroy, Paul C; Caron, Sarah E; Sherman, Bonnie J; Heeren, Timothy C; Battaglia, Tracy A

2015-10-01

Shared decision making (SDM) related to test preference has been advocated as a potentially effective strategy for increasing adherence to colorectal cancer (CRC) screening, yet primary care providers (PCPs) are often reluctant to comply with patient preferences if they differ from their own. Risk stratification advanced colorectal neoplasia (ACN) provides a rational strategy for reconciling these differences. To assess the importance of risk stratification in PCP decision making related to test preference for average-risk patients and receptivity to use of an electronic risk assessment tool for ACN to facilitate SDM. Mixed methods, including qualitative key informant interviews and a cross-sectional survey. PCPs at an urban, academic safety-net institution. Screening preferences, factors influencing patient recommendations and receptivity to use of a risk stratification tool. Nine PCPs participated in interviews and 57 completed the survey. Despite an overwhelming preference for colonoscopy by 95% of respondents, patient risk (67%) and patient preferences (63%) were more influential in their decision making than patient comorbidities (31%; P < 0.001). Age was the single most influential risk factor (excluding family history), with <20% of respondents choosing factors other than age. Most respondents reported that they would be likely to use a risk stratification tool in their practice either 'often' (43%) or sometimes (53%). Risk stratification was perceived to be important in clinical decision making, yet few providers considered risk factors other than age for average-risk patients. Providers were receptive to the use of a risk assessment tool for ACN when recommending an appropriate screening test for select patients. © 2013 John Wiley & Sons Ltd.

Do Teachers Make Decisions Like Firefighters? Applying Naturalistic Decision-Making Methods to Teachers' In-Class Decision Making in Mathematics

ERIC Educational Resources Information Center

Jazby, Dan

2014-01-01

Research into human decision making (DM) processes from outside of education paint a different picture of DM than current DM models in education. This pilot study assesses the use of critical decision method (CDM)--developed from observations of firefighters' DM -- in the context of primary mathematics teachers' in-class DM. Preliminary results…

[Structural elements of critical thinking of nurses in emergency care].

PubMed

Crossetti, Maria da Graça Oliveira; Bittencourt, Greicy Kelly Gouveia Dias; Lima, Ana Amélia Antunes; de Góes, Marta Georgina Oliveira; Saurin, Gislaine

2014-09-01

The objective of this study was to analyze the structural elements of critical thinking (CT) of nurses in the clinical decision-making process. This exploratory, qualitative study was conducted with 20 emergency care nurses in three hospitals in southern Brazil. Data were collected from April to June 2009, and a validated clinical case was applied from which nurses listed health problems, prescribed care and listed the structural elements of CT. Content analysis resulted in categories used to determine priority structural elements of CT, namely theoretical foundations and practical relationship to clinical decision making; technical and scientific knowledge and clinical experience, thought processes and clinical decision making: clinical reasoning and basis for clinical judgments of nurses: patient assessment and ethics. It was concluded that thinking critically is a skill that enables implementation of a secure and effective nursing care process.

A prospective cohort study of treatment decision-making for prostate cancer following participation in a multidisciplinary clinic.

PubMed

Hurwitz, Lauren M; Cullen, Jennifer; Elsamanoudi, Sally; Kim, Daniel J; Hudak, Jane; Colston, Maryellen; Travis, Judith; Kuo, Huai-Ching; Porter, Christopher R; Rosner, Inger L

2016-05-01

Patients diagnosed with prostate cancer (PCa) are presented with several treatment options of similar efficacy but varying side effects. Understanding how and why patients make their treatment decisions, as well as the effect of treatment choice on long-term outcomes, is critical to ensuring effective, patient-centered care. This study examined treatment decision-making in a racially diverse, equal-access, contemporary cohort of patients with PCa counseled on treatment options at a multidisciplinary clinic. A prospective cohort study was initiated at the Walter Reed National Military Medical Center (formerly Walter Reed Army Medical Center) in 2006. Newly diagnosed patients with PCa were enrolled before attending a multidisciplinary clinic. Patients completed surveys preclinic and postclinic to assess treatment preferences, reasons for treatment choice, and decisional regret. As of January 2014, 925 patients with PCa enrolled in this study. Surgery (54%), external radiation (20%), and active surveillance (12%) were the most common primary treatments for patients with low- and intermediate-risk PCa, whereas patients with high-risk PCa chose surgery (34%) or external radiation with neoadjuvant hormones (57%). Treatment choice differed by age at diagnosis, race, comorbidity status, and calendar year in both univariable and multivariable analyses. Patients preferred to play an active role in the decision-making process and cited doctors at the clinic as the most helpful source of treatment-related information. Almost all patients reported satisfaction with their decision. This is one of the first prospective cohort studies to examine treatment decision-making in an equal-access, multidisciplinary clinic setting. Studies of this cohort would aid in understanding and improving the PCa decision-making process. Published by Elsevier Inc.

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

PubMed

Hamann, Johannes; Bühner, Markus; Rüsch, Nicolas

2017-08-01

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

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

Withdrawal of anticancer therapy in advanced disease: a systematic literature review.

PubMed

Clarke, G; Johnston, S; Corrie, P; Kuhn, I; Barclay, S

2015-11-11

Current guidelines set out when to start anticancer treatments, but not when to stop as the end of life approaches. Conventional cytotoxic agents are administered intravenously and have major life-threatening toxicities. Newer drugs include molecular targeted agents (MTAs), in particular, small molecule kinase-inhibitors (KIs), which are administered orally. These have fewer life-threatening toxicities, and are increasingly used to palliate advanced cancer, generally offering additional months of survival benefit. MTAs are substantially more expensive, between £2-8 K per month, and perceived as easier to start than stop. A systematic review of decision-making concerning the withdrawal of anticancer drugs towards the end of life within clinical practice, with a particular focus on MTAs. Nine electronic databases searched. PRISMA guidelines followed. Forty-two studies included. How are decisions made? Decision-making was shared and ongoing, including stopping, starting and trying different treatments. Oncologists often experienced 'professional role dissonance' between their self-perception as 'treaters', and talking about end of life care. Why are decisions made? Clinical factors: disease progression, worsening functional status, treatment side-effects. Non-clinical factors: physicians' personal experience, values, emotions. Some patients continued treatment to maintain 'hope', often reflecting limited understanding of palliative goals. When are decisions made? Limited evidence reveals patients' decisions based upon quality of life benefits. Clinicians found timing withdrawal particularly challenging. Who makes the decisions? Decisions were based within physician-patient interaction. Oncologists report that decisions around stopping chemotherapy treatment are challenging, with limited evidence-based guidance outside of clinical trial protocols. The increasing availability of oral MTAs is transforming the management of incurable cancer; blurring boundaries between active treatment and palliative care. No studies specifically addressing decision-making around stopping MTAs in clinical practice were identified. There is a need to develop an evidence base to support physicians and patients with decision-making around the withdrawal of these high cost treatments.

Treatment selection of early stage non-small cell lung cancer: the role of the patient in clinical decision making.

PubMed

Mokhles, S; Nuyttens, J J M E; de Mol, M; Aerts, J G J V; Maat, A P W M; Birim, Ö; Bogers, A J J C; Takkenberg, J J M

2018-01-15

The objective of this study is to investigate the role and experience of early stage non-small cell lung cancer (NSCLC) patient in decision making process concerning treatment selection in the current clinical practice. Stage I-II NSCLC patients (surgery 55 patients, SBRT 29 patients, median age 68) were included in this prospective study and completed a questionnaire that explored: (1) perceived patient knowledge of the advantages and disadvantages of the treatment options, (2) experience with current clinical decision making, and (3) the information that the patient reported to have received from their treating physician. This was assessed by multiple-choice, 1-5 Likert Scale, and open questions. The Decisional Conflict Scale was used to assess the decisional conflict. Health related quality of life (HRQoL) was measured with SF-36 questionnaire. In 19% of patients, there was self-reported perceived lack of knowledge about the advantages and disadvantages of the treatment options. Seventy-four percent of patients felt that they were sufficiently involved in decision-making by their physician, and 81% found it important to be involved in decision making. Forty percent experienced decisional conflict, and one-in-five patients to such an extent that it made them feel unsure about the decision. Subscores with regard to feeling uninformed and on uncertainty, contributed the most to decisional conflict, as 36% felt uninformed and 17% of patients were not satisfied with their decision. HRQoL was not influenced by patient experience with decision-making or patient preferences for shared decision making. Dutch early-stage NSCLC patients find it important to be involved in treatment decision making. Yet a substantial proportion experiences decisional conflict and feels uninformed. Better patient information and/or involvement in treatment-decision-making is needed in order to improve patient knowledge and hopefully reduce decisional conflict.

An integrated strategy of knowledge application for optimal e-health implementation: A multi-method study protocol

PubMed Central

Gagnon, Marie-Pierre; Légaré, France; Fortin, Jean-Paul; Lamothe, Lise; Labrecque, Michel; Duplantie, Julie

2008-01-01

Background E-health is increasingly valued for supporting: 1) access to quality health care services for all citizens; 2) information flow and exchange; 3) integrated health care services and 4) interprofessional collaboration. Nevertheless, several questions remain on the factors allowing an optimal integration of e-health in health care policies, organisations and practices. An evidence-based integrated strategy would maximise the efficacy and efficiency of e-health implementation. However, decisions regarding e-health applications are usually not evidence-based, which can lead to a sub-optimal use of these technologies. This study aims at understanding factors influencing the application of scientific knowledge for an optimal implementation of e-health in the health care system. Methods A three-year multi-method study is being conducted in the Province of Quebec (Canada). Decision-making at each decisional level (political, organisational and clinical) are analysed based on specific approaches. At the political level, critical incidents analysis is being used. This method will identify how decisions regarding the implementation of e-health could be influenced or not by scientific knowledge. Then, interviews with key-decision-makers will look at how knowledge was actually used to support their decisions, and what factors influenced its use. At the organisational level, e-health projects are being analysed as case studies in order to explore the use of scientific knowledge to support decision-making during the implementation of the technology. Interviews with promoters, managers and clinicians will be carried out in order to identify factors influencing the production and application of scientific knowledge. At the clinical level, questionnaires are being distributed to clinicians involved in e-health projects in order to analyse factors influencing knowledge application in their decision-making. Finally, a triangulation of the results will be done using mixed methodologies to allow a transversal analysis of the results at each of the decisional levels. Results This study will identify factors influencing the use of scientific evidence and other types of knowledge by decision-makers involved in planning, financing, implementing and evaluating e-health projects. Conclusion These results will be highly relevant to inform decision-makers who wish to optimise the implementation of e-health in the Quebec health care system. This study is extremely relevant given the context of major transformations in the health care system where e-health becomes a must. PMID:18435853

Informed consent in medical decision-making in commercial gestational surrogacy: a mixed methods study in New Delhi, India.

PubMed

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

2015-05-01

To investigate ethical issues in informed consent for decisions regarding embryo transfer and fetal reduction in commercial gestational surrogacy. Mixed methods study employing observations, an interview-guide and semi-structured interviews. Fertility clinics and agencies in Delhi, India, between December 2011 and December 2012. Doctors providing conceptive technologies to commissioning couples and carrying out surrogacy procedures; surrogate mothers; agents functioning as links for surrogacy. Interviews using semi-structured interview guides were carried out among 20 doctors in 18 fertility clinics, five agents from four agencies and 14 surrogate mothers. Surrogate mothers were interviewed both individually and in the presence of doctors and agents. Data on socio-economic context and experiences among and between various actors in the surrogacy process were coded to identify categories of ethical concern. Numerical and grounded theory-oriented analyses were used. Informed consent, number of embryos transferred, fetal reduction, conflict of interest among the involved parties. None of the 14 surrogate mothers were able to explain the risks involved in embryo transfer and fetal reduction. The majority of the doctors took unilateral decisions about embryo transfer and fetal reduction. The commissioning parents were usually only indirectly involved. In the qualitative analysis, difficulties in explaining procedures, autonomy, self-payment of fertility treatment and conflicts of interest were the main themes. Clinical procedural decisions were primarily made by the doctors. Surrogate mothers were not adequately informed. There is a need for regulation on decision-making procedures to safeguard the interests of surrogate mothers. © 2015 Nordic Federation of Societies of Obstetrics and Gynecology.

Reflections in the clinical practice.

PubMed

Borrell-Carrió, F; Hernández-Clemente, J C

2014-03-01

The purpose of this article is to analyze some models of expert decision and their impact on the clinical practice. We have analyzed decision-making considering the cognitive aspects (explanatory models, perceptual skills, analysis of the variability of a phenomenon, creating habits and inertia of reasoning and declarative models based on criteria). We have added the importance of emotions in decision making within highly complex situations, such as those occurring within the clinical practice. The quality of the reflective act depends, among other factors, on the ability of metacognition (thinking about what we think). Finally, we propose an educational strategy based on having a task supervisor and rectification scenarios to improve the quality of medical decision making. Copyright © 2013 Elsevier España, S.L. All rights reserved.

Depression and Anxiety During Pregnancy: Evaluating the Literature in Support of Clinical Risk-Benefit Decision-Making.

PubMed

Dalke, Katharine Baratz; Wenzel, Amy; Kim, Deborah R

2016-06-01

Depression and anxiety during pregnancy are common, and patients and providers are faced with complex decisions regarding various treatment modalities. A structured discussion of the risks and benefits of options with the patient and her support team is recommended to facilitate the decision-making process. This clinically focused review, with emphasis on the last 3 years of published study data, evaluates the major risk categories of medication treatments, namely pregnancy loss, physical malformations, growth impairment, behavioral teratogenicity, and neonatal toxicity. Nonpharmacological treatment options, including neuromodulation and psychotherapy, are also briefly reviewed. Specific recommendations, drawn from the literature and the authors' clinical experience, are also offered to help guide the clinician in decision-making.

Evidence, research, knowledge: a call for conceptual clarity.

PubMed

Scott-Findlay, Shannon; Pollock, Carolee

2004-01-01

To dispel some of the conceptual confusion in the field of evidence-based practice that has resulted from the overlapping use of the terms research, evidence, and knowledge. Theoretical discussion. Often the terms research and knowledge are used as synonyms for evidence, but the overlap is never complete. The term evidence has long been understood to mean the findings of research. Recent attempts to broaden the definition of evidence to include clinical experience and experiential knowledge have been misguided. Broadening our understanding of the basis for clinical decision making and conceptualizing evidence are quite different tasks. Other factors (not other forms of evidence) do shape the clinical decision-making process, but they are not evidence. We might better term them knowledge. Confusing evidence with these other factors has hindered research and the improvement of clinical decision making in health care. We argue that this confusion results from the use of the term evidence when we really mean either research findings or knowledge. In this article, we have argued for specificity in the use of the term evidence. We urge the restriction of the term evidence to research findings, and while we acknowledge the importance of other influences on the clinical decision-making process, we insist that they are not evidence. The time has come to value personal experience and experiential knowledge for what they are-we should not have to disguise them as types of evidence for them to be deemed of any value. Being specific to language, the goal is to improve clinical decision making by increasing practitioners' reliance on research findings (evidence) while acknowledging (and valuing) the important part played by other forms of knowledge in the decision-making process. The distinctions are important.

Cool Decision-Making in Adolescents with Behavior Disorder and/or Mild-to-Borderline Intellectual Disability.

PubMed

Bexkens, Anika; Jansen, Brenda R J; Van der Molen, Maurits W; Huizenga, Hilde M

2016-02-01

Adolescents with Behavior Disorders (BD), Mild-to-Borderline Intellectual Disability (MBID), and with both BD and MBID (BD + MBID) are known to take more risks than normal controls. To examine the processes underlying this increased risk-taking, the present study investigated cool decision-making strategies in 479 adolescents (12-18 years, 55.9 % male) from these four groups. Cool decision-making was assessed with the paper-and-pencil Gambling Machine Task. This task, in combination with advanced latent group analysis, allows for an assessment of decision strategies. Results indicated that adolescents with BD and controls were almost equivalent in their decision-making strategies, whereas adolescents with MBID and adolescents with BD + MBID were characterized by suboptimal decision-making strategies, with only minor differences between these two clinical groups. These findings may have important clinical implications, as they suggest that risk taking in adolescents with MBID and in adolescents with BD + MBID can be (partly) attributed to the strategies that these adolescents use to make their decisions. Interventions may therefore focus on an improvement of these strategies.

A regret theory approach to decision curve analysis: A novel method for eliciting decision makers' preferences and decision-making

PubMed Central

2010-01-01

Background Decision curve analysis (DCA) has been proposed as an alternative method for evaluation of diagnostic tests, prediction models, and molecular markers. However, DCA is based on expected utility theory, which has been routinely violated by decision makers. Decision-making is governed by intuition (system 1), and analytical, deliberative process (system 2), thus, rational decision-making should reflect both formal principles of rationality and intuition about good decisions. We use the cognitive emotion of regret to serve as a link between systems 1 and 2 and to reformulate DCA. Methods First, we analysed a classic decision tree describing three decision alternatives: treat, do not treat, and treat or no treat based on a predictive model. We then computed the expected regret for each of these alternatives as the difference between the utility of the action taken and the utility of the action that, in retrospect, should have been taken. For any pair of strategies, we measure the difference in net expected regret. Finally, we employ the concept of acceptable regret to identify the circumstances under which a potentially wrong strategy is tolerable to a decision-maker. Results We developed a novel dual visual analog scale to describe the relationship between regret associated with "omissions" (e.g. failure to treat) vs. "commissions" (e.g. treating unnecessary) and decision maker's preferences as expressed in terms of threshold probability. We then proved that the Net Expected Regret Difference, first presented in this paper, is equivalent to net benefits as described in the original DCA. Based on the concept of acceptable regret we identified the circumstances under which a decision maker tolerates a potentially wrong decision and expressed it in terms of probability of disease. Conclusions We present a novel method for eliciting decision maker's preferences and an alternative derivation of DCA based on regret theory. Our approach may be intuitively more appealing to a decision-maker, particularly in those clinical situations when the best management option is the one associated with the least amount of regret (e.g. diagnosis and treatment of advanced cancer, etc). PMID:20846413

Speech pathologists' experience of involving people with stroke-induced aphasia in clinical decision making during rehabilitation.

PubMed

Berg, Karianne; Rise, Marit By; Balandin, Susan; Armstrong, Elizabeth; Askim, Torunn

2016-01-01

Although client participation has been part of legislation and clinical guidelines for several years, the evidence of these recommendations being implemented into clinical practice is scarce, especially for people with communication disorders. The aim of this study was to investigate how speech pathologists experienced client participation during the process of goal-setting and clinical decision making for people with aphasia. Twenty speech pathologists participated in four focus group interviews. A qualitative analysis using Systematic Text Condensation was undertaken. Analysis revealed three different approaches to client participation: (1) client-oriented, (2) next of kin-oriented and (3) professional-oriented participation. Participants perceived client-oriented participation as the gold standard. The three approaches were described as overlapping, with each having individual characteristics incorporating different facilitators and barriers. There is a need for greater emphasis on how to involve people with severe aphasia in goal setting and treatment planning, and frameworks made to enhance collaboration could preferably be used. Participants reported use of next of kin as proxies in goal-setting and clinical decision making for people with moderate-to-severe aphasia, indicating the need for awareness towards maintaining the clients' autonomy and addressing the goals of next of kin. Speech pathologists, and most likely other professionals, should place greater emphasis on client participation to ensure active involvement of people with severe aphasia. To achieve this, existing tools and techniques made to enhance collaborative goal setting and clinical decision making have to be better incorporated into clinical rehabilitation practice. To ensure the autonomy of the person with aphasia, as well as to respect next of kin's own goals, professionals need to make ethical considerations when next of kin are used as proxies in collaborative goal setting and clinical decision making.

Evidence-based practice of transfusion medicine: is it possible and what do the words mean?

PubMed

Vamvakas, Eleftherios C

2004-10-01

Evidence-based medicine (EBM) optimizes clinical decision making by dictating that clinical decisions be based on the best available research evidence and by integrating best research evidence with clinical expertise and patient values. Several rankings of the strength of the evidence generated from different types of clinical research designs have been presented, and, in addressing a particular problem, clinicians can base their decision making on the types of clinical reports that have been published, along with an assessment of the strengths and weaknesses of each study. At a policy level, the concept of EBM would dictate that policy decisions also be made based on the best available research evidence. In transfusion medicine, however, decisions are based on a broader range of inputs, and the criteria for evaluating the efficacy and/or cost-effectiveness of proposed interventions differ from those used in other areas. Reasons why policy decisions are often based on considerations other than the best research evidence include public expectations about transfusion safety and proposals for applying the precautionary principle to transfusion medicine. Using the debate over the appropriateness of introducing universal white-cell reduction as an example, this review describes 2 perspectives for assessing evidence and/or making clinical or policy decisions: the evidence-based approach and the precautionary-principle approach; and also considers whether decisions in transfusion medicine can be truly evidence based.

Effective follow-up consultations: the importance of patient-centered communication and shared decision making.

PubMed

Brand, Paul L P; Stiggelbout, Anne M

2013-12-01

Paediatricians spend a considerable proportion of their time performing follow-up visits for children with chronic conditions, but they rarely receive specific training on how best to perform such consultations. The traditional method of running a follow-up consultation is based on the doctor's agenda, and is problem-oriented. Patients and parents, however, prefer a patient-centered, and solution-focused approach. Although many physicians now recognize the importance of addressing the patient's perspective in a follow-up consultation, a number of barriers hamper its implementation in practice, including time constraints, lack of appropriate training, and a strong tradition of the biomedical, doctor-centered approach. Addressing the patient's perspective successfully can be achieved through shared decision making, clinicians and patients making decisions together based on the best clinical evidence. Research shows that shared decision making not only increases patient, parent, and physician satisfaction with the consultation, but also may improve health outcomes. Shared decision making involves building a physician-patient-parent partnership, agreeing on the problem at hand, laying out the available options with their benefits and risks, eliciting the patient's views and preferences on these options, and agreeing on a course of action. Shared decision making requires specific communication skills, which can be learned, and should be mastered through deliberate practice. Copyright © 2013 Elsevier Ltd. All rights reserved.

Decisional Control Preferences, Disclosure of Information Preferences, and Satisfaction Among Hispanic Patients With Advanced Cancer

PubMed Central

Noguera, Antonio; Yennurajalingam, Sriram; Torres-Vigil, Isabel; Parsons, Henrique Afonseca; Duarte, Eva Rosina; Palma, Alejandra; Bunge, Sofia; Palmer, J. Lynn; Bruera, Eduardo

2017-01-01

Context Studies to determine the decisional control preferences (DCPs) in Hispanic patients receiving palliative care are limited. Objectives The aims of this study were to describe DCPs, disclosure of information, and satisfaction with decision making among Hispanics, and to determine the degree of concordance between patients’ DCPs and their self-reported decisions. Methods We surveyed 387 cancer patients referred to outpatient palliative care clinics in Argentina, Chile, Guatemala, and the U.S. DCPs were measured with the Control Preference Scale, disclosure preferences with the Disclosure of Information Preferences questionnaire, and satisfaction with care with the Satisfaction with Decision Scale. Results In this study, 182 patients (47.6%) preferred shared decisional control, 119 (31.2%) active decisional control, and 81 (21.2%) preferred a passive approach. Concerning diagnosis and prognosis, 345 (92%) patients wanted to know their diagnosis, and 355 (94%) wanted to know their prognosis. Three hundred thirty-seven (87%) patients were satisfied with the decision-making process. DCPs were concordant with the self-reported decision-making process in 264 (69%) patients (weighted kappa, 0.55). Patients’ greater satisfaction with the decision-making process was correlated with older age (P≤0.001) and with a preference for enhanced diagnostic disclosure (P≤0.024). Satisfaction did not correlate with concordance in the decision-making process. Conclusion The vast majority preferred a shared or active decision-making process and wanted information about their diagnosis and prognosis. Older patients and those who wanted to know their diagnosis seemed to be more satisfied with the way treatment decisions were made. PMID:24035071

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…

Optimization of the decision-making process for the selection of therapeutics to undergo clinical testing for spinal cord injury in the North American Clinical Trials Network.

PubMed

Guest, James; Harrop, James S; Aarabi, Bizhan; Grossman, Robert G; Fawcett, James W; Fehlings, Michael G; Tator, Charles H

2012-09-01

The North American Clinical Trials Network (NACTN) includes 9 clinical centers funded by the US Department of Defense and the Christopher Reeve Paralysis Foundation. Its purpose is to accelerate clinical testing of promising therapeutics in spinal cord injury (SCI) through the development of a robust interactive infrastructure. This structure includes key committees that serve to provide longitudinal guidance to the Network. These committees include the Executive, Data Management, and Neurological Outcome Assessments Committees, and the Therapeutic Selection Committee (TSC), which is the subject of this manuscript. The NACTN brings unique elements to the SCI field. The Network's stability is not restricted to a single clinical trial. Network members have diverse expertise and include experts in clinical care, clinical trial design and methodology, pharmacology, preclinical and clinical research, and advanced rehabilitation techniques. Frequent systematic communication is assigned a high value, as is democratic process, fairness and efficiency of decision making, and resource allocation. This article focuses on how decision making occurs within the TSC to rank alternative therapeutics according to 2 main variables: quality of the preclinical data set, and fit with the Network's aims and capabilities. This selection process is important because if the Network's resources are committed to a therapeutic, alternatives cannot be pursued. A proposed methodology includes a multicriteria decision analysis that uses a Multi-Attribute Global Inference of Quality matrix to quantify the process. To rank therapeutics, the TSC uses a series of consensus steps designed to reduce individual and group bias and limit subjectivity. Given the difficulties encountered by industry in completing clinical trials in SCI, stable collaborative not-for-profit consortia, such as the NACTN, may be essential to clinical progress in SCI. The evolution of the NACTN also offers substantial opportunity to refine decision making and group dynamics. Making the best possible decisions concerning therapeutics selection for trial testing is a cornerstone of the Network's function.

TREATMENT SWITCHING: STATISTICAL AND DECISION-MAKING CHALLENGES AND APPROACHES.

PubMed

Latimer, Nicholas R; Henshall, Chris; Siebert, Uwe; Bell, Helen

2016-01-01

Treatment switching refers to the situation in a randomized controlled trial where patients switch from their randomly assigned treatment onto an alternative. Often, switching is from the control group onto the experimental treatment. In this instance, a standard intention-to-treat analysis does not identify the true comparative effectiveness of the treatments under investigation. We aim to describe statistical methods for adjusting for treatment switching in a comprehensible way for nonstatisticians, and to summarize views on these methods expressed by stakeholders at the 2014 Adelaide International Workshop on Treatment Switching in Clinical Trials. We describe three statistical methods used to adjust for treatment switching: marginal structural models, two-stage adjustment, and rank preserving structural failure time models. We draw upon discussion heard at the Adelaide International Workshop to explore the views of stakeholders on the acceptability of these methods. Stakeholders noted that adjustment methods are based on assumptions, the validity of which may often be questionable. There was disagreement on the acceptability of adjustment methods, but consensus that when these are used, they should be justified rigorously. The utility of adjustment methods depends upon the decision being made and the processes used by the decision-maker. Treatment switching makes estimating the true comparative effect of a new treatment challenging. However, many decision-makers have reservations with adjustment methods. These, and how they affect the utility of adjustment methods, require further exploration. Further technical work is required to develop adjustment methods to meet real world needs, to enhance their acceptability to decision-makers.

Many faces of rationality: Implications of the great rationality debate for clinical decision-making.

PubMed

Djulbegovic, Benjamin; Elqayam, Shira

2017-10-01

Given that more than 30% of healthcare costs are wasted on inappropriate care, suboptimal care is increasingly connected to the quality of medical decisions. It has been argued that personal decisions are the leading cause of death, and 80% of healthcare expenditures result from physicians' decisions. Therefore, improving healthcare necessitates improving medical decisions, ie, making decisions (more) rational. Drawing on writings from The Great Rationality Debate from the fields of philosophy, economics, and psychology, we identify core ingredients of rationality commonly encountered across various theoretical models. Rationality is typically classified under umbrella of normative (addressing the question how people "should" or "ought to" make their decisions) and descriptive theories of decision-making (which portray how people actually make their decisions). Normative theories of rational thought of relevance to medicine include epistemic theories that direct practice of evidence-based medicine and expected utility theory, which provides the basis for widely used clinical decision analyses. Descriptive theories of rationality of direct relevance to medical decision-making include bounded rationality, argumentative theory of reasoning, adaptive rationality, dual processing model of rationality, regret-based rationality, pragmatic/substantive rationality, and meta-rationality. For the first time, we provide a review of wide range of theories and models of rationality. We showed that what is "rational" behaviour under one rationality theory may be irrational under the other theory. We also showed that context is of paramount importance to rationality and that no one model of rationality can possibly fit all contexts. We suggest that in context-poor situations, such as policy decision-making, normative theories based on expected utility informed by best research evidence may provide the optimal approach to medical decision-making, whereas in the context-rich circumstances other types of rationality, informed by human cognitive architecture and driven by intuition and emotions such as the aim to minimize regret, may provide better solution to the problem at hand. The choice of theory under which we operate is important as it determines both policy and our individual decision-making. © 2017 The Authors Journal of Evaluation in Clinical Practice Published by John Wiley & Sons Ltd.

Initiating decision-making conversations in palliative care: an ethnographic discourse analysis.

PubMed

Bélanger, Emmanuelle; Rodríguez, Charo; Groleau, Danielle; Légaré, France; Macdonald, Mary Ellen; Marchand, Robert

2014-01-01

Conversations about end-of-life care remain challenging for health care providers. The tendency to delay conversations about care options represents a barrier that impedes the ability of terminally-ill patients to participate in decision-making. Family physicians with a palliative care practice are often responsible for discussing end-of-life care preferences with patients, yet there is a paucity of research directly observing these interactions. In this study, we sought to explore how patients and family physicians initiated decision-making conversations in the context of a community hospital-based palliative care service. This qualitative study combined discourse analysis with ethnographic methods. The field research lasted one year, and data were generated through participant observation and audio-recordings of consultations. A total of 101 consultations were observed longitudinally between 18 patients, 6 family physicians and 2 pivot nurses. Data analysis consisted in exploring the different types of discourses initiating decision-making conversations and how these discourses were affected by the organizational context in which they took place. The organization of care had an impact on decision-making conversations. The timing and origin of referrals to palliative care shaped whether patients were still able to participate in decision-making, and the decisions that remained to be made. The type of decisions to be made also shaped how conversations were initiated. Family physicians introduced decision-making conversations about issues needing immediate attention, such as symptom management, by directly addressing or eliciting patients' complaints. When decisions involved discussing impending death, decision-making conversations were initiated either indirectly, by prompting the patients to express their understanding of the disease and its progression, or directly, by providing a justification for broaching a difficult topic. Decision-making conversations and the initiation thereof were framed by the organization of care and the referral process prior to initial encounters. While symptom management was taken for granted as part of health care professionals' expected role, engaging in decisions regarding preparation for death implicitly remained under patients' control. This work makes important clinical contributions by exposing the rhetorical function of family physicians' discourse when introducing palliative care decisions.

The role of emotions in moral case deliberation: theory, practice, and methodology.

PubMed

Molewijk, Bert; Kleinlugtenbelt, Dick; Widdershoven, Guy

2011-09-01

In clinical moral decision making, emotions often play an important role. However, many clinical ethicists are ignorant, suspicious or even critical of the role of emotions in making moral decisions and in reflecting on them. This raises practical and theoretical questions about the understanding and use of emotions in clinical ethics support services. This paper presents an Aristotelian view on emotions and describes its application in the practice of moral case deliberation. According to Aristotle, emotions are an original and integral part of (virtue) ethics. Emotions are an inherent part of our moral reasoning and being, and therefore they should be an inherent part of any moral deliberation. Based on Aristotle's view, we examine five specific aspects of emotions: the description of emotions, the attitude towards emotions, the thoughts present in emotions, the reliability of emotions, and the reasonable principle that guides an emotion. We then discuss three ways of dealing with emotions in the process of moral case deliberation. Finally, we present an Aristotelian conversation method, and present practical experiences using this method. © 2011 Blackwell Publishing Ltd.

Rational decision-making in mental health: the role of systematic reviews.

PubMed

Gilbody, Simon M.; Petticrew, Mark

1999-09-01

BACKGROUND: "Systematic reviews" have come to be recognized as the most rigorous method of summarizing confusing and often contradictory primary research in a transparent and reproducible manner. Their greatest impact has been in the summarization of epidemiological literature - particularly that relating to clinical effectiveness. Systematic reviews also have a potential to inform rational decision-making in healthcare policy and to form a component of economic evaluation. AIMS OF THE STUDY: This article aims to introduce the rationale behind systematic reviews and, using examples from mental health, to introduce the strengths and limitations of systematic reviews, particularly in informing mental health policy and economic evaluation. METHODS: Examples are selected from recent controversies surrounding the introduction of new psychiatric drugs (anti-depressants and anti-schizophrenia drugs) and methods of delivering psychiatric care in the community (case management and assertive community treatment). The potential for systematic reviews to (i) produce best estimates of clinical efficacy and effectiveness, (ii) aid economic evaluation and policy decision-making and (iii) highlight gaps in the primary research knowledge base are discussed. Lastly examples are selected from outside mental health to show how systematic reviews have a potential to be explicitly used in economic and health policy evaluation. RESULTS: Systematic reviews produce the best estimates of clinical efficacy, which can form an important component of economic evaluation. Importantly, serious methodological flaws and areas of uncertainty in the primary research literature are identified within an explicit framework. Summary indices of clinical effectiveness can be produced, but it is difficult to produce such summary indices of cost effectiveness by pooling economic data from primary studies. Modelling is commonly used in economic and policy evaluation. Here, systematic reviews can provide the best estimates of effectiveness and, importantly, highlight areas of uncertainty that can be used in "sensitivity analysis". DISCUSSION: Systematic reviews are an important recent methodological advance, the potential for which has only begun to be realized in mental health. This use of systematic reviews is probably most advanced in producing critical summaries of clinical effectiveness data. Systematic reviews cannot produce valid and believable conclusions when the primary research literature is of poor quality. An important function of systematic reviews will be in highlighting this poor quality research which is of little use in mental health decision making. IMPLICATIONS FOR HEALTH PROVISION: Health care provision should be both clinically and cost effective. Systematic reviews are a key component in ensuring that this goal is achieved. IMPLICATIONS FOR HEALTH POLICIES: Systematic reviews have potential to inform health policy. Examples presented show that health policy is often made without due consideration of the research evidence. Systematic reviews can provide robust and believable answers, which can help inform rational decision-making. Importantly, systematic reviews can highlight the need for important primary research and can inform the design of this research such that it provides answers that will help in forming healthcare policy. IMPLICATIONS FOR FURTHER RESEARCH: Systematic reviews should precede costly (and often unnecessary) primary research. Many areas of health policy and practice have yet to be evaluated using systematic review methodology. Methods for the summarization of economic data are methodologically complex and deserve further research

Adjuvant chemotherapy in elderly women with breast cancer: patients' perspectives on information giving and decision making.

PubMed

Harder, Helena; Ballinger, Rachel; Langridge, Carolyn; Ring, Alistair; Fallowfield, Lesley J

2013-12-01

Decisions about adjuvant chemotherapy in older women with early stage breast cancer (EBC) are often challenging. Uncertainty about benefits due to limited data about treatment efficacy and outcomes complicates decision making. This qualitative study explored older patients' experiences and preferences towards information giving and ultimate decisions about adjuvant chemotherapy. Clinicians from 24 UK breast cancer teams reported on adjuvant chemotherapy decisions for women aged ≥70 years with EBC from April 2010 to December 2011. Women who were offered chemotherapy were invited to participate in structured interviews. Self-reported quality of life (QoL) and functional ability were assessed. Qualitative methods were used to identify themes associated with information giving and decision making. A total of 58/95 eligible women (61%) participated. Median age was 73 years (range 70-83). Mean total scores for QoL and functional ability were average. The majority of women preferred to make their treatment decisions collaboratively with a clinician (59%) or on their own (19%). The main reasons influencing decisions to accept chemotherapy were categorised as prevention of recurrence and clinician recommendation. Side effects, length of treatment, impact on QoL, low survival benefits and clinician recommendation influenced decisions to decline chemotherapy. The majority (80%) were satisfied with information provision, the communication with their clinician and explanation of treatment. Older women with EBC preferred to be involved in clinical decision making. Clinician recommendation plays a significant role in either accepting or declining chemotherapy. Well-informed decision making and effective communication between clinicians, older women and their family members are therefore important. Copyright © 2013 John Wiley & Sons, Ltd.

Flexible functional regression methods for estimating individualized treatment regimes.

PubMed

Ciarleglio, Adam; Petkova, Eva; Tarpey, Thaddeus; Ogden, R Todd

2016-01-01

A major focus of personalized medicine is on the development of individualized treatment rules. Good decision rules have the potential to significantly advance patient care and reduce the burden of a host of diseases. Statistical methods for developing such rules are progressing rapidly, but few methods have considered the use of pre-treatment functional data to guide in decision-making. Furthermore, those methods that do allow for the incorporation of functional pre-treatment covariates typically make strong assumptions about the relationships between the functional covariates and the response of interest. We propose two approaches for using functional data to select an optimal treatment that address some of the shortcomings of previously developed methods. Specifically, we combine the flexibility of functional additive regression models with Q -learning or A -learning in order to obtain treatment decision rules. Properties of the corresponding estimators are discussed. Our approaches are evaluated in several realistic settings using synthetic data and are applied to real data arising from a clinical trial comparing two treatments for major depressive disorder in which baseline imaging data are available for subjects who are subsequently treated.

Clinicians' perceptions of decision making regarding discharge from public hospitals to in-patient rehabilitation following trauma.

PubMed

Kimmel, Lara A; Holland, Anne E; Lannin, Natasha; Edwards, Elton R; Page, Richard S; Bucknill, Andrew; Hau, Raphael; Gabbe, Belinda J

2017-05-01

Objective The aim of the present study was to investigate the perceptions of consultant surgeons, allied health clinicians and rehabilitation consultants regarding discharge destination decision making from the acute hospital following trauma. Methods A qualitative study was performed using individual in-depth interviews of clinicians in Victoria (Australia) between April 2013 and September 2014. Thematic analysis was used to derive important themes. Case studies provided quantitative information to enhance the information gained via interviews. Results Thirteen rehabilitation consultants, eight consultant surgeons and 13 allied health clinicians were interviewed. Key themes that emerged included the importance of financial considerations as drivers of decision making and the perceived lack of involvement of medical staff in decisions regarding discharge destination following trauma. Other themes included the lack of consistency of factors thought to be important drivers of discharge and the difficulty in acting on trauma patients' requests in terms of discharge destination. Importantly, as the complexity of the patient increases in terms of acquired brain injury, the options for rehabilitation become scarcer. Conclusions The information gained in the present study highlights the large variation in discharge practises between and within clinical groups. Further consultation with stakeholders involved in the care of trauma patients, as well as government bodies involved in hospital funding, is needed to derive a more consistent approach to discharge destination decision making. What is known about the topic? Little is known about the drivers for referral to, or acceptance at, in-patient rehabilitation following acute hospital care for traumatic injury in Victoria, Australia, including who makes these decisions of behalf of patients and how these decisions are made. What does this paper add? This paper provides information regarding the perceptions of acute hospital consultant surgeons and allied health, as well as rehabilitation clinicians, in terms of discharge destination decision making from the acute hospital following trauma. The use of case studies further highlights differences between, and within, these specialities with regard to this decision making. This research also highlights the importance of financial considerations as drivers of decision making, and the lack of consistency of the factors thought to be important drivers of discharge between these different clinical groupings. What are the implications for practitioners? This research shows that financial factors are significant drivers of discharge destination decision making for trauma patients. The present study highlights opportunities to engage with stakeholders (acute care, rehabilitation, administration, government and patients) to develop more consistent discharge processes that optimise the use of rehabilitation resources for those patients who could benefit from in-patient rehabilitation.

Avoiding bias in medical ethical decision-making. Lessons to be learnt from psychology research.

PubMed

Albisser Schleger, Heidi; Oehninger, Nicole R; Reiter-Theil, Stella

2011-05-01

When ethical decisions have to be taken in critical, complex medical situations, they often involve decisions that set the course for or against life-sustaining treatments. Therefore the decisions have far-reaching consequences for the patients, their relatives, and often for the clinical staff. Although the rich psychology literature provides evidence that reasoning may be affected by undesired influences that may undermine the quality of the decision outcome, not much attention has been given to this phenomenon in health care or ethics consultation. In this paper, we aim to contribute to the sensitization of the problem of systematic reasoning biases by showing how exemplary individual and group biases can affect the quality of decision-making on an individual and group level. We are addressing clinical ethicists as well as clinicians who guide complex decision-making processes of ethical significance. Knowledge regarding exemplary group psychological biases (e.g. conformity bias), and individual biases (e.g. stereotypes), will be taken from the disciplines of social psychology and cognitive decision science and considered in the field of ethical decision-making. Finally we discuss the influence of intuitive versus analytical (systematical) reasoning on the validity of ethical decision-making.

Can patients' preferences for involvement in decision-making regarding the use of medicines be predicted?

PubMed

Garfield, S; Smith, F; Francis, S A; Chalmers, C

2007-06-01

The current study aimed to develop a model of patients' preferences for involvement in decision-making concerning the use of medicines for chronic conditions in the UK and test it in a large representative sample of patients with one of two clinical conditions. Following a structured literature review, an instrument was developed which measured the variables that had been identified as predictors of patients' preferences for involvement in decision making in previous research. Five hundred and sixteen patients with rheumatoid arthritis or type 2 diabetes were recruited from outpatient and primary care clinics and asked to complete the instrument. Multivariate analysis revealed that age, social class and clinical condition were associated with preferences for involvement in decision-making concerning the use of medicines for chronic illness but gender, ethnic group, concerns about medicines, beliefs about necessity of medicines, health status, quality of life and time since diagnosis were not. In total, the fitted model explained only 14% of the variance. This study has demonstrated that current research does not provide a basis for predicting patients' preferences for involvement in decision-making. Building concordant relationships may depend on practitioners developing strategies to establish individuals' preferences for involvement in decision-making as part of the ongoing prescriber-patient relationship.

The Evolution of an Interprofessional Shared Decision-Making Research Program: Reflective Case Study of an Emerging Paradigm.

PubMed

Dogba, Maman Joyce; Menear, Matthew; Stacey, Dawn; Brière, Nathalie; Légaré, France

2016-07-19

Healthcare research increasingly focuses on interprofessional collaboration and on shared decision making, but knowledge gaps remain about effective strategies for implementing interprofessional collaboration and shared decision-making together in clinical practice. We used Kuhn's theory of scientific revolutions to reflect on how an integrated interprofessional shared decision-making approach was developed and implemented over time. In 2007, an interdisciplinary team initiated a new research program to promote the implementation of an interprofessional shared decision-making approach in clinical settings. For this reflective case study, two new team members analyzed the team's four projects, six research publications, one unpublished and two published protocols and organized them into recognizable phases according to Kuhn's theory. The merging of two young disciplines led to challenges characteristic of emerging paradigms. Implementation of interprofessional shared-decision making was hindered by a lack of conceptual clarity, a dearth of theories and models, little methodological guidance, and insufficient evaluation instruments. The team developed a new model, identified new tools, and engaged knowledge users in a theory-based approach to implementation. However, several unresolved challenges remain. This reflective case study sheds light on the evolution of interdisciplinary team science. It offers new approaches to implementing emerging knowledge in the clinical context.

Case-based explanation of non-case-based learning methods.

PubMed Central

Caruana, R.; Kangarloo, H.; Dionisio, J. D.; Sinha, U.; Johnson, D.

1999-01-01

We show how to generate case-based explanations for non-case-based learning methods such as artificial neural nets or decision trees. The method uses the trained model (e.g., the neural net or the decision tree) as a distance metric to determine which cases in the training set are most similar to the case that needs to be explained. This approach is well suited to medical domains, where it is important to understand predictions made by complex machine learning models, and where training and clinical practice makes users adept at case interpretation. PMID:10566351

Using Simulation in a Vocational Programme: Does the Method Support the Theory?

ERIC Educational Resources Information Center

Rush, Sue; Acton, Lesley; Tolley, Kim; Marks-Maran, Di; Burke, Linda

2010-01-01

Use of simulation is well established as a way of learning and assessing skills in vocational disciplines. In many institutions the use of simulation with student nurses is being tested as a way of helping them learn clinical skills, problem-solving, clinical assessment and decision-making. This paper explores the value of simulation as a learning…

Information Seeking Behaviour of Parents of Paediatric Patients for Clinical Decision Making: The Central Role of Information Literacy in a Participatory Setting

ERIC Educational Resources Information Center

Kostagiolas, Petros; Martzoukou, Konstantina; Georgantzi, Georgia; Niakas, Dimitris

2013-01-01

Introduction: This study investigated the information seeking behaviour and needs of parents of paediatric patients and their motives for seeking Internet-based information. Method: A questionnaire survey of 121 parents was conducted in a paediatric clinic of a Greek university hospital. Analysis: The data were analysed using SPSS; descriptive…

Examining the relationship between critical-thinking skills and decision-making ability of emergency medicine students.

PubMed

Heidari, Mohammad; Ebrahimi, Parvin

2016-10-01

Critical-thinking ability would enable students to think creatively and make better decisions and makes them make a greater effort to concentrate on situations related to clinical matters and emergencies. This can bridge the gap between the clinical and theoretical training. Therefore, the aim of the present study is to examine the relationship between critical-thinking ability and decision-making skills of the students of Emergency Medicine. This descriptive and analytical research was conducted on all the students of medical emergency students ( n = 86) in Shahrekord, Iran. The demographic information questionnaire, the California Critical Thinking Skills Test, and a decision-making researcher-made questionnaire were used to collect data. The data were analyzed by SPSS software version 16 using descriptive and analytical statistical tests and Pearson's correlation coefficient. The results of the present study indicate that the total mean score for the critical thinking was 8.32 ± 2.03 and for decision making 8.66 ± 1.89. There is a significant statistical relationship between the critical-thinking score and decision-making score ( P < 0.05). Although critical-thinking skills and decision-making ability are essential for medical emergency professional competence, the results of this study show that these skills are poor among the students.

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

PubMed

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

2009-11-01

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

[Evidence-based medicine - the current self-reflection of an individualised approach to medicine as an action science].

PubMed

Behrens, Johann

2010-01-01

Evidence-based Medicine (EbM) is the ongoing self-reflection of an individualised approach to medicine in terms of a science that originates from and focuses on clinical decision-making (pragmatic science="Handlungswissenschaft"). EbM is particularly suitable for self-reflecting individualised medicine on the basis of decision-oriented pragmatic science because it consistently distinguishes between external evidence (i.e., other subjects' experience gained through "qualitative" and "quantitative" scientific methods) and internal evidence, i.e., the individual user's, or patient's, own experience manifesting and developing in the individual contact between therapist and patient. Therefore, internal evidence is completely different from the individual clinical experience, expertise, and conviction which therapists contribute to the encounter with clients. A deeper understanding of internal evidence as a result of this encounter has emerged only in the past 15 years. However, it is an integral part of the logic of evidence-based professional decision-making. Scientifically justified beneficial and effective treatment in the individual case cannot be deduced from external evidence but can only be gathered from internal evidence for which the best external evidence available has been utilised. In the past 15 years nursing science has not only carved out the decision-oriented scientific core of evidence-based practice but has also tried to increase the validity of studies on external evidence by employing a combination of 'qualitative' social science studies and clinical epidemiological methods. Copyright © 2010. Published by Elsevier GmbH.

Differences in Simulated Doctor and Patient Medical Decision Making: A Construal Level Perspective

PubMed Central

Zhang, Yan; Liu, Quanhui; Miao, Danmin; Xiao, Wei

2013-01-01

Background Patients are often confronted with diverse medical decisions. Often lacking relevant medical knowledge, patients fail to independently make medical decisions and instead generally rely on the advice of doctors. Objective This study investigated the characteristics of and differences in doctor–patient medical decision making on the basis of construal level theory. Methods A total of 420 undergraduates majoring in clinical medicine were randomly assigned to six groups. Their decisions to opt for radiotherapy and surgery were investigated, with the choices described in a positive/neutral/negative frame × decision making for self/others. Results Compared with participants giving medical advice to patients, participants deciding for themselves were more likely to select radiotherapy (F1, 404 = 13.92, p = 011). Participants from positive or neutral frames exhibited a higher tendency to choose surgery than did those from negative frames (F2, 404 = 22.53, p<.001). The effect of framing on independent decision making was nonsignificant (F2, 404 = 1.07, p = 35); however the effect of framing on the provision of advice to patients was significant (F2, 404 = 12.95, p<.001). The effect of construal level was significant in the positive frame (F1, 404 = 8.06, p = 005) and marginally significant in the neutral frame (F2, 404 = 3.31, p = 07) but nonsignificant in the negative frame (F2, 404 = .29, p = 59). Conclusion Both social distance and framing depiction significantly affected medical decision making and exhibited a significant interaction. Differences in medical decision making between doctors and patients need further investigation. PMID:24244445

Decision-Making in Audiology: Balancing Evidence-Based Practice and Patient-Centered Care

PubMed Central

Clemesha, Jennifer; Lundmark, Erik; Crome, Erica; Barr, Caitlin; McMahon, Catherine M.

2017-01-01

Health-care service delivery models have evolved from a practitioner-centered approach toward a patient-centered ideal. Concurrently, increasing emphasis has been placed on the use of empirical evidence in decision-making to increase clinical accountability. The way in which clinicians use empirical evidence and client preferences to inform decision-making provides an insight into health-care delivery models utilized in clinical practice. The present study aimed to investigate the sources of information audiologists use when discussing rehabilitation choices with clients, and discuss the findings within the context of evidence-based practice and patient-centered care. To assess the changes that may have occurred over time, this study uses a questionnaire based on one of the few studies of decision-making behavior in audiologists, published in 1989. The present questionnaire was completed by 96 audiologists who attended the World Congress of Audiology in 2014. The responses were analyzed using qualitative and quantitative approaches. Results suggest that audiologists rank clinical test results and client preferences as the most important factors for decision-making. Discussion with colleagues or experts was also frequently reported as an important source influencing decision-making. Approximately 20% of audiologists mentioned utilizing research evidence to inform decision-making when no clear solution was available. Information shared at conferences was ranked low in terms of importance and reliability. This study highlights an increase in awareness of concepts associated with evidence-based practice and patient-centered care within audiology settings, consistent with current research-to-practice dissemination pathways. It also highlights that these pathways may not be sufficient for an effective clinical implementation of these practices. PMID:28752808

A YinYang bipolar fuzzy cognitive TOPSIS method to bipolar disorder diagnosis.

PubMed

Han, Ying; Lu, Zhenyu; Du, Zhenguang; Luo, Qi; Chen, Sheng

2018-05-01

Bipolar disorder is often mis-diagnosed as unipolar depression in the clinical diagnosis. The main reason is that, different from other diseases, bipolarity is the norm rather than exception in bipolar disorder diagnosis. YinYang bipolar fuzzy set captures bipolarity and has been successfully used to construct a unified inference mathematical modeling method to bipolar disorder clinical diagnosis. Nevertheless, symptoms and their interrelationships are not considered in the existing method, circumventing its ability to describe complexity of bipolar disorder. Thus, in this paper, a YinYang bipolar fuzzy multi-criteria group decision making method to bipolar disorder clinical diagnosis is developed. Comparing with the existing method, the new one is more comprehensive. The merits of the new method are listed as follows: First of all, multi-criteria group decision making method is introduced into bipolar disorder diagnosis for considering different symptoms and multiple doctors' opinions. Secondly, the discreet diagnosis principle is adopted by the revised TOPSIS method. Last but not the least, YinYang bipolar fuzzy cognitive map is provided for the understanding of interrelations among symptoms. The illustrated case demonstrates the feasibility, validity, and necessity of the theoretical results obtained. Moreover, the comparison analysis demonstrates that the diagnosis result is more accurate, when interrelations about symptoms are considered in the proposed method. In a conclusion, the main contribution of this paper is to provide a comprehensive mathematical approach to improve the accuracy of bipolar disorder clinical diagnosis, in which both bipolarity and complexity are considered. Copyright © 2018 Elsevier B.V. All rights reserved.

[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. Copyright © 2014 SECA. Published by Elsevier Espana. All rights reserved.

Impact of clinical and health services research projects on decision-making: a qualitative study

PubMed Central

2013-01-01

Background This article reports on the impact assessment experience of a funding program of non-commercial clinical and health services research. The aim was to assess the level of implementation of results from a subgroup of research projects (on respiratory diseases), and to detect barriers (or facilitators) in the translation of new knowledge to informed decision-making. Methods A qualitative study was performed. The sample consisted of six projects on respiratory diseases funded by the Agency for Health Quality and Assessment of Catalonia between 1996 and 2004. Semi-structured interviews to key informants including researchers and healthcare decision-makers were carried out. Interviews were recorded, transcribed verbatim and analysed on an individual (key informant) and group (project) basis. In addition, the differences between achieved and expected impacts were described. Results Twenty-three semi-structured interviews were conducted. Most participants indicated changes in health services or clinical practice had resulted from research. The channels used to transfer new knowledge were mainly conventional ones, but also in less explicit ways, such as with the involvement of local scientific societies, or via debates and discussions with colleagues and local leaders. The barriers and facilitators identified were mostly organizational (in research management, and clinical and healthcare practice), although there were also some related to the nature of the research as well as personal factors. Both the expected and achieved impacts enabled the identification of the gaps between what is expected and what is truly achieved. Conclusions In this study and according to key informants, the impact of these research projects on decision-making can be direct (the application of a finding or innovation) or indirect, contributing to a more complex change in clinical practice and healthcare organization, both having other contextual factors. The channels used to transfer this new knowledge to clinical practice are complex. Local scientific societies and the relationships between researchers and decision-makers can play a very important role. Specifically, the relationships between managers and research teams and the mutual knowledge of their activity have shown to be effective in applying research funding to practice and decision-making. Finally the facilitating factors and barriers identified by the respondents are closely related to the idiosyncrasy of the human relations between the different stakeholders involved. PMID:23663364

Primary Care Physicians' Collection, Comfort, and Use of Race and Ethnicity in Clinical Practice in the United States.

PubMed

Bonham, Vence L; Umeh, Nkeiruka I; Cunningham, Brooke A; Abdallah, Khadijah E; Sellers, Sherrill L; Cooper, Lisa A

2017-01-01

The clinical utility of race and ethnicity has been debated. It is important to understand if and how race and ethnicity are communicated and collected in clinical settings. We investigated physicians' self-reported methods of collecting a patient's race and ethnicity in the clinical encounter, their comfort with collecting race and ethnicity, and associations with use of race in clinical decision-making. A national cross-sectional study of 787 clinically active general internists in the United States. Physicians' self-reported comfort with collecting patient race and ethnicity, their collection practices, and use of race in clinical care were assessed. Bivariate and multivariable regression analyses were conducted to examine associations between comfort, collection practices, and use of race. Most physicians asked patients to self-report their race or ethnicity (26.5%) on an intake form or collected this information directly from patients (26.2%). Most physicians were comfortable collecting patient race and ethnicity (84.3%). Physicians who were more comfortable collecting patient race and ethnicity ( β = 1.65; [95% confidence interval; CI 0.03-3.28]) or who directly collected patients' race and ethnicity ( β = 1.24 [95% CI 0.07-2.41]) were more likely to use race in clinical decision-making than physicians who were uncomfortable. This study documents variation in physician comfort level and practice patterns regarding patient race and ethnicity data collection. As the U.S. population becomes more diverse, future work should examine how physicians speak about race and ethnicity with patients and their use of race and ethnicity data impact patient-physician relationships, clinical decision-making, and patient outcomes.

Use and perceptions of information among family physicians: sources considered accessible, relevant, and reliable

PubMed Central

Kosteniuk, Julie G.; Morgan, Debra G.; D'Arcy, Carl K.

2013-01-01

Objectives: The research determined (1) the information sources that family physicians (FPs) most commonly use to update their general medical knowledge and to make specific clinical decisions, and (2) the information sources FPs found to be most physically accessible, intellectually accessible (easy to understand), reliable (trustworthy), and relevant to their needs. Methods: A cross-sectional postal survey of 792 FPs and locum tenens, in full-time or part-time medical practice, currently practicing or on leave of absence in the Canadian province of Saskatchewan was conducted during the period of January to April 2008. Results: Of 666 eligible physicians, 331 completed and returned surveys, resulting in a response rate of 49.7% (331/666). Medical textbooks and colleagues in the main patient care setting were the top 2 sources for the purpose of making specific clinical decisions. Medical textbooks were most frequently considered by FPs to be reliable (trustworthy), and colleagues in the main patient care setting were most physically accessible (easy to access). Conclusions: When making specific clinical decisions, FPs were most likely to use information from sources that they considered to be reliable and generally physically accessible, suggesting that FPs can best be supported by facilitating easy and convenient access to high-quality information. PMID:23405045

Equipment Selection by using Fuzzy TOPSIS Method

NASA Astrophysics Data System (ADS)

Yavuz, Mahmut

2016-10-01

In this study, Fuzzy TOPSIS method was performed for the selection of open pit truck and the optimal solution of the problem was investigated. Data from Turkish Coal Enterprises was used in the application of the method. This paper explains the Fuzzy TOPSIS approaches with group decision-making application in an open pit coal mine in Turkey. An algorithm of the multi-person multi-criteria decision making with fuzzy set approach was applied an equipment selection problem. It was found that Fuzzy TOPSIS with a group decision making is a method that may help decision-makers in solving different decision-making problems in mining.

Uncertainty and equipoise: at interplay between epistemology, decision making and ethics.

PubMed

Djulbegovic, Benjamin

2011-10-01

In recent years, various authors have proposed that the concept of equipoise be abandoned because it conflates the practice of clinical care with clinical research. At the same time, the equipoise opponents acknowledge the necessity of clinical research if there are unresolved uncertainties about the effects of proposed healthcare interventions. As equipoise represents just 1 measure of uncertainty, proposals to abandon equipoise while maintaining a requirement for addressing uncertainties are contradictory and ultimately not valid. As acknowledgment and articulation of uncertainties represent key scientific and moral requirements for human experimentation, the concept of equipoise remains the most useful framework to link the theory of human experimentation with the theory of rational choice. In this article, I show how uncertainty (equipoise) is at the intersection between epistemology, decision making and ethics of clinical research. In particular, I show how our formulation of responses to uncertainties of hoped-for benefits and unknown harms of testing is a function of the way humans cognitively process information. This approach is based on the view that considerations of ethics and rationality cannot be separated. I analyze the response to uncertainties as it relates to the dual-processing theory, which postulates that rational approach to (clinical research) decision making depends both on analytical, deliberative processes embodied in scientific method (system II), and good human intuition (system I). Ultimately, our choices can only become wiser if we understand a close and intertwined relationship between irreducible uncertainty, inevitable errors and unavoidable injustice.

Uncertainty and Equipoise: At Interplay Between Epistemology, Decision-Making and Ethics

PubMed Central

Djulbegovic, Benjamin

2011-01-01

In recent years, various authors have proposed that the concept of equipoise be abandoned since it conflates the practice of clinical care with clinical research. At the same time, the equipoise opponents acknowledge the necessity of clinical research if there are unresolved uncertainties about the effects of proposed healthcare interventions. Since equipoise represents just one measure of uncertainty, proposals to abandon equipoise while maintaining a requirement for addressing uncertainties are contradictory and ultimately not valid. As acknowledgment and articulation of uncertainties represent key scientific and moral requirements for human experimentation, the concept of equipoise remains the most useful framework to link the theory of human experimentation with the theory of rational choice. In this paper, I show how uncertainty (equipoise) is at the intersection between epistemology, decision-making and ethics of clinical research. In particular, I show how our formulation of responses to uncertainties of hoped-for benefits and unknown harms of testing is a function of the way humans cognitively process information. This approach is based on the view that considerations of ethics and rationality cannot be separated. I analyze the response to uncertainties as it relates to the dual-processing theory, which postulates that rational approach to (clinical research) decision-making depends both on analytical, deliberative processes embodied in scientific method (system II) and “good” human intuition (system I). Ultimately, our choices can only become wiser if we understand a close and intertwined relationship between irreducible uncertainty, inevitable errors, and unavoidable injustice. PMID:21817885

"Ultimately, mom has the call": Viewing clinical trial decision making among patients with ovarian cancer through the lens of relational autonomy.

PubMed

Asiedu, Gladys B; Ridgeway, Jennifer L; Carroll, Katherine; Jatoi, Aminah; Radecki Breitkopf, Carmen

2018-04-14

This study employs the concept of relational autonomy to understand how relational encounters with family members (FMs) and care providers may shape decisions around ovarian cancer patients' clinical trial (CT) participation. The study also offers unique insights into how FMs view patients' decision making. In-depth interviews were conducted with 33 patients with ovarian cancer who had been offered a CT and 39 FMs. Data were inductively analysed using a thematic approach and deductively informed by constructs derived from the theory of relational autonomy (RA). Patients' relationships, experiences and social status were significant resources that shaped their decisions. Patients did not give equal weight to all relationships and created boundaries around whom to include in decision making. Doctors' recommendations and perceived enthusiasm were described as influential in CT decisions. Both patients with ovarian cancer and their FMs maintained that patients have the "final say," indicating an individualistic autonomy. However, maintaining the "final say" in the decision-making process is constitutive of patients' relationships, emphasizing a relational approach to autonomy. FMs support patients' autonomy and they do so particularly when they believe the patient is capable of making the right choices. Although ethical principles underlying informed consent for CT participation emphasize individual autonomy, greater attention to relational autonomy is warranted for a more comprehensive understanding of CT decision making. © 2018 Mayo Clinic. Health Expectations published by John Wiley & Sons Ltd.

Quantitative light-induced fluorescence (QLF): a tool for early occlusal dental caries detection and supporting decision making in vivo.

PubMed

Alammari, M R; Smith, P W; de Josselin de Jong, E; Higham, S M

2013-02-01

This study reports the development and assessment of a novel method using quantitative light-induced fluorescence (QLF), to determine whether QLF parameters ΔF and ΔQ were appropriate for aiding diagnosis and clinical decision making of early occlusal mineral loss by comparing QLF analysis with actual restorative management. Following ethical approval, 46 subjects attending a dental teaching hospital were enrolled. White light digital (WL) and QLF images/analyses of 46 unrestored posterior teeth with suspected occlusal caries were made after a clinical decision had already been taken to explore fissures operatively. WL and QLF imaging/analysis were repeated after initial cavity preparation. The type of restorative treatment was determined by the supervising clinician independent of any imaging performed. Actual restorative management carried out was recorded as fissure sealant/preventive resin restoration (F/P) or class I occlusal restoration (Rest.) thus reflecting the extent of intervention (=gold standard). All QLF images were analysed independently. The results showed statistically significant differences between the two treatment groups ΔF (p=0.002) (mean 22.60 - F/P and 28.80 - Rest.) and ΔQ (p=0.012) (mean 230.49 - F/P and 348.30 - Rest.). ΔF and ΔQ values may be useful in aiding clinical diagnosis and decision making in relation to the management of early mineral loss and restorative intervention of occlusal caries. QLF has the potential to be a valuable tool for caries diagnosis in clinical practice. Copyright © 2012 Elsevier Ltd. All rights reserved.

Can procedural and substantive elements of decision-making be reconciled in assessments of mental capacity?

PubMed Central

Banner, Natalie F.

2016-01-01

Capacity legislation aims to protect individual autonomy and avoid undue paternalism as far as possible, partly through ensuring patients are not deemed to lack capacity because they make an unwise decision. To this end, the law employs a procedural test of capacity that excludes substantive judgments about patients’ decisions. However, clinical intuitions about patients’ capacity to make decisions about their treatment often conflict with a strict reading of the legal criteria for assessing capacity, particularly in psychiatry. In this article I argue that this tension arises because the procedural conception of capacity is inadequate and does not reflect the clinical or legal realities of assessing capacity. I propose that conceptualising capacity as having ‘recognisable reasons’ for a treatment decision provides a practical way of legitimately incorporating both procedural and substantive elements of decision-making into assessments of capacity. PMID:27891169

A serious game can be a valid method to train clinical decision-making in surgery.

PubMed

Graafland, Maurits; Vollebergh, Maarten F; Lagarde, Sjoerd M; van Haperen, M; Bemelman, Willem A; Schijven, Marlies P

2014-12-01

A serious game was developed to train surgical residents in clinical decision-making regarding biliary tract disease. Serious or applied gaming is a novel educational approach to postgraduate training, combining training and assessment of clinical decision-making in a fun and challenging way. Although interest for serious games in medicine is rising, evidence on its validity is lacking. This study investigates face, content, and construct validity of this serious game. Experts structurally validated the game's medical content. Subsequently, 41 participants played the game. Decision scores and decision speed were compared among surgeons, surgical residents, interns, and medical students, determining the game's discriminatory ability between different levels of expertise. After playing, participants completed a questionnaire on the game's perceived realism and teaching ability. Surgeons solved more cases correctly (mean 77 %) than surgical residents (67 %), interns (60 %), master-degree students (50 %), and bachelor-degree students (39 % (p < 0.01). Trainees performed significantly better in their second play session than in the first (median 72 vs. 48 %, p = 0.00). Questionnaire results showed that educators and surgical trainees found the game both realistic and useful for surgical training. The majority perceived the game as fun (91.2 %), challenging (85.3 %), and would recommend the game to educate their colleagues (81.8 %). This serious game showed clear discriminatory ability between different levels of expertise in biliary tract disease management and clear teaching capability. It was perceived as appealing and realistic. Serious gaming has the potential to increase adherence to training programs in surgical residency training and medical school.

Mothers' process of decision making for gastrostomy placement.

PubMed

Brotherton, Ailsa; Abbott, Janice

2012-05-01

In this article we present the findings of an exploration of mothers' discourses on decision making for gastrostomy placement for their child. Exploring in-depth interviews of a purposive sample, we analyzed the mothers' discourses of the decision-making process to understand how their experiences of the process influenced their subsequent constructions of decision making. Mothers negotiated decision making by reflecting on their personal experiences of feeding their child, either orally or via a tube, and interwove their background experiences with the communications from members of the health care team until a decision was reached. Decision making was often fraught with difficulty, resulting in anxiety and guilt. Experiences of decision making ranged from perceived coercion to true choice, which encompasses a truly child-centered decision. The resulting impact of the decision-making process on the mothers was profound. We conclude with an exploration of the implications for clinical practice and describe how health care professionals can support mothers to ensure that decision-making processes for gastrostomy placement in children are significantly improved.

Making informed capital investment decisions for clinical technology.

PubMed

Poplin, Brian

2011-02-01

Hospitals can make more-informed decisions related to clinical equipment purchases by using a variety of data sources in planning their investment strategies. Data sources generally fall into three buckets: Data that are internally generated by hospitals. Public data. Industry data that are available for purchase.

Data-Based Decision-Making: Developing a Method for Capturing Teachers' Understanding of CBM Graphs

ERIC Educational Resources Information Center

Espin, Christine A.; Wayman, Miya Miura; Deno, Stanley L.; McMaster, Kristen L.; de Rooij, Mark

2017-01-01

In this special issue, we explore the decision-making aspect of "data-based decision-making". The articles in the issue address a wide range of research questions, designs, methods, and analyses, but all focus on data-based decision-making for students with learning difficulties. In this first article, we introduce the topic of…

How does pre-dialysis education need to change? Findings from a qualitative study with staff and patients.

PubMed

Combes, Gill; Sein, Kim; Allen, Kerry

2017-11-23

Pre-dialysis education (PDE) is provided to thousands of patients every year, helping them decide which renal replacement therapy (RRT) to choose. However, its effectiveness is largely unknown, with relatively little previous research into patients' views about PDE, and no research into staff views. This study reports findings relevant to PDE from a larger mixed methods study, providing insights into what staff and patients think needs to improve. Semi-structured interviews in four hospitals with 96 clinical and managerial staff and 93 dialysis patients, exploring experiences of and views about PDE, and analysed using thematic framework analysis. Most patients found PDE helpful and staff valued its role in supporting patient decision-making. However, patients wanted to see teaching methods and materials improve and biases eliminated. Staff were less aware than patients of how informal staff-patient conversations can influence patients' treatment decision-making. Many staff felt ill equipped to talk about all treatment options in a balanced and unbiased way. Patient decision-making was found to be complex and patients' abilities to make treatment decisions were adversely affected in the pre-dialysis period by emotional distress. Suggested improvements to teaching methods and educational materials are in line with previous studies and current clinical guidelines. All staff, irrespective of their role, need to be trained about all treatment options so that informal conversations with patients are not biased. The study argues for a more individualised approach to PDE which is more like counselling than education and would demand a higher level of skill and training for specialist PDE staff. The study concludes that even if these improvements are made to PDE, not all patients will benefit, because some find decision-making in the pre-dialysis period too complex or are unable to engage with education due to illness or emotional distress. It is therefore recommended that pre-dialysis treatment decisions are temporary, and that PDE is replaced with on-going RRT education which provides opportunities for personalised education and on-going review of patients' treatment choices. Emotional support to help overcome the distress of the transition to end-stage renal disease will also be essential to ensure all patients can benefit from RRT education.

Development and Pilot Testing of a Decision Aid for Genomic Research Participants Notified of Clinically Actionable Research Findings for Cancer Risk.

PubMed

Willis, Amanda M; Smith, Sian K; Meiser, Bettina; Ballinger, Mandy L; Thomas, David M; Tattersall, Martin; Young, Mary-Anne

2018-02-17

Germline genomic testing is increasingly used in research to identify genetic causes of disease, including cancer. However, there is evidence that individuals who are notified of clinically actionable research findings have difficulty making informed decisions regarding uptake of genetic counseling for these findings. This study aimed to produce and pilot test a decision aid to assist participants in genomic research studies who are notified of clinically actionable research findings to make informed choices regarding uptake of genetic counseling. Development was guided by published literature, the International Patient Decision Aid Standards, and the expertise of a steering committee of clinicians, researchers, and consumers. Decision aid acceptability was assessed by self-report questionnaire. All 19 participants stated that the decision aid was easy to read, clearly presented, increased their understanding of the implications of taking up research findings, and would be helpful in decision-making. While low to moderate levels of distress/worry were reported after reading the booklet, a majority of participants also reported feeling reassured. All participants would recommend the booklet to others considering uptake of clinically actionable research findings. Results indicate the decision aid is acceptable to the target audience, with potential as a useful decision support tool for genomic research participants.

Administrative decision making: a stepwise method.

PubMed

Oetjen, Reid M; Oetjen, Dawn M; Rotarius, Timothy

2008-01-01

Today's health care organizations face tremendous challenges and fierce competition. These pressures impact the decisions that managers must execute on any given day, not to mention the ever-present constraints of time, personnel, competencies, and finances. The importance of making quality and informed decisions cannot be underestimated. Traditional decision making methods are inadequate for today's larger, more complex health care organizations and the rapidly changing health care environment. As a result, today's health care managers and their teams need new approaches to making decisions for their organizations. This article examines the managerial decision making process and offers a model that can be used as a decision making template to help managers successfully navigate the choppy health care seas. The administrative decision making model will enable health care managers and other key decision makers to avoid the common pitfalls of poor decision making and guide their organizations to success.

Challenges in shared decision making in advanced cancer care: a qualitative longitudinal observational and interview study.

PubMed

Brom, Linda; De Snoo-Trimp, Janine C; Onwuteaka-Philipsen, Bregje D; Widdershoven, Guy A M; Stiggelbout, Anne M; Pasman, H Roeline W

2017-02-01

Patients' preferences and expectations should be taken into account in treatment decision making in the last phase of life. Shared decision making (SDM) is regarded as a way to give the patient a central role in decision making. Little is known about how SDM is used in clinical practice in advanced cancer care. To examine whether and how the steps of SDM can be recognized in decision making about second- and third-line chemotherapy. Fourteen advanced cancer patients were followed over time using face-to-face in-depth interviews and observations of the patients' out-clinic visits. Interviews and outpatient clinic visits in which treatment options were discussed or decisions made were transcribed verbatim and analysed using open coding. Patients were satisfied with the decision-making process, but the steps of SDM were barely seen in daily practice. The creation of awareness about available treatment options by physicians was limited and not discussed in an equal way. Patients' wishes and concerns were not explicitly assessed, which led to different expectations about improved survival from subsequent lines of chemotherapy. To reach SDM in daily practice, physicians should create awareness of all treatment options, including forgoing treatment, and communicate the risk of benefit and harm. Open and honest communication is needed in which patients' expectations and concerns are discussed. Through this, the difficult process of decision making in the last phase of life can be facilitated and the focus on the best care for the specific patient is strengthened. © 2015 The Authors. Health Expectations Published by John Wiley & Sons Ltd.

Training surgeons in shared decision-making with cancer patients aged 65 years and older: a pilot study.

PubMed

Geessink, Noralie H; Schoon, Yvonne; Olde Rikkert, Marcel Gm; van Goor, Harry

2017-01-01

Treatment decision-making in older patients with colorectal (CRC) or pancreatic cancer (PC) needs improvement. We introduced the EASYcare in Geriatric Onco-surgery (EASY-GO) intervention to optimize the shared decision-making (SDM) process among these patients. The EASY-GO intervention comprised a working method with geriatric assessment and SDM training for surgeons. A non-equivalent control group design was used. Newly diagnosed CRC/PC patients aged ≥65 years were included. Primary patient-reported experiences were the quality of SDM (SDM-Q-9, range 0-100), involvement in decision-making (Visual Analog Scale for Involvement in the decision-making process [range 0-10]), satisfaction about decision-making (Visual Analog Scale for Satisfaction concerning the decision-making process [range 0-10]), and decisional regret (Decisional Regret Scale [DRS], range 0-100). Only for DRS, lower scores are better. A total of 71.4% of the involved consultants and 42.9% of the involved residents participated in the EASY-GO training. Only 4 trained surgeons consulted patients both before (n=19) and after (n=19) training and were consequently included in the analyses. All patient-reported experience measures showed a consistent but non-significant change in the direction of improved decision-making after training. According to surgeons, decisions were significantly more often made together with the patient after training (before, 38.9% vs after, 73.7%, p =0.04). Sub-analyses per diagnosis showed that patient experiences among older PC patients consistent and clinically relevant changed in the direction of improved decision-making after training (SDM-Q-9 +13.4 [95% CI -7.9; 34.6], VAS-I +0.27 [95% CI -1.1; 1.6], VAS-S +0.88 [95% CI -0.5; 2.2], DRS -10.3 [95% CI -27.8; 7.1]). This pilot study strengthens the practical potential of the intervention's concept among older surgical cancer patients.

The ethics of end-of-life decisions in the elderly: deliberations from the ECOPE study.

PubMed

Reiter-Theil, Stella

2003-06-01

Is age a factor underlying clinical decision-making? Should age be a criterion in the allocation of health care resources? Is it correct to criticize this approach as 'ageism'? What role does 'paternalism' play? These questions are the focus of this chapter which takes an interdisciplinary perspective of clinical ethics in order to provide an ethical evaluation of the situation of the elderly in health care. First, the text of the chapter is based on the descriptive level referring to (a) clinical ethics consultation, (b) the ECOPE study on 'Ethical Conditions of Passive Euthanasia' focusing on decision-making, and studies about age as a factor in clinical decisions, such as the American SUPPORT study. Second, at the normative level, ethical deliberations are discussed for and against age as a criterion for allocating health care resources. Finally, it is suggested that the differences in evidence to be found about the role of age as a factor in clinical decision-making may be due to the different national health policies as well as to the insufficient awareness of ethical principles violated by covert 'ageist' attitudes.

Jordanian Physicians' Attitudes toward Disclosure of Cancer Information and Patient Participation in Treatment Decision-making.

PubMed

Obeidat, Rana; Khrais, Huthaifah I

2016-01-01

This study aims to determine the attitude of Jordanian physicians toward disclosure of cancer information, comfort and use of different decision-making approaches, and treatment decision making. A descriptive, comparative research design was used. A convenience sample of 86 Jordanian medical and radiation oncologists and surgeons practicing mainly in oncology was recruited. A modified version of a structured questionnaire was used for data collection. The questionnaire is a valid measure of physicians' views of shared decision making. Almost 91% of all physicians indicated that the doctor should tell the patient and let him/her decide if the family should know of an early-stage cancer diagnosis. Physicians provide abundant information about the extent of the disease, the side effects and benefits of the treatment, and details of the treatment procedures. They also provided less information on the effects of treatment on the sexuality, mood, and family of the patient. Almost 48% of the participating physicians reported using shared decision making as their usual approach for treatment decision making, and 67% reported that they were comfortable with this approach. The main setting of clinical activity was the only factor associated with physicians' usual approach to medical decision making. Moreover, age, years of experience, and main setting of clinical activity were associated with physicians' comfort level with the shared approach. Although Jordanian physicians appreciate patient autonomy, self-determination, and right to information, paternalistic decision making and underuse of the shared decision-making approach persist. Strategies that target both healthcare providers and patients must be employed to promote shared decision making in the Jordanian healthcare system.

Preferred information sources for clinical decision making: critical care nurses' perceptions of information accessibility and usefulness.

PubMed

Marshall, Andrea P; West, Sandra H; Aitken, Leanne M

2011-12-01

Variability in clinical practice may result from the use of diverse information sources to guide clinical decisions. In routine clinical practice, nurses privilege information from colleagues over more formal information sources. It is not clear whether similar information-seeking behaviour is exhibited when critical care nurses make decisions about a specific clinical practice, where extensive practice variability exists alongside a developing research base. This study explored the preferred sources of information intensive care nurses used and their perceptions of the accessibility and usefulness of this information for making decisions in clinically uncertain situations specific to enteral feeding practice. An instrumental case study design, incorporating concurrent verbal protocols, Q methodology and focus groups, was used to determine intensive care nurses' perspectives of information use in the resolution of clinical uncertainty. A preference for information from colleagues to support clinical decisions was observed. People as information sources were considered most useful and most accessible in the clinical setting. Text and electronic information sources were seen as less accessible, mainly because of the time required to access the information within the documents. When faced with clinical uncertainty, obtaining information from colleagues allows information to be quickly accessed and applied within the context of a specific clinical presentation. Seeking information from others also provides opportunities for shared decision-making and potential validation of clinical judgment, although differing views may exacerbate clinical uncertainty. The social exchange of clinical information may meet the needs of nurses working in a complex, time-pressured environment but the extent of the evidence base for information passed through verbal communication is unclear. The perceived usefulness and accessibility of information is premised on the ease of use and access and thus the variability in information may be contributing to clinical uncertainty. Copyright ©2011 Sigma Theta Tau International.

Implementation of standardization in clinical practice: not always an easy task.

PubMed

Panteghini, Mauro

2012-02-29

As soon as a new reference measurement system is adopted, clinical validation of correctly calibrated commercial methods should take place. Tracing back the calibration of routine assays to a reference system can actually modify the relation of analyte results to existing reference intervals and decision limits and this may invalidate some of the clinical decision-making criteria currently used. To maintain the accumulated clinical experience, the quantitative relationship to the previous calibration system should be established and, if necessary, the clinical decision-making criteria should be adjusted accordingly. The implementation of standardization should take place in a concerted action of laboratorians, manufacturers, external quality assessment scheme organizers and clinicians. Dedicated meetings with manufacturers should be organized to discuss the process of assay recalibration and studies should be performed to obtain convincing evidence that the standardization works, improving result comparability. Another important issue relates to the surveillance of the performance of standardized assays through the organization of appropriate analytical internal and external quality controls. Last but not least, uncertainty of measurement that fits for this purpose must be defined across the entire traceability chain, starting with the available reference materials, extending through the manufacturers and their processes for assignment of calibrator values and ultimately to the final result reported to clinicians by laboratories.

Which research is needed to support clinical decision-making on integrative medicine?- Can comparative effectiveness research close the gap?

PubMed

Witt, Claudia M; Huang, Wen-jing; Lao, Lixing; Bm, Berman

2012-10-01

In clinical research on complementary and integrative medicine, experts and scientists have often pursued a research agenda in spite of an incomplete understanding of the needs of end users. Consequently, the majority of previous clinical trials have mainly assessed the efficacy of interventions. Scant data is available on their effectiveness. Comparative effectiveness research (CER) promises to support decision makers by generating evidence that compares the benefits and harms of the best care options. This evidence, more generalizable than the evidence generated by traditional randomized controlled trials (RCTs), is better suited to inform real-world care decisions. An emphasis on CER supports the development of the evidence base for clinical and policy decision-making. Whereas in most areas of complementary and integrative medicine data on comparative effectiveness is scarce, available acupuncture research already contributes to CER evidence. This paper will introduce CER and make suggestions for future research.

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

PubMed

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

2017-01-01

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

Decision-Making in Patients with Hyperthyroidism: A Neuropsychological Study

PubMed Central

Zhang, Fangfang; Ma, Huijuan; Chen, Xingui; Dai, Fang; Wang, Kai

2015-01-01

Introduction Cognitive and behavioral impairments are common in patients with abnormal thyroid function; these impairments cause a reduction in their quality of life. The current study investigates the decision making performance in patients with hyperthyroidism to explore the possible mechanism of their cognitive and behavioral impairments. Methods Thirty-eight patients with hyperthyroidism and forty healthy control subjects were recruited to perform the Iowa Gambling Task (IGT), which assessed decision making under ambiguous conditions. Results Patients with hyperthyroidism had a higher score on the Zung Self-Rating Anxiety Scale (Z-SAS), and exhibited poorer executive function and IGT performance than did healthy control subjects. The patients preferred to choose decks with a high immediate reward, despite a higher future punishment, and were not capable of effectively using feedback information from previous choices. No clinical characteristics were associated with the total net score of the IGT in the current study. Conclusions Patients with hyperthyroidism had decision-making impairment under ambiguous conditions. The deficits may result from frontal cortex and limbic system metabolic disorders and dopamine dysfunction. PMID:26090955

The use of economic evaluations in NHS decision-making: a review and empirical investigation.

PubMed

Williams, I; McIver, S; Moore, D; Bryan, S

2008-04-01

To determine the extent to which health economic information is used in health policy decision-making in the UK, and to consider factors associated with the utilisation of such research findings. Major electronic databases were searched up to 2004. A systematic review of existing reviews on the use of economic evaluations in policy decision-making, of health and non-health literature on the use of economic analyses in policy making and of studies identifying actual or perceived barriers to the use of economic evaluations was undertaken. Five UK case studies of committees from four local and one national organisation [the Technology Appraisal Committee of the National Institute for Health and Clinical Excellence (NICE)] were conducted. Local case studies were augmented by documentary analysis of new technology request forms and by workshop discussions with members of local decision-making committees. The systematic review demonstrated few previous systematic reviews of evidence in the area. At the local level in the NHS, it was an exception for economic evaluation to inform technology coverage decisions. Local decision-making focused primarily on evidence of clinical benefit and cost implications. And whilst information on implementation was frequently requested, cost-effectiveness information was rarely accessed. A number of features of the decision-making environment appeared to militate against emphasis on cost-effectiveness analysis. Constraints on the capacity to generate, access and interpret information, led to a minor role for cost-effectiveness analysis in the local decision-making process. At the national policy level in the UK, economic analysis was found to be highly integrated into NICE's technology appraisal programme. Attitudes to economic evaluation varied between committee members with some significant disagreement and extraneous factors diluted the health economics analysis available to the committee. There was strong evidence of an ordinal approach to consideration of clinical effectiveness and cost-effectiveness information. Some interviewees considered the key role of a cost-effectiveness analysis to be the provision of a framework for decision-making. Interviewees indicated that NICE makes use of some form of cost-effectiveness threshold but expressed concern about its basis and its use in decision-making. Frustrations with the appraisal process were expressed in terms of the scope of the policy question being addressed. Committee members raised concerns about lack of understanding of the economic analysis but felt that a single measure of benefit, e.g. the quality-adjusted life-year, was useful in allowing comparison of disparate health interventions and in providing a benchmark for later decisions. The importance of ensuring that committee members understood the limitations of the analysis was highlighted for model-based analyses. This study suggests that research is needed into structures, processes and mechanisms by which technology coverage decisions can and should be made in healthcare. Further development of 'resource centres' may be useful to provide independent published analyses in order to support local decision-makers. Improved methods of economic analyses and of their presentation, which take account of the concerns of their users, are needed. Finally, the findings point to the need for further assessment of the feasibility and value of a formal process of clarification of the objectives that we seek from investments in healthcare.

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

PubMed

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

2014-11-01

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

Understanding antibiotic decision making in surgery-a qualitative analysis.

PubMed

Charani, E; Tarrant, C; Moorthy, K; Sevdalis, N; Brennan, L; Holmes, A H

2017-10-01

To investigate the characteristics and culture of antibiotic decision making in the surgical specialty. A qualitative study including ethnographic observation and face-to-face interviews with participants from six surgical teams at a teaching hospital in London was conducted. Over a 3-month period: (a) 30 ward rounds (WRs) (100 h) were observed, (b) face-to-face follow-up interviews took place with 13 key informants, (c) multidisciplinary meetings on the management of surgical patients and daily practice on wards were observed. Applying these methods provided rich data for characterizing the antibiotic decision making in surgery and enabled cross-validation and triangulation of the findings. Data from the interview transcripts and the observational notes were coded and analysed iteratively until saturation was reached. The surgical team is in a state of constant flux with individuals having to adjust to the context in which they work. The demands placed on the team to be in the operating room, and to address the surgical needs of the patient mean that the responsibility for antibiotic decision making is uncoordinated and diffuse. Antibiotic decision making is considered by surgeons as a secondary task, commonly delegated to junior members of their team and occurs in the context of disjointed communication. There is lack of clarity around medical decision making for treating infections in surgical patients. The result is sub-optimal and uncoordinated antimicrobial management. Developing the role of a perioperative clinician may help to improve patient-level outcomes and optimize decision making. Copyright © 2017 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Supporting shared decision making using an Option Grid for osteoarthritis of the knee in an interface musculoskeletal clinic: A stepped wedge trial.

PubMed

Elwyn, Glyn; Pickles, Tim; Edwards, Adrian; Kinsey, Katharine; Brain, Kate; Newcombe, Robert G; Firth, Jill; Marrin, Katy; Nye, Alan; Wood, Fiona

2016-04-01

To evaluate whether introducing tools, specifically designed for use in clinical encounters, namely Option Grids, into a clinical practice setting leads to higher levels of shared decision making. A stepped wedge trial design where 6 physiotherapists at an interface clinic in Oldham, UK, were sequentially instructed in how to use an Option Grid for osteoarthritis of the knee. Patients with suspected or confirmed osteoarthritis of the knee were recruited, six per clinician prior to instruction, and six per clinician afterwards. We measured shared decision making, patient knowledge, and readiness to decide. A total of 72 patients were recruited; 36 were allocated to the intervention group. There was an 8.4 point (95% CI 4.4 to 12.2) increase in the Observer OPTION score (range 0-100) in the intervention group. The mean gain in knowledge was 0.9 points (score range 0-5, 95% CI, 0.3 to 1.5). There was no increase in encounter duration. Shared decision making increased when clinicians used the knee osteoarthritis Option Grid. Tools designed to support collaboration and deliberation about treatment options lead to increased levels of shared decision making. Copyright © 2015 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.

Education in the workplace for the physician: clinical management states as an organizing framework.

PubMed

Greenes, R A

2000-01-01

Medical educators are interested in approaches to making selected relevant knowledge available in the context of problem-based care. This is of value both during the process of care and as a means of organizing information for offline self-study. Four trends in health information technology are relevant to achieving the goal and can be expected to play a growing role in the future. First, health care enterprises are developing approaches for access to information resources related to the care of a patient, including clinical data and images but also communication tools, referral and other logistic tools, decision support, and educational materials. Second, information for patients and methods for patient-doctor interaction and decision making are becoming available. Third, computer-based methods for representation of practice guidelines are being developed to support applications that can incorporate their logic. Finally, considering patients as being in particular "clinical management states" (or CMSs) for specific problems, approaches are being developed to use guidelines as a kind of "predictive" framework to enable development of interfaces for problem-based clinical encounters. The guidelines for a CMS can be used to identify the kinds of resources specifically needed for clinical encounters of that type. As the above trends converge to produce problem-specific environments, professional specialty organizations and continuing medical education course designers will need to focus energies on organizing and updating medical knowledge to make it available in CMS-specific contexts.

Designing and evaluating an interprofessional shared decision-making and goal-setting decision aid for patients with diabetes in clinical care - systematic decision aid development and study protocol

PubMed Central

2014-01-01

Background Care of patients with diabetes often occurs in the context of other chronic illness. Competing disease priorities and competing patient-physician priorities present challenges in the provision of care for the complex patient. Guideline implementation interventions to date do not acknowledge these intricacies of clinical practice. As a result, patients and providers are left overwhelmed and paralyzed by the sheer volume of recommendations and tasks. An individualized approach to the patient with diabetes and multiple comorbid conditions using shared decision-making (SDM) and goal setting has been advocated as a patient-centred approach that may facilitate prioritization of treatment options. Furthermore, incorporating interprofessional integration into practice may overcome barriers to implementation. However, these strategies have not been taken up extensively in clinical practice. Objectives To systematically develop and test an interprofessional SDM and goal-setting toolkit for patients with diabetes and other chronic diseases, following the Knowledge to Action framework. Methods 1. Feasibility study: Individual interviews with primary care physicians, nurses, dietitians, pharmacists, and patients with diabetes will be conducted, exploring their experiences with shared decision-making and priority-setting, including facilitators and barriers, the relevance of a decision aid and toolkit for priority-setting, and how best to integrate it into practice. 2. Toolkit development: Based on this data, an evidence-based multi-component SDM toolkit will be developed. The toolkit will be reviewed by content experts (primary care, endocrinology, geriatricians, nurses, dietitians, pharmacists, patients) for accuracy and comprehensiveness. 3. Heuristic evaluation: A human factors engineer will review the toolkit and identify, list and categorize usability issues by severity. 4. Usability testing: This will be done using cognitive task analysis. 5. Iterative refinement: Throughout the development process, the toolkit will be refined through several iterative cycles of feedback and redesign. Discussion Interprofessional shared decision-making regarding priority-setting with the use of a decision aid toolkit may help prioritize care of individuals with multiple comorbid conditions. Adhering to principles of user-centered design, we will develop and refine a toolkit to assess the feasibility of this approach. PMID:24450385

A clinical decision-making mechanism for context-aware and patient-specific remote monitoring systems using the correlations of multiple vital signs.

PubMed

Forkan, Abdur Rahim Mohammad; Khalil, Ibrahim

2017-02-01

In home-based context-aware monitoring patient's real-time data of multiple vital signs (e.g. heart rate, blood pressure) are continuously generated from wearable sensors. The changes in such vital parameters are highly correlated. They are also patient-centric and can be either recurrent or can fluctuate. The objective of this study is to develop an intelligent method for personalized monitoring and clinical decision support through early estimation of patient-specific vital sign values, and prediction of anomalies using the interrelation among multiple vital signs. In this paper, multi-label classification algorithms are applied in classifier design to forecast these values and related abnormalities. We proposed a completely new approach of patient-specific vital sign prediction system using their correlations. The developed technique can guide healthcare professionals to make accurate clinical decisions. Moreover, our model can support many patients with various clinical conditions concurrently by utilizing the power of cloud computing technology. The developed method also reduces the rate of false predictions in remote monitoring centres. In the experimental settings, the statistical features and correlations of six vital signs are formulated as multi-label classification problem. Eight multi-label classification algorithms along with three fundamental machine learning algorithms are used and tested on a public dataset of 85 patients. Different multi-label classification evaluation measures such as Hamming score, F1-micro average, and accuracy are used for interpreting the prediction performance of patient-specific situation classifications. We achieved 90-95% Hamming score values across 24 classifier combinations for 85 different patients used in our experiment. The results are compared with single-label classifiers and without considering the correlations among the vitals. The comparisons show that multi-label method is the best technique for this problem domain. The evaluation results reveal that multi-label classification techniques using the correlations among multiple vitals are effective ways for early estimation of future values of those vitals. In context-aware remote monitoring this process can greatly help the doctors in quick diagnostic decision making. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Colorectal cancer patients’ attitudes towards involvement in decision making

PubMed Central

Beaver, Kinta; Campbell, Malcolm; Craven, Olive; Jones, David; Luker, Karen A.; Susnerwala, Shabbir S.

2009-01-01

Abstract Objectives  To design and administer an attitude rating scale, exploring colorectal cancer patients’ views of involvement in decision making. To examine the impact of socio‐demographic and/or treatment‐related factors on decision making. To conduct principal components analysis to determine if the scale could be simplified into a number of factors for future clinical utility. Methods  An attitude rating scale was constructed based on previous qualitative work and administered to colorectal cancer patients using a cross‐sectional survey approach. Results  375 questionnaires were returned (81.7% response). For patients it was important to be informed and involved in the decision‐making process. Information was not always used to make decisions as patients placed their trust in medical expertise. Women had more positive opinions on decision making and were more likely to want to make decisions. Written information was understood to a greater degree than verbal information. The scale could be simplified to a number of factors, indicating clinical utility. Conclusion  Few studies have explored the attitudes of colorectal cancer patients towards involvement in decision making. This study presents new insights into how patients view the concept of participation; important when considering current policy imperatives in the UK of involving service users in all aspects of care and treatment. PMID:19250150

Genders of patients and clinicians and their effect on shared decision making: a participant-level meta-analysis.

PubMed

Wyatt, Kirk D; Branda, Megan E; Inselman, Jonathan W; Ting, Henry H; Hess, Erik P; Montori, Victor M; LeBlanc, Annie

2014-09-02

Gender differences in communication styles between clinicians and patients have been postulated to impact patient care, but the extent to which the gender dyad structure impacts outcomes in shared decision making remains unclear. Participant-level meta-analysis of 775 clinical encounters within 7 randomized trials where decision aids, shared decision making tools, were used at the point of care. Outcomes analysed include decisional conflict scale scores, satisfaction with the clinical encounter, concordance between stated decision and action taken, and degree of patient engagement by the clinician using the OPTION scale. An estimated minimal important difference was used to determine if nonsignificant results could be explained by low power. We did not find a statistically significant interaction between clinician/patient gender mix and arm for decisional conflict, satisfaction with the clinical encounter or patient engagement. A borderline significant interaction (p = 0.05) was observed for one outcome: concordance between stated decision and action taken, where encounters with female clinician/male patient showed increased concordance in the decision aid arm compared to control (8% more concordant encounters). All other gender dyads showed decreased concordance with decision aid use (6% fewer concordant encounters for same-gender, 16% fewer concordant encounters for male clinician/female patient). In this participant-level meta-analysis of 7 randomized trials, decision aids used at the point of care demonstrated comparable efficacy across gender dyads. Purported barriers to shared decision making based on gender were not detected when tested for a minimum detected difference. ClinicalTrials.gov NCT00888537, NCT01077037, NCT01029288, NCT00388050, NCT00578981, NCT00949611, NCT00217061.

Eliciting societal preferences of reimbursement decision criteria for anti cancer drugs in South Korea.

PubMed

Kwon, Sun-Hong; Park, Sun-Kyeong; Byun, Ji-Hye; Lee, Eui-Kyung

2017-08-01

In order to look beyond the cost-effectiveness analysis, this study used a multi-criteria decision analysis (MCDA), which reflects societal values with regard to reimbursement decisions. This study aims to elicit societal preferences of the reimbursement decision criteria for anti cancer drugs from public and healthcare professionals. Eight criteria were defined based on a literature review and focus group sessions: disease severity, disease population size, pediatrics targets, unmet needs, innovation, clinical benefits, cost-effectiveness, and budget impacts. Using quota sampling and purposive sampling, 300 participants from the Korean public and 30 healthcare professionals were selected for the survey. Preferences were elicited using an analytic hierarchy process. Both groups rated clinical benefits the highest, followed by cost-effectiveness and disease severity, but differed with regard to disease population size and unmet needs. Innovation was the least preferred criteria. Clinical benefits and other social values should be reflected appropriately with cost-effectiveness in healthcare coverage. MCDA can be used to assess decision priorities for complicated health policy decisions, including reimbursement decisions. It is a promising method for making logical and transparent drug reimbursement decisions that consider a broad range of factors, which are perceived as important by relevant stakeholders.

Improving performance with clinical decision support.

PubMed

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

1996-07-01

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

Evaluating the decision accuracy and speed of clinical data visualizations.

PubMed

Pieczkiewicz, David S; Finkelstein, Stanley M

2010-01-01

Clinicians face an increasing volume of biomedical data. Assessing the efficacy of systems that enable accurate and timely clinical decision making merits corresponding attention. This paper discusses the multiple-reader multiple-case (MRMC) experimental design and linear mixed models as means of assessing and comparing decision accuracy and latency (time) for decision tasks in which clinician readers must interpret visual displays of data. These tools can assess and compare decision accuracy and latency (time). These experimental and statistical techniques, used extensively in radiology imaging studies, offer a number of practical and analytic advantages over more traditional quantitative methods such as percent-correct measurements and ANOVAs, and are recommended for their statistical efficiency and generalizability. An example analysis using readily available, free, and commercial statistical software is provided as an appendix. While these techniques are not appropriate for all evaluation questions, they can provide a valuable addition to the evaluative toolkit of medical informatics research.

Decision-Making Difficulties Experienced by Adults with Autism Spectrum Conditions

ERIC Educational Resources Information Center

Luke, Lydia; Clare, Isabel C. H.; Ring, Howard; Redley, Marcus; Watson, Peter

2012-01-01

Autobiographical and clinical accounts, as well as a limited neuropsychological research literature, suggest that, in some situations, men and women with autism spectrum conditions (ASCs) may have difficulty making decisions. Little is known, however, about how people with ASCs experience decision-making or how they might best be supported to make…

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

Bayesian randomized clinical trials: From fixed to adaptive design.

PubMed

Yin, Guosheng; Lam, Chi Kin; Shi, Haolun

2017-08-01

Randomized controlled studies are the gold standard for phase III clinical trials. Using α-spending functions to control the overall type I error rate, group sequential methods are well established and have been dominating phase III studies. Bayesian randomized design, on the other hand, can be viewed as a complement instead of competitive approach to the frequentist methods. For the fixed Bayesian design, the hypothesis testing can be cast in the posterior probability or Bayes factor framework, which has a direct link to the frequentist type I error rate. Bayesian group sequential design relies upon Bayesian decision-theoretic approaches based on backward induction, which is often computationally intensive. Compared with the frequentist approaches, Bayesian methods have several advantages. The posterior predictive probability serves as a useful and convenient tool for trial monitoring, and can be updated at any time as the data accrue during the trial. The Bayesian decision-theoretic framework possesses a direct link to the decision making in the practical setting, and can be modeled more realistically to reflect the actual cost-benefit analysis during the drug development process. Other merits include the possibility of hierarchical modeling and the use of informative priors, which would lead to a more comprehensive utilization of information from both historical and longitudinal data. From fixed to adaptive design, we focus on Bayesian randomized controlled clinical trials and make extensive comparisons with frequentist counterparts through numerical studies. Copyright © 2017 Elsevier Inc. All rights reserved.

Can Classification Tree Analyses Help Improve Decision Making About Treatments for Depression and Anxiety Disorders? A Preliminary Investigation

PubMed Central

Rhodes, Louisa; Naumann, Ulrike M.

2011-01-01

Objective: To identify how decisions about treatment are being made in secondary services for anxiety disorders and depression and, specifically, whether it was possible to predict the decisions to refer for evidence-based treatments. Method: Post hoc classification tree analysis was performed using a sample from an audit on implementation of the National Institute for Health and Clinical Excellence Guidelines for Depression and Anxiety Disorders. The audit was of 5 teams offering secondary care services; they included psychiatrists, psychologists, community psychiatric nurses, social workers, dual-diagnosis workers, and vocational workers. The patient sample included all of those with a primary problem of depression (n = 56) or an anxiety disorder (n = 16) who were offered treatment from February 16 to April 3, 2009. The outcome variable was whether or not evidence-based treatments were offered, and the predictor variables were presenting problem, risk, comorbid problem, social problems, and previous psychiatric history. Results: Treatment decisions could be more accurately predicted for anxiety disorders (93% correct) than for depression (55%). For anxiety disorders, the presence or absence of social problems was a good predictor for whether evidence-based or non–evidence-based treatments were offered; 44% (4/9) of those with social problems vs 100% (6/6) of those without social problems were offered evidence-based treatments. For depression, patients’ risk rating had the largest impact on treatment decisions, although no one variable could be identified as individually predictive of all treatment decisions. Conclusions: Treatment decisions were generally consistent for anxiety disorders but more idiosyncratic for depression, making the development of a decision-making model very difficult for depression. The lack of clarity of some terms in the clinical guidelines and the more complex nature of depression could be factors contributing to this difficulty. Further research is needed to understand the complex nature of decision making with depressed patients. PMID:22295255

Ethically-based clinical decision-making in physical therapy: process and issues.

PubMed

Finch, Elspeth; Geddes, E Lynne; Larin, Hélène

2005-01-01

The identification and consideration of relevant ethical issues in clinical decision-making, and the education of health care professionals (HCPs) in these skills are key factors in providing quality health care. This qualitative study explores the way in which physical therapists (PTs) integrate ethical issues into clinical practice decisions and identifies ethical themes used by PTs. A purposive sample of eight PTs was asked to describe a recent ethically-based clinical decision. Transcribed interviews were coded and themes identified related to the following categories: 1) the integration of ethical issues in the clinical decision-making process, 2) patient welfare, 3) professional ethos of the PT, and 4) health care economics and business practices. Participants readily described clinical situations involving ethical issues but rarely identified specific conflicting ethical issues in their description. Ethical dilemmas were more frequently resolved when there were fewer emotional sequelae associated with the dilemma, and the PT had a clear understanding of professional ethos, valued patient autonomy, and explored a variety of alternative actions before implementing one. HCP students need to develop a clear professional ethos and an increased understanding of the economic factors that will present ethical issues in practice.

Clarifying values: an updated review

PubMed Central

2013-01-01

Background Consensus guidelines have recommended that decision aids include a process for helping patients clarify their values. We sought to examine the theoretical and empirical evidence related to the use of values clarification methods in patient decision aids. Methods Building on the International Patient Decision Aid Standards (IPDAS) Collaboration’s 2005 review of values clarification methods in decision aids, we convened a multi-disciplinary expert group to examine key definitions, decision-making process theories, and empirical evidence about the effects of values clarification methods in decision aids. To summarize the current state of theory and evidence about the role of values clarification methods in decision aids, we undertook a process of evidence review and summary. Results Values clarification methods (VCMs) are best defined as methods to help patients think about the desirability of options or attributes of options within a specific decision context, in order to identify which option he/she prefers. Several decision making process theories were identified that can inform the design of values clarification methods, but no single “best” practice for how such methods should be constructed was determined. Our evidence review found that existing VCMs were used for a variety of different decisions, rarely referenced underlying theory for their design, but generally were well described in regard to their development process. Listing the pros and cons of a decision was the most common method used. The 13 trials that compared decision support with or without VCMs reached mixed results: some found that VCMs improved some decision-making processes, while others found no effect. Conclusions Values clarification methods may improve decision-making processes and potentially more distal outcomes. However, the small number of evaluations of VCMs and, where evaluations exist, the heterogeneity in outcome measures makes it difficult to determine their overall effectiveness or the specific characteristics that increase effectiveness. PMID:24625261

Comparing Drug-Disease Associations in Clinical Practice Guideline Recommendations and Drug Product Label Indications.

PubMed

Leung, Tiffany I; Dumontier, Michel

2015-01-01

Clinical practice guidelines (CPGs) and structured product labels (SPLs) are both intended to promote evidence-based medical practices and guide clinicians' prescribing decisions. However, it is unclear how well CPG recommendations about pharmacologic therapies for certain diseases match SPL indications for recommended drugs. In this study, we use publicly available data and text mining methods to examine drug-disease associations in CPG recommendations and SPL treatment indications for 15 common chronic conditions. Preliminary results suggest that there is a mismatch between guideline-recommended pharmacologic therapies and SPL indications. Conflicting or inconsistent recommendations and indications may complicate clinical decision making and implementation or measurement of best practices.

[Advantages and disadvantages of femtosecond laser assisted LASIK and SMILE].

PubMed

Zhang, F J; Sun, M S

2018-01-11

With the development of excimer laser and femtosecond laser equipment, application of diversified and customized surgical decision in modern corneal refractive surgery has been an inevitable trend. However, how to make a personalized decision with an accurate surgical design to achieve better visual quality becomes the main focus in clinical applications. Small-incision lenticule extraction (SMILE) and femtosecond assisted laser in situ keratomileusis (FS-LASIK) have been commonly acknowledged as the mainstream of corneal refractive surgery for ametropia correction nowadays. Both methods have been verified by clinical practice for many years. This article compares and elaborates the different characteristics with advantages and disadvantages of the two methods so as to provide some reasonable treatment options for refractive surgery. (Chin J Ophthalmol, 2018, 54: 7-10) .

Toward theoretical understanding of the fertility preservation decision-making process: Examining information processing among young women with cancer

PubMed Central

Hershberger, Patricia E.; Finnegan, Lorna; Altfeld, Susan; Lake, Sara; Hirshfeld-Cytron, Jennifer

2014-01-01

Background Young women with cancer now face the complex decision about whether to undergo fertility preservation. Yet little is known about how these women process information involved in making this decision. Objective The purpose of this paper is to expand theoretical understanding of the decision-making process by examining aspects of information processing among young women diagnosed with cancer. Methods Using a grounded theory approach, 27 women with cancer participated in individual, semi-structured interviews. Data were coded and analyzed using constant-comparison techniques that were guided by five dimensions within the Contemplate phase of the decision-making process framework. Results In the first dimension, young women acquired information primarily from clinicians and Internet sources. Experiential information, often obtained from peers, occurred in the second dimension. Preferences and values were constructed in the third dimension as women acquired factual, moral, and ethical information. Women desired tailored, personalized information that was specific to their situation in the fourth dimension; however, women struggled with communicating these needs to clinicians. In the fifth dimension, women offered detailed descriptions of clinician behaviors that enhance or impede decisional debriefing. Conclusion Better understanding of theoretical underpinnings surrounding women’s information processes can facilitate decision support and improve clinical care. PMID:24552086

Multicriteria decision analysis: Overview and implications for environmental decision making

USGS Publications Warehouse

Hermans, Caroline M.; Erickson, Jon D.; Erickson, Jon D.; Messner, Frank; Ring, Irene

2007-01-01

Environmental decision making involving multiple stakeholders can benefit from the use of a formal process to structure stakeholder interactions, leading to more successful outcomes than traditional discursive decision processes. There are many tools available to handle complex decision making. Here we illustrate the use of a multicriteria decision analysis (MCDA) outranking tool (PROMETHEE) to facilitate decision making at the watershed scale, involving multiple stakeholders, multiple criteria, and multiple objectives. We compare various MCDA methods and their theoretical underpinnings, examining methods that most realistically model complex decision problems in ways that are understandable and transparent to stakeholders.

Community sensitization and decision-making for trial participation: a mixed-methods study from The Gambia.

PubMed

Dierickx, Susan; O'Neill, Sarah; Gryseels, Charlotte; Immaculate Anyango, Edna; Bannister-Tyrrell, Melanie; Okebe, Joseph; Mwesigwa, Julia; Jaiteh, Fatou; Gerrets, René; Ravinetto, Raffaella; D'Alessandro, Umberto; Peeters Grietens, Koen

2017-08-16

Ensuring individual free and informed decision-making for research participation is challenging. It is thought that preliminarily informing communities through 'community sensitization' procedures may improve individual decision-making. This study set out to assess the relevance of community sensitization for individual decision-making in research participation in rural Gambia. This anthropological mixed-methods study triangulated qualitative methods and quantitative survey methods in the context of an observational study and a clinical trial on malaria carried out by the Medical Research Council Unit Gambia. Although 38.7% of the respondents were present during sensitization sessions, 91.1% of the respondents were inclined to participate in the trial when surveyed after the sensitization and prior to the informed consent process. This difference can be explained by the informal transmission of information within the community after the community sensitization, expectations such as the benefits of participation based on previous research experiences, and the positive reputation of the research institute. Commonly mentioned barriers to participation were blood sampling and the potential disapproval of the household head. Community sensitization is effective in providing first-hand, reliable information to communities as the information is cascaded to those who could not attend the sessions. However, further research is needed to assess how the informal spread of information further shapes people's expectations, how the process engages with existing social relations and hierarchies (e.g. local political power structures; permissions of heads of households) and how this influences or changes individual consent. © 2017 The Authors Developing World Bioethics Published by John Wiley & Sons Ltd.

Informed consent procedures: responsibilities of researchers in developing countries.

PubMed

Sanchez, S; Salazar, G; Tijero, M; Diaz, S

2001-10-01

We describe the informed consent procedures in a research clinic in Santiago, Chile, and a qualitative study that evaluated these procedures. The recruitment process involves information, counseling and screening of volunteers, and three or four visits to the clinic. The study explored the decision-making process of women participating in contraceptive trials through 36 interviews. Women understood the research as experimentation or progress. The decision to participate was facilitated by the information provided; time to consider it and to discuss it with partners or relatives; and perceived benefits such as quality of care, non-cost provision of methods and medical care. For some women, participation was an opportunity to express altruism. The main obstacles for participation were perceived side effects or risks. The final risk-benefit balance was strongly influenced by women's needs. Women perceived that the consent form benefited the clinic, proving that participants had made a free decision, and benefited the volunteers by warranting their right to free medical care. The most important problem detected was occasional misunderstanding of the information given on the form. We concluded that a full decision-making process enhances women's ability to exercise their right to choose, and assures research institutions that trials are conducted without coercion and that the participants are committed to the study. Researchers have the responsibility of conducting this process.

Measuring survival time: a probability-based approach useful in healthcare decision-making.

PubMed

2011-01-01

In some clinical situations, the choice between treatment options takes into account their impact on patient survival time. Due to practical constraints (such as loss to follow-up), survival time is usually estimated using a probability calculation based on data obtained in clinical studies or trials. The two techniques most commonly used to estimate survival times are the Kaplan-Meier method and the actuarial method. Despite their limitations, they provide useful information when choosing between treatment options.

Family nurse practitioner student perception of journal abstract usefulness in clinical decision making: a randomized controlled trial.

PubMed

Johnson, Heather L; Fontelo, Paul; Olsen, Cara H; Jones, Kenneth D; Gimbel, Ronald W

2013-11-01

To assess family nurse practitioner (FNP) student perception of research abstract usefulness in clinical decision making. A randomized controlled trial conducted in a simulated environment with graduate FNP students of the Graduate School of Nursing, Uniformed Services University of the Health Sciences. Given a clinical case study and modified MEDLINE search tool accessible via an iPad device, participants were asked to develop a treatment plan and complete a data collection form. The primary measure was perceived usefulness of the research abstracts in clinical decision making regarding a simulated obese patient seeking to prevent type 2 diabetes. Secondary measures related to participant demographics and accessibility and usefulness of full-text manuscripts. The majority of NP students identified readily available research abstracts as useful in shaping their clinical decision making. The presence or absence of full-text manuscripts associated with the abstracts did not appear to influence the perceived abstract usefulness. The majority of students with full-text manuscript access in the timed simulated clinical encounter read at least one paper, but cited insufficient time to read full-text as a constraint. Research abstracts at point of care may be valuable to FNPs if easily accessible and integrated into clinical workflow. ©2013 The Author(s) ©2013 American Association of Nurse Practitioners.

Patient decision-making preference and physician decision-making style for contraceptive method choice in an Asian culture: does concordance matter?

PubMed

Alden, Dana Latham; Merz, Miwa Yamazaki; Thi, Le Minh

2010-12-01

This study investigates preferences for patient-physician decision-making in an emerging economy with an Asian culture. A survey of 445 randomly sampled women, aged 20-40 in Hanoi, Vietnam, revealed that pre-consultation attitudes were most positive toward a "shared" decision-making approach with the physician for contraceptive method choice. However, following random assignment to one of three vignettes (passive, shared or autonomous) featuring a young Vietnamese woman reaching a contraceptive method decision with her physician, preference was highest for the "autonomous" approach. Furthermore, discordance between pre-consultation preference for decision-making style and the physician's decision-making style negatively impacted evaluations under some but not all circumstances. This study demonstrates that, despite living in a hierarchic Asian culture, active participation in contraceptive method choice is desired by many urban Vietnamese women. However, there is variation on this dimension and adjusting the physician's style to be concordant with patient preference appears important to maximizing patient satisfaction.

Hesitant Fuzzy Thermodynamic Method for Emergency Decision Making Based on Prospect Theory.

PubMed

Ren, Peijia; Xu, Zeshui; Hao, Zhinan

2017-09-01

Due to the timeliness of emergency response and much unknown information in emergency situations, this paper proposes a method to deal with the emergency decision making, which can comprehensively reflect the emergency decision making process. By utilizing the hesitant fuzzy elements to represent the fuzziness of the objects and the hesitant thought of the experts, this paper introduces the negative exponential function into the prospect theory so as to portray the psychological behaviors of the experts, which transforms the hesitant fuzzy decision matrix into the hesitant fuzzy prospect decision matrix (HFPDM) according to the expectation-levels. Then, this paper applies the energy and the entropy in thermodynamics to take the quantity and the quality of the decision values into account, and defines the thermodynamic decision making parameters based on the HFPDM. Accordingly, a whole procedure for emergency decision making is conducted. What is more, some experiments are designed to demonstrate and improve the validation of the emergency decision making procedure. Last but not the least, this paper makes a case study about the emergency decision making in the firing and exploding at Port Group in Tianjin Binhai New Area, which manifests the effectiveness and practicability of the proposed method.

Ethnic bias and clinical decision-making among New Zealand medical students: an observational study.

PubMed

Harris, Ricci; Cormack, Donna; Stanley, James; Curtis, Elana; Jones, Rhys; Lacey, Cameron

2018-01-23

Health professional racial/ethnic bias may impact on clinical decision-making and contribute to subsequent ethnic health inequities. However, limited research has been undertaken among medical students. This paper presents findings from the Bias and Decision-Making in Medicine (BDMM) study, which sought to examine ethnic bias (Māori (indigenous peoples) compared with New Zealand European) among medical students and associations with clinical decision-making. All final year New Zealand (NZ) medical students in 2014 and 2015 (n = 888) were invited to participate in a cross-sectional online study. Key components included: two chronic disease vignettes (cardiovascular disease (CVD) and depression) with randomized patient ethnicity (Māori or NZ European) and questions on patient management; implicit bias measures (an ethnicity preference Implicit Association Test (IAT) and an ethnicity and compliant patient IAT); and, explicit ethnic bias questions. Associations between ethnic bias and clinical decision-making responses to vignettes were tested using linear regression. Three hundred and two students participated (34% response rate). Implicit and explicit ethnic bias favoring NZ Europeans was apparent among medical students. In the CVD vignette, no significant differences in clinical decision-making by patient ethnicity were observed. There were also no differential associations by patient ethnicity between any measures of ethnic bias (implicit or explicit) and patient management responses in the CVD vignette. In the depression vignette, some differences in the ranking of recommended treatment options were observed by patient ethnicity and explicit preference for NZ Europeans was associated with increased reporting that NZ European patients would benefit from treatment but not Māori (slope difference 0.34, 95% CI 0.08, 0.60; p = 0.011), although this was the only significant finding in these analyses. NZ medical students demonstrated ethnic bias, although overall this was not associated with clinical decision-making. This study both adds to the small body of literature internationally on racial/ethnic bias among medical students and provides relevant and important information for medical education on indigenous health and ethnic health inequities in New Zealand.

Intelligent Structured Intermittent Auscultation (ISIA): evaluation of a decision-making framework for fetal heart monitoring of low-risk women

PubMed Central

2014-01-01

Background Research-informed fetal monitoring guidelines recommend intermittent auscultation (IA) for fetal heart monitoring for low-risk women. However, the use of cardiotocography (CTG) continues to dominate many institutional maternity settings. Methods A mixed methods intervention study with before and after measurement was undertaken in one secondary level health service to facilitate the implementation of an initiative to encourage the use of IA. The intervention initiative was a decision-making framework called Intelligent Structured Intermittent Auscultation (ISIA) introduced through an education session. Results Following the intervention, medical records review revealed an increase in the use of IA during labour represented by a relative change of 12%, with improved documentation of clinical findings from assessments, and a significant reduction in the risk of receiving an admission CTG (RR 0.75, 95% CI, 0.60 – 0.95, p = 0.016). Conclusion The ISIA informed decision-making framework transformed the practice of IA and provided a mechanism for knowledge translation that enabled midwives to implement evidence-based fetal heart monitoring for low risk women. PMID:24884597

Critical thinking in clinical nurse education: application of Paul's model of critical thinking.

PubMed

Andrea Sullivan, E

2012-11-01

Nurse educators recognize that many nursing students have difficulty in making decisions in clinical practice. The ability to make effective, informed decisions in clinical practice requires that nursing students know and apply the processes of critical thinking. Critical thinking is a skill that develops over time and requires the conscious application of this process. There are a number of models in the nursing literature to assist students in the critical thinking process; however, these models tend to focus solely on decision making in hospital settings and are often complex to actualize. In this paper, Paul's Model of Critical Thinking is examined for its application to nursing education. I will demonstrate how the model can be used by clinical nurse educators to assist students to develop critical thinking skills in all health care settings in a way that makes critical thinking skills accessible to students. Copyright © 2012 Elsevier Ltd. All rights reserved.

To dialyse or delay: a qualitative study of older New Zealanders’ perceptions and experiences of decision-making, with stage 5 chronic kidney disease

PubMed Central

Lovell, Sarah; Walker, Robert J; Schollum, John B W; Marshall, Mark R; McNoe, Bronwen M; Derrett, Sarah

2017-01-01

Background Issues related to renal replacement therapy in elderly people with end stage kidney disease (ESKD) are complex. There is inadequate empirical data related to: decision-making by older populations, treatment experiences, implications of dialysis treatment and treatment modality on quality of life, and how these link to expectations of ageing. Study population Participants for this study were selected from a larger quantitative study of dialysis and predialysis patients aged 65 years or older recruited from three nephrology services across New Zealand. All participants had reached chronic kidney disease (CKD) stage 5 and had undergone dialysis education but had not started dialysis or recently started dialysis within the past 6 months. Methodology Serial qualitative interviews were undertaken to explore the decision-making processes and subsequent treatment experiences of patients with ESKD. Analytical approach: A framework method guided the iterative process of analysis. Decision-making codes were generated within NVivo software and then compared with the body of the interviews. Results Interviews were undertaken with 17 participants. We observed that decision-making was often a fluid process, rather than occurring at a single point in time, and was heavily influenced by perceptions of oneself as becoming old, social circumstances, life events and health status. Limitations This study focuses on participants' experiences of decision-making about treatment and does not include perspectives of their nephrologists or other members of the nephrology team. Conclusions Older patients often delay dialysis as an act of self-efficacy. They often do not commit to a dialysis decision following predialysis education. Delaying decision-making and initiating dialysis were common. This was not seen by participants as a final decision about therapy. Predialysis care and education should be different for older patients, who will delay decision-making until the time of facing obvious uraemic symptoms, threatening blood tests or paternalistic guidance from their nephrologist. Trial registration number Australasian Clinical Trials Registry ACTRN 12611000024943; results. PMID:28360253

User needs elicitation via analytic hierarchy process (AHP). A case study on a Computed Tomography (CT) scanner.

PubMed

Pecchia, Leandro; Martin, Jennifer L; Ragozzino, Angela; Vanzanella, Carmela; Scognamiglio, Arturo; Mirarchi, Luciano; Morgan, Stephen P

2013-01-05

The rigorous elicitation of user needs is a crucial step for both medical device design and purchasing. However, user needs elicitation is often based on qualitative methods whose findings can be difficult to integrate into medical decision-making. This paper describes the application of AHP to elicit user needs for a new CT scanner for use in a public hospital. AHP was used to design a hierarchy of 12 needs for a new CT scanner, grouped into 4 homogenous categories, and to prepare a paper questionnaire to investigate the relative priorities of these. The questionnaire was completed by 5 senior clinicians working in a variety of clinical specialisations and departments in the same Italian public hospital. Although safety and performance were considered the most important issues, user needs changed according to clinical scenario. For elective surgery, the five most important needs were: spatial resolution, processing software, radiation dose, patient monitoring, and contrast medium. For emergency, the top five most important needs were: patient monitoring, radiation dose, contrast medium control, speed run, spatial resolution. AHP effectively supported user need elicitation, helping to develop an analytic and intelligible framework of decision-making. User needs varied according to working scenario (elective versus emergency medicine) more than clinical specialization. This method should be considered by practitioners involved in decisions about new medical technology, whether that be during device design or before deciding whether to allocate budgets for new medical devices according to clinical functions or according to hospital department.

Nurse supervisors' actions in relation to their decision-making style and ethical approach to clinical supervision.

PubMed

Berggren, Ingela; Severinsson, Elisabeth

2003-03-01

The aim of the study was to explore the decision-making style and ethical approach of nurse supervisors by focusing on their priorities and interventions in the supervision process. Clinical supervision promotes ethical awareness and behaviour in the nursing profession. A focus group comprised of four clinical nurse supervisors with considerable experience was studied using qualitative hermeneutic content analysis. The essence of the nurse supervisors' decision-making style is deliberations and priorities. The nurse supervisors' willingness, preparedness, knowledge and awareness constitute and form their way of creating a relationship. The nurse supervisors' ethical approach focused on patient situations and ethical principles. The core components of nursing supervision interventions, as demonstrated in supervision sessions, are: guilt, reconciliation, integrity, responsibility, conscience and challenge. The nurse supervisors' interventions involved sharing knowledge and values with the supervisees and recognizing them as nurses and human beings. Nurse supervisors frequently reflected upon the ethical principle of autonomy and the concept and substance of integrity. The nurse supervisors used an ethical approach that focused on caring situations in order to enhance the provision of patient care. They acted as role models, shared nursing knowledge and ethical codes, and focused on patient related situations. This type of decision-making can strengthen the supervisees' professional identity. The clinical nurse supervisors in the study were experienced and used evaluation decisions as their form of clinical decision-making activity. The findings underline the need for further research and greater knowledge in order to improve the understanding of the ethical approach to supervision.

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

PubMed

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

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

SU-D-BRB-05: Quantum Learning for Knowledge-Based Response-Adaptive Radiotherapy

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

El Naqa, I; Ten, R

Purpose: There is tremendous excitement in radiotherapy about applying data-driven methods to develop personalized clinical decisions for real-time response-based adaptation. However, classical statistical learning methods lack in terms of efficiency and ability to predict outcomes under conditions of uncertainty and incomplete information. Therefore, we are investigating physics-inspired machine learning approaches by utilizing quantum principles for developing a robust framework to dynamically adapt treatments to individual patient’s characteristics and optimize outcomes. Methods: We studied 88 liver SBRT patients with 35 on non-adaptive and 53 on adaptive protocols. Adaptation was based on liver function using a split-course of 3+2 fractions with amore » month break. The radiotherapy environment was modeled as a Markov decision process (MDP) of baseline and one month into treatment states. The patient environment was modeled by a 5-variable state represented by patient’s clinical and dosimetric covariates. For comparison of classical and quantum learning methods, decision-making to adapt at one month was considered. The MDP objective was defined by the complication-free tumor control (P{sup +}=TCPx(1-NTCP)). A simple regression model represented state-action mapping. Single bit in classical MDP and a qubit of 2-superimposed states in quantum MDP represented the decision actions. Classical decision selection was done using reinforcement Q-learning and quantum searching was performed using Grover’s algorithm, which applies uniform superposition over possible states and yields quadratic speed-up. Results: Classical/quantum MDPs suggested adaptation (probability amplitude ≥0.5) 79% of the time for splitcourses and 100% for continuous-courses. However, the classical MDP had an average adaptation probability of 0.5±0.22 while the quantum algorithm reached 0.76±0.28. In cases where adaptation failed, classical MDP yielded 0.31±0.26 average amplitude while the quantum approach averaged a more optimistic 0.57±0.4, but with high phase fluctuations. Conclusion: Our results demonstrate that quantum machine learning approaches provide a feasible and promising framework for real-time and sequential clinical decision-making in adaptive radiotherapy.« less

Shared decision making and use of decision AIDS for localized prostate cancer : perceptions from radiation oncologists and urologists.

PubMed

Wang, Elyn H; Gross, Cary P; Tilburt, Jon C; Yu, James B; Nguyen, Paul L; Smaldone, Marc C; Shah, Nilay D; Abouassally, Robert; Sun, Maxine; Kim, Simon P

2015-05-01

The current attitudes of prostate cancer specialists toward decision aids and their use in clinical practice to facilitate shared decision making are poorly understood. To assess attitudes toward decision aids and their dissemination in clinical practice. A survey was mailed to a national random sample of 1422 specialists (711 radiation oncologists and 711 urologists) in the United States from November 1, 2011, through April 30, 2012. Respondents were asked about familiarity, perceptions, and use of decision aids for clinically localized prostate cancer and trust in various professional societies in developing decision aids. The Pearson χ2 test was used to test for bivariate associations between physician characteristics and outcomes. Similar response rates were observed for radiation oncologists and urologists (44.0% vs 46.1%; P=.46). Although most respondents had some familiarity with decision aids, only 35.5% currently use a decision aid in clinic practice. The most commonly cited barriers to decision aid use included the perception that their ability to estimate the risk of recurrence was superior to that of decision aids (7.7% in those not using decision aids and 26.2% in those using decision aids; P<.001) and the concern that patients could not process information from a decision aid (7.6% in those not using decision aids and 23.7% in those using decision aids; P<.001). In assessing trust in decision aids established by various professional medical societies, specialists consistently reported trust in favor of their respective organizations, with 9.2% being very confident and 59.2% being moderately confident (P=.01). Use of decision aids among specialists treating patients with prostate cancer is relatively low. Efforts to address barriers to clinical implementation of decision aids may facilitate greater shared decision making for patients diagnosed as having prostate cancer.

What factors hinder the decision-making process for women with cancer and contemplating fertility preservation treatment?

PubMed

Jones, Georgina; Hughes, Jane; Mahmoodi, Neda; Smith, Emily; Skull, Jonathan; Ledger, William

2017-07-01

Although fertility preservation (FP) treatment options have increased, the existing evidence suggests that many women with cancer do not feel well supported in making these decisions, but find them stressful and complex and fail to take up fertility care at this crucial time. Whilst existing reviews have all made important contributions to our understanding of the FP decision-making process, none of them examine solely and specifically these processes for women of reproductive age with a diagnosis of any cancer, leaving a gap in the knowledge base. Given the expectation that care is patient-centred, our review aims to address this gap which may be of help to those managing patients struggling to make difficult decisions in the often brief period before potentially sterilizing cancer treatment is started. Underpinning this narrative review was the question 'What factors hinder the decision-making process for women with any cancer and contemplating FP treatment?' Our objectives were to (i) assess and summarize this existing literature, (ii) identify the factors that hinder this decision-making process, (iii) explore to what extent these factors may differ for women choosing different methods of FP and (iv) make recommendations for service delivery and future research. A systematic search of the medical and social science literature from the 1 January 2005 up to the end of January 2016 was carried out using three electronic databases (Web of Science (PubMed), Ovid SP Medline and CINAHL via Ebsco). Included in the review were quantitative, qualitative and mixed-method studies. Reference lists of relevant papers were also hand searched. From the 983 papers identified, 46 papers were included. Quality assessment was undertaken using the Mixed Methods Appraisal Tool and thematic analysis was used to analyse the data. From the analysis, 6 key themes with 15 sub-themes emerged: (i) fertility information provision (lack of information, timing of the information, patient-provider communication); (ii) fear concerning the perceived risks associated with pursuing FP (delaying cancer treatment, aggravating a hormone positive cancer and consequences of a future pregnancy); (iii) non-referral from oncology (personal situation, having a hormone positive cancer, FP not a priority and transition between service issues); (iv) the dilemma (in survival mode, whether to prioritize one treatment over another); (v) personal situation (parity, relationship status) and (iv) costs (financial concerns). This review has found that a wide range of internal and external factors impact the FP decision-making process. Key external issues related to current service delivery such as the provision and timing of FP information, and lack of referral from oncology to the fertility clinic. However, internal issues such as women's fears concerning the perceived risks associated with pursuing FP also hindered decision-making but these 'risks' were typically overestimated and non-evidence based. These findings suggest that the implementation of a range of decision support interventions may be of benefit within the clinical care pathway of FP and cancer. Women would benefit from the provision of more evidence-based FP information, ideally received at cancer diagnosis, in advance of seeing a fertility specialist, for example through the implementation of patient decision aids. Healthcare professionals in both oncology and fertility services may also benefit from the implementation of training programmes and educational tools targeted at improving the communication skills needed to improve collaborative decision-making and deliver care that is patient-centred. Exploration of the current barriers, both intellectual and practical, that prevent some patients from accepting FP will help care providers to do better for their patients in the future. Finally, the extent to which a poorer prognosis and moral, ethical and religious beliefs influence the FP decision-making process also warrant further research. © The Author 2017. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Determining the psychometric properties of the Enhancing Decision-making Assessment in Midwifery (EDAM) measure in a cross cultural context.

PubMed

Jefford, Elaine; Jomeen, Julie; Martin, Colin R

2016-04-28

The ability to act on and justify clinical decisions as autonomous accountable midwifery practitioners, is encompassed within many international regulatory frameworks, yet decision-making within midwifery is poorly defined. Decision-making theories from medicine and nursing may have something to offer, but fail to take into consideration midwifery context and philosophy and the decisional autonomy of women. Using an underpinning qualitative methodology, a decision-making framework was developed, which identified Good Clinical Reasoning and Good Midwifery Practice as two conditions necessary to facilitate optimal midwifery decision-making during 2nd stage labour. This study aims to confirm the robustness of the framework and describe the development of Enhancing Decision-making Assessment in Midwifery (EDAM) as a measurement tool through testing of its factor structure, validity and reliability. A cross-sectional design for instrument development and a 2 (country; Australia/UK) x 2 (Decision-making; optimal/sub-optimal) between-subjects design for instrument evaluation using exploratory and confirmatory factor analysis, internal consistency and known-groups validity. Two 'expert' maternity panels, based in Australia and the UK, comprising of 42 participants assessed 16 midwifery real care episode vignettes using the empirically derived 26 item framework. Each item was answered on a 5 point likert scale based on the level of agreement to which the participant felt each item was present in each of the vignettes. Participants were then asked to rate the overall decision-making (optimal/sub-optimal). Post factor analysis the framework was reduced to a 19 item EDAM measure, and confirmed as two distinct scales of 'Clinical Reasoning' (CR) and 'Midwifery Practice' (MP). The CR scale comprised of two subscales; 'the clinical reasoning process' and 'integration and intervention'. The MP scale also comprised two subscales; women's relationship with the midwife' and 'general midwifery practice'. EDAM would generally appear to be a robust, valid and reliable psychometric instrument for measuring midwifery decision-making, which performs consistently across differing international contexts. The 'women's relationship with midwife' subscale marginally failed to meet the threshold for determining good instrument reliability, which may be due to its brevity. Further research using larger samples and in a wider international context to confirm the veracity of the instrument's measurement properties and its wider global utility, would be advantageous.

Evidence-informed decision-making by professionals working in addiction agencies serving women: a descriptive qualitative study

PubMed Central

2011-01-01

Background Effective approaches to the prevention and treatment of substance abuse among mothers have been developed but not widely implemented. Implementation studies suggest that the adoption of evidence-based practices in the field of addictions remains low. There is a need, therefore, to better understand decision making processes in addiction agencies in order to develop more effective approaches to promote the translation of knowledge gained from addictions research into clinical practice. Methods A descriptive qualitative study was conducted to explore: 1) the types and sources of evidence used to inform practice-related decisions within Canadian addiction agencies serving women; 2) how decision makers at different levels report using research evidence; and 3) factors that influence evidence-informed decision making. A purposeful sample of 26 decision-makers providing addiction treatment services to women completed in-depth qualitative interviews. Interview data were coded and analyzed using directed and summative content analysis strategies as well as constant comparison techniques. Results Across all groups, individuals reported locating and using multiple types of evidence to inform decisions. Some decision-makers rely on their experiential knowledge of addiction and recovery in decision-making. Research evidence is often used directly in decision-making at program management and senior administrative levels. Information for decision-making is accessed from a range of sources, including web-based resources and experts in the field. Individual and organizational facilitators and barriers to using research evidence in decision making were identified. Conclusions There is support at administrative levels for integrating EIDM in addiction agencies. Knowledge transfer and exchange strategies should be focussed towards program managers and administrators and include capacity building for locating, appraising and using research evidence, knowledge brokering, and for partnering with universities. Resources are required to maintain web-based databases of searchable evidence to facilitate access to research evidence. A need exists to address the perception that there is a paucity of research evidence available to inform program decisions. Finally, there is a need to consider how experiential knowledge influences decision-making and what guidance research evidence has to offer regarding the implementation of different treatment approaches within the field of addictions. PMID:22059528

Parental decision making in pediatric otoplasty: The role of shared decision making in parental decisional conflict and decisional regret.

PubMed

Hong, Paul; Gorodzinsky, Ayala Y; Taylor, Benjamin A; Chorney, Jill MacLaren

2016-07-01

To date, there has been little research on shared decision making and decisional outcomes in pediatric surgery. The objectives of this study were to describe the level of decisional conflict and decisional regret experienced by parents considering otoplasty for their children, and to determine if they are related to perceptions of shared decision making. Prospective cohort clinical study. Sixty-five consecutive parents of children who underwent surgical consultation for otoplasty were prospectively enrolled. Participants completed the Demographic Form, the Decisional Conflict Scale, and the Shared Decision-Making Questionnaire after the consultation visit. The consulting surgeons completed the physician version of the Shared Decision-Making Questionnaire. Six months after surgery, parents completed the Decisional Regret Scale. The median decisional conflict was 15.63; 21 (32.8%) parents scored 25 or above, a previously defined cutoff indicating clinically significant decisional conflict. Parent ratings of shared decision making and decisional conflict were significantly negatively correlated (P < 0.001); however, there was no significant correlation between physician ratings of shared decision making and parental decisional conflict. Significant decisional regret was reported in two (3.2%) participants. Decisional regret and parent and physician ratings of shared decision making were both significantly negatively correlated (P = 0.044 and P = 0.001, respectively). Decisional regret and decisional conflict scores were significantly positively correlated (P = 0.001). Parent and physician ratings of shared decision making were correlated (intraclass correlation = 0.625, P < 0.001). Many parents experienced significant decisional conflict when making decisions about their child's elective surgical treatment. Fewer parents experienced significant decisional regret after the procedure. Parents who perceived themselves as being more involved in the decision making process reported less decisional conflict and decisional regret. Parents and physicians had varied perceptions of the degree of shared decision making. Future research should develop interventions to increase parents' involvement in decision making and explore the influence of significant decisional conflict and decisional regret on health outcomes. 2b. Laryngoscope, 126:S5-S13, 2016. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Constructing a clinical decision-making framework for image-guided radiotherapy using a Bayesian Network

NASA Astrophysics Data System (ADS)

Hargrave, C.; Moores, M.; Deegan, T.; Gibbs, A.; Poulsen, M.; Harden, F.; Mengersen, K.

2014-03-01

A decision-making framework for image-guided radiotherapy (IGRT) is being developed using a Bayesian Network (BN) to graphically describe, and probabilistically quantify, the many interacting factors that are involved in this complex clinical process. Outputs of the BN will provide decision-support for radiation therapists to assist them to make correct inferences relating to the likelihood of treatment delivery accuracy for a given image-guided set-up correction. The framework is being developed as a dynamic object-oriented BN, allowing for complex modelling with specific subregions, as well as representation of the sequential decision-making and belief updating associated with IGRT. A prototype graphic structure for the BN was developed by analysing IGRT practices at a local radiotherapy department and incorporating results obtained from a literature review. Clinical stakeholders reviewed the BN to validate its structure. The BN consists of a sub-network for evaluating the accuracy of IGRT practices and technology. The directed acyclic graph (DAG) contains nodes and directional arcs representing the causal relationship between the many interacting factors such as tumour site and its associated critical organs, technology and technique, and inter-user variability. The BN was extended to support on-line and off-line decision-making with respect to treatment plan compliance. Following conceptualisation of the framework, the BN will be quantified. It is anticipated that the finalised decision-making framework will provide a foundation to develop better decision-support strategies and automated correction algorithms for IGRT.

Evolution of Pediatric Chronic Disease Treatment Decisions: A Qualitative, Longitudinal View of Parents' Decision-Making Process.

PubMed

Lipstein, Ellen A; Britto, Maria T

2015-08-01

In the context of pediatric chronic conditions, patients and families are called upon repeatedly to make treatment decisions. However, little is known about how their decision making evolves over time. The objective was to understand parents' processes for treatment decision making in pediatric chronic conditions. We conducted a qualitative, prospective longitudinal study using recorded clinic visits and individual interviews. After consent was obtained from health care providers, parents, and patients, clinic visits during which treatment decisions were expected to be discussed were video-recorded. Parents then participated in sequential telephone interviews about their decision-making experience. Data were coded by 2 people and analyzed using framework analysis with sequential, time-ordered matrices. 21 families, including 29 parents, participated in video-recording and interviews. We found 3 dominant patterns of decision evolution. Each consisted of a series of decision events, including conversations, disease flares, and researching of treatment options. Within all 3 patterns there were both constant and evolving elements of decision making, such as role perceptions and treatment expectations, respectively. After parents made a treatment decision, they immediately turned to the next decision related to the chronic condition, creating an iterative cycle. In this study, decision making was an iterative process occurring in 3 distinct patterns. Understanding these patterns and the varying elements of parents' decision processes is an essential step toward developing interventions that are appropriate to the setting and that capitalize on the skills families may develop as they gain experience with a chronic condition. Future research should also consider the role of children and adolescents in this decision process. © The Author(s) 2015.

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

PubMed Central

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

2009-01-01

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

Predicting the preferences for involvement in medical decision making among patients with mental disorders

PubMed Central

Michaelis, Svea; Kriston, Levente; Härter, Martin; Watzke, Birgit; Schulz, Holger; Melchior, Hanne

2017-01-01

Background The involvement of patients in medical decision making has been investigated widely in somatic diseases. However, little is known about the preferences for involvement and variables that could predict these preferences in patients with mental disorders. Objective This study aims to determine what roles mentally ill patients actually want to assume when making medical decisions and to identify the variables that could predict this role, including patients’ self-efficacy. Method Demographic and clinical data of 798 patients with mental disorders from three psychotherapeutic units in Germany were elicited using self-report questionnaires. Control preference was measured using the Control Preferences Scale, and patients’ perceived self-efficacy was assessed using the Self-Efficacy Scale. Bivariate and multivariate regression analyses were conducted to investigate the associations between patient variables and control preference. Results Most patients preferred a collaborative role (57.5%), followed by a semi passive (21.2%), a partly autonomous (16.2%), an autonomous (2.8%) and a fully passive (2.3%) role when making medical decisions. Age, sex, diagnosis, employment status, medical pretreatment and perceived self-efficacy were associated with the preference for involvement in the multivariate logistic model. Conclusion Our results confirm the preferences for involvement in medical decisions of mentally ill patients. We reconfirmed previous findings that older patients prefer a shared role over an autonomous role and that subjects with a high qualification prefer a more autonomous role over a shared role. The knowledge about predictors may help strengthen treatment effectiveness because matching the preferred and actual role preferences has been shown to improve clinical outcome. PMID:28837621

Challenging Operations: An Ethical Framework to Assist Humanitarian Aid Workers in their Decision-making Processes

PubMed Central

Clarinval, Caroline; Biller-Andorno, Nikola

2014-01-01

Introduction: This paper aims to raise awareness regarding ethical issues in the context of humanitarian action, and to offer a framework for systematically and effectively addressing such issues. Methods: Several cases highlight ethical issues that humanitarian aid workers are confronted with at different levels over the course of their deployments. The first case discusses a situation at a macro-level concerning decisions being made at the headquarters of a humanitarian organization. The second case looks at meso-level issues that need to be solved at a country or regional level. The third case proposes an ethical dilemma at the micro-level of the individual patient-provider relationship. Discussion: These real-life cases have been selected to illustrate the ethical dimension of conflicts within the context of humanitarian action that might remain unrecognized in everyday practice. In addition, we propose an ethical framework to assist humanitarian aid workers in their decision-making process. The framework draws on the principles and values that guide humanitarian action and public health ethics more generally. Beyond identifying substantive core values, the framework also includes a ten-step process modelled on tools used in the clinical setting that promotes a transparent and clear decision-making process and improves the monitoring and evaluation of aid interventions. Finally, we recommend organizational measures to implement the framework effectively. Conclusion: This paper uses a combination of public health/clinical ethics concepts and practices and applies them to the decision-making challenges encountered in relief operations in the humanitarian aid context. PMID:24987575

Decision problems in management of construction projects

NASA Astrophysics Data System (ADS)

Szafranko, E.

2017-10-01

In a construction business, one must oftentimes make decisions during all stages of a building process, from planning a new construction project through its execution to the stage of using a ready structure. As a rule, the decision making process is made more complicated due to certain conditions specific for civil engineering. With such diverse decision situations, it is recommended to apply various decision making support methods. Both, literature and hands-on experience suggest several methods based on analytical and computational procedures, some less and some more complex. This article presents the methods which can be helpful in supporting decision making processes in the management of civil engineering projects. These are multi-criteria methods, such as MCE, AHP or indicator methods. Because the methods have different advantages and disadvantages, whereas decision situations have their own specific nature, a brief summary of the methods alongside some recommendations regarding their practical applications has been given at the end of the paper. The main aim of this article is to review the methods of decision support and their analysis for possible use in the construction industry.

Resisting Prescribed Opioids: A Qualitative Study of Decision Making in Patients Taking Opioids for Chronic Noncancer Pain.

PubMed

Paterson, Charlotte; Ledgerwood, Kay; Arnold, Carolyn; Hogg, Malcolm; Xue, Charlie; Zheng, Zhen

2016-04-01

Opioids are increasingly prescribed for chronic noncancer pain across the developed world. Clinical guidelines for management of these patients focus on over-use. However, research into other types of long-term medication indicates that many patients minimize drug use whenever possible. To identify the varying influences on patients' decisions about their use of prescribed opioids and explore whether concepts of resistance and minimization of intake apply to these patients. A multiprofessional team performed a qualitative interview study using the constant-comparative method. Patient's decision making was explored in depth and with a thematic analysis utilizing a published "Model of medicine-taking." A purposive sample of 20 participants drawn from two pain clinics in Melbourne, Australia. The sample was biased toward patients interested in nonmedication pain management options. Patients' needs to obtain relief from severe pain, maintain function, and minimize side effects could lead to under-use as well as over-use of prescribed opioids. In keeping with the published Model of medicine-taking, resistance to taking opioids was a common and important influence on behavior. In the face of severe chronic pain, many participants used a variety of strategies to evaluate, avoid, reduce, self-regulate, and replace opioids. Furthermore, participants perceived a resistance to opioids within the system and among some healthcare professionals. This sometimes adversely affected their adherence. Both patients and doctors exhibit aspects of resistance to the use of prescribed opioids for chronic noncancer pain, suggesting that this shared concern could be the basis of a productive therapeutic alliance to improve communication and shared decision making. Clinical guidelines for opioids use for chronic noncancer pain focus on over-use. Our qualitative interview study found that many patients resisted and minimized the use of opioids. Using a published "Model of medicine-taking," we identified various influences on patient decision making. Both patients and doctors had concerns about using opioids for chronic noncancer pain. These could be the basis of a productive therapeutic alliance to improve communication and shared decision making. © 2015 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Lessons learned in detailed clinical modeling at Intermountain Healthcare

PubMed Central

Oniki, Thomas A; Coyle, Joseph F; Parker, Craig G; Huff, Stanley M

2014-01-01

Background and objective Intermountain Healthcare has a long history of using coded terminology and detailed clinical models (DCMs) to govern storage of clinical data to facilitate decision support and semantic interoperability. The latest iteration of DCMs at Intermountain is called the clinical element model (CEM). We describe the lessons learned from our CEM efforts with regard to subjective decisions a modeler frequently needs to make in creating a CEM. We present insights and guidelines, but also describe situations in which use cases conflict with the guidelines. We propose strategies that can help reconcile the conflicts. The hope is that these lessons will be helpful to others who are developing and maintaining DCMs in order to promote sharing and interoperability. Methods We have used the Clinical Element Modeling Language (CEML) to author approximately 5000 CEMs. Results Based on our experience, we have formulated guidelines to lead our modelers through the subjective decisions they need to make when authoring models. Reported here are guidelines regarding precoordination/postcoordination, dividing content between the model and the terminology, modeling logical attributes, and creating iso-semantic models. We place our lessons in context, exploring the potential benefits of an implementation layer, an iso-semantic modeling framework, and ontologic technologies. Conclusions We assert that detailed clinical models can advance interoperability and sharing, and that our guidelines, an implementation layer, and an iso-semantic framework will support our progress toward that goal. PMID:24993546

Development and Evaluation of Assessments for Counseling Professionals

ERIC Educational Resources Information Center

Lenz, A. Stephen; Wester, Kelly L.

2017-01-01

It is imperative that counselors understand how to critically evaluate assessments before using them to make clinical decisions. This evaluation can be conducted through integrating the 5 sources of validity. Each source of validity is discussed, along with methods to appraise psychometric quality, throughout this special issue.

Gender Differences in Bladder Cancer Treatment Decision Making.

PubMed

Pozzar, Rachel A; Berry, Donna L

2017-03-01

To explore gender differences in bladder cancer treatment decision making.
. Secondary qualitative analysis of interview transcripts.
. One multidisciplinary genitourinary oncology clinic (Dana-Farber Cancer Institute) and two urology clinics (Brigham and Women's Hospital and Beth Israel Deaconess Medical Center) in Boston, MA.
. As part of the original study, 45 men and 15 women with bladder cancer participated in individual interviews. Participants were primarily Caucasian, and most had at least some college education.
. Word frequency reports were used to identify thematic differences between the men's and women's statements. Line-by-line coding of constructs prevalent among women was then performed on all participants in NVivo 9. Coding results were compared between genders using matrix coding queries.
. The role of family in the decision-making process was found to be a dominant theme for women but not for men. Women primarily described family members as facilitators of bladder cancer treatment-related decisions, but men were more likely to describe family in a nonsupportive role.
. The results suggest that influences on the decision-making process are different for men and women with bladder cancer. Family may play a particularly important role for women faced with bladder cancer treatment-related decisions.
. Clinical nurses who care for individuals with bladder cancer should routinely assess patients' support systems and desired level of family participation in decision making. For some people with bladder cancer, family may serve as a stressor. Nurses should support the decision-making processes of all patients and be familiar with resources that can provide support to patients who do not receive it from family.

Health professionals' decision-making in wound management: a grounded theory.

PubMed

Gillespie, Brigid M; Chaboyer, Wendy; St John, Winsome; Morley, Nicola; Nieuwenhoven, Paul

2015-06-01

To develop a conceptual understanding of the decision-making processes used by healthcare professionals in wound care practice. With the global move towards using an evidence-base in standardizing wound care practices and the need to reduce hospital wound care costs, it is important to understand health professionals' decision-making in this important yet under-researched area. A grounded theory approach was used to explore clinical decision-making of healthcare professionals in wound care practice. Interviews were conducted with 20 multi-disciplinary participants from nursing, surgery, infection control and wound care who worked at a metropolitan hospital in Australia. Data were collected during 2012-2013. Constant comparative analysis underpinned by Strauss and Corbin's framework was used to identify clinical decision-making processes. The core category was 'balancing practice-based knowledge with evidence-based knowledge'. Participants' clinical practice and actions embedded the following processes: 'utilizing the best available information', 'using a consistent approach in wound assessment' and 'using a multidisciplinary approach'. The substantive theory explains how practice and evidence knowledge was balanced and the variation in use of intuitive practice-based knowledge versus evidence-based knowledge. Participants considered patients' needs and preferences, costs, outcomes, technologies, others' expertise and established practices. Participants' decision-making tended to be more heavily weighted towards intuitive practice-based processes. These findings offer a better understanding of the processes used by health professionals' in their decision-making in wound care. Such an understanding may inform the development of evidence-based interventions that lead to better patient outcomes. © 2014 John Wiley & Sons Ltd.

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